Partial gastrectomy with Roux-en-Y gastrojejunostomy - general and visceral surgery

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    Open the abdomen through an epigastric midline incision, with left periumbilical extension caudad After inserting the abdominal retractor system, explore the abdominal cavity and assess the location and extent of the primary tumor as well as any lymph node involvement and organ metastases.

  • Freeing the greater omentum and transecting the gastroepiploic vessels

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    Pull up the greater omentum and apply measured traction against the transverse colon. Dissect the greater omentum close to the upper aspect of the transverse colon and open the lesser sac.
    After freeing the hepatic flexure and descending duodenum and carefully dividing the greater omentum off its adhesions with the mesocolon on the right, divide the gastroepiploic vessels entering here. Divide the right gastroepiploic vein before its union with the superior mesenteric vein, and the right gastroepiploic artery where it leaves the gastroduodenal artery.

  • Lymphadenectomy I (hepatoduodenal ligament/LN stations 12 and 13)

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    Lymphadenectomy (LAD) starts at the hepatic hilum and continues along the hepatoduodenal ligament and common hepatic artery to the celiac trunk.

    After the cholecystectomy, not demonstrated here, incise the lesser omentum with bipolar scissors close to the liver. Start the incision on the left side of the hepatoduodenal ligament and continue to the level of the cardia. With forceps lift the connective tissue together with all its lymph nodes (LN) anterior to the common hepatic artery at the left aspect of the hepatoduodenal ligament and expose the artery. Gradually dissect the LN tissue bundle (station 12) off the portal vein and common bile duct. After inserting the index finger into the omental foramen, palpate the common hepatic artery, hepatic artery proper, portal vein, and any possibly suspect lymph nodes with thumb and index finger. Now take down LN station 13 between the head of the pancreas and the portal vein.

  • Lymphadenectomy II (common hepatic artery/station 8)

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    Transect and ligate the right gastric artery between Overholt dissecting forceps. After encircling the hepatic artery proper with a vessel loop, pull the LN tissue bundle (station 8) craniomediad and with bipolar scissors gradually take it down completely along the common hepatic artery toward the celiac trunk. Since the lymph nodes are immediately adjacent to the adventitia, ensure that the dissection is carried out close to the latter. Encircling the common hepatic artery with a vessel loop simplifies the dissection. The posterior margin of the lymph node dissection is defined by the anterior aspect of the inferior vena cava.

  • Lymphadenectomy III (celiac trunk/station 9)

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    Expose the common hepatic artery and splenic artery branching off the celiac trunk as described above and free them from the LN tissue bundle. Complete the LAD by taking down the left gastric artery close to its origin and delivering the LN tissue bundle. Do not fully expose the origin of the celiac trunk and the aorta.

  • Gastric resection

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    After grasping the stomach with organ holding forceps on the large curvature, judiciously pull the stomach craniad, thereby providing easy access to both the spleen and gastrolienal ligament. Take down any adhesions between the spleen and its surroundings with bipolar scissors.
    Transect the gastrocolic ligament on the left up to the proximal resection line. Here, transect the gastroepiploic arcade while sparing the short gastric vessels.
    Define the resection line on the lesser curvature 2 cm distal to the cardia.
    Transect the stomach with linear cutters (in the video the reusable cutters use 50 mm and 90 mm long magazines).

  • Transecting the duodenum

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    Encircle the proximal duodenum with a vessel loop about 2 cm distal to the pylorus and transect it with a linear cutter (50 mm).

  • Taking down adhesions with the pancreas and removing the specimen

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    In the video, the tumor at the posterior gastric wall adheres to the transverse mesocolon and the capsule of the pancreas. Gently dissect these adhesions which are left on the specimen. Ensure that the pancreas is not injured, and at the same time remove the tumor in its entirety with the appropriate margin. As final step – remove the specimen.

    Note: The video demonstrates inflammatory adhesions in the vicinity of the tumor, necessitating resection of the pancreatic capsule and parts of the transverse mesocolon as well.

  • Closing the mesocolic window, Lembert sutures of the staple lines

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    Close the window in the transverse mesocolon with a continuous suture. Now cover the staple line of the duodenal stump with a continuous Lembert suture PDS 4/0. The staple line at the gastric stump is secured in the same fashion. This suture starts at the lesser curvature but ends about 6 cm before reaching the greater curvature. This part of the greater curvature remains free for the anastomosis. After knotting the suture, arm the free end of the suture with a mosquito for later use in the gastroenterostomy (see step 10).

  • Preparing the Roux-en-Y limb

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    Under transillumination of the vascular arcades select a jejunal loop about 30 cm distad to the superior duodenal fold (ligament of Treitz). Divide avascular parts of the mesojejunum with electrocautery, divide any crossing vessels between clamps and secure their stumps with suture ligatures (PDS 4/0). Transect the intestine with the linear cutter. Secure the staple line of the distal limb with Lembert suture as described in step 8 (not demonstrated).

    Tips:

    • The resection line of the mesentery must ensure good blood supply to the intestine and provide enough length of the distal jejunal limb to be transposed into the upper abdomen for the gastrojejunostomy.
    • If there are neither strong primary branches nor continuous arterial arcades, the adjacent primary branches may be temporarily occluded with bulldog clamps. This will demonstrate whether the selected primary branch provides adequate blood flow to the jejunal limb.
    • Beware of obese patients! Transillumination may be fraught with problems in a fatty mesentery. In order not to endanger the intestinal blood supply divide the mesentery carefully and in steps.
    • If the blood supply is inadequate, extend the resection!
  • End-to-side gastrojejunostomy, antecolic: Suturing the posterior wall I

  • End-to-side gastrojejunostomy, antecolic: Suturing the posterior wall II

  • End-to-side gastrojejunostomy, antecolic: Suturing the anterior wall I

  • End-to-side gastrojejunostomy, antecolic: Suturing the anterior wall II

  • End-to-side jejunojejunostomy ("Roux-en-Y reconstruction") I

  • End-to-side jejunojejunostomy ("Roux-en-Y reconstruction") II

  • Closing the abdominal wall