Gastrectomy - general and visceral surgery
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Bucket-handle incision
Open the abdomen via a transverse upper abdominal incision with upper midline extension, the so-called "inverted T".
Transect the subcutaneous tissue with electrocautery, tunnel both rectus muscles with a nonmetal probe and divide them with electrocautery.
Explore the abdominal cavity to assess the location and extent of the tumor and thus its resectability after ruling out distant metastases, specifically in the peritoneum and liver. In this case the tumor is in the middle third of the stomach at the large curvature.
Dividing the lesser omentum, dissecting the gastroesophageal junction
After dividing the pericholecystic adhesions, transect the lesser omentum close to the liver in a distal to proximal direction while sparing the hepatoduodenal ligament. Continue the dissection to the gastroesophageal junction. Expose the full circumference of the abdominal esophagus and loop it with a tape.
Kocher maneuver
Follow this with the Kocher maneuver. To this end, incise the paraduodenal peritoneum about 1 cm from its lateral edge and in a largely avascular plane lift the duodenum from posterior away from the retroperitoneum and expose the vena cava.
Exposing the hepatoduodenal ligament
Dividing the greater omentum and gastroepiploic vessels
Freeing the greater omentum from the transverse colon will completely open the lesser sac. Leave the greater omentum attached to the large curvature. In the next step, divide the gastroepiploic vessels centrad between Overholt forceps.
Note: Complete mobilization of the stomach requires that later on the short gastric vessels from the gastric fundus to the spleen, as well as smaller vessels at the posterior wall of the stomach, a possible posterior gastric artery, and also the dense part of the lesser omentum, be divided or ligated.
Transecting the duodenum
Lymphadenectomy along the hepatic artery
Lymphadenectomy along the splenic artery
Transecting the specimen
Constructing the Roux limb
End-to-side esophagojejunostomy
Jejunojejunostomy
Closing the abdomen
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