Gastrectomy

Now expose the full circumference of the duodenum about 3 cm distal to the pylorus and transect it with a linear stapler (not shown in the video). Secure the staple line of the duodenal stump with serosizing interrupted sutures.

Note: Tension-free, secure closure of the duodenal stump is only possible if the duodenum has been mobilized enough by the previous Kocher maneuver.

Continue the lymphadenectomy to the left along the adventitia of the looped common hepatic artery. The first vessel encountered is the left gastric vein (formerly known as vena coronaria ventriculi), which is ligated and divided. The final step reaches the celiac trunk, where the left gastric artery is divided close its origin.

Caution! Rule out beforehand any aberrant left hepatic artery or large branches thereof arising from the left gastric artery.

Continue the para-aortic lymphadenectomy on the right to the right crus of the diaphragm.

Complete the lymphadenectomy on the superior aspect of the pancreas along the splenic artery to the splenic hilum. Lift the entire lymph node package, which remains attached to the specimen, en bloc off the superior aspect of the pancreas and both arteries (common hepatic artery and splenic artery).

Note: In the video the specimen is still in situ at the completion of the surgical step.

After truncal vagotomy transect the esophagus openly and remove the specimen. In the video the specimen has been opened and enlarged. The video then demonstrates the surgical site after the specimen had been removed, with the common hepatic artery and splenic artery still looped.

Note: Intraoperative frozen section of the esophageal resection margin is mandatory.

In the next step construct a jejunal Roux limb. Under transillumination identify the mesenteric vessels about 20 cm–30 cm distal to the duodenojejunal flexure. Fashion an asymmetrical vascular pedicle proximad, since the blood supply should be primarily from distad. Transect the jejunum with a linear stapler (GIA) and serosize the distal stump. Now pass this efferent jejunal limb of adequate length into the upper abdomen through a window in the mesocolon.

Construct the end-to-side esophagojejunostomy as a hand sewn single-layer anastomosis. First, incise the jejunal limb passed retrocolically into the upper abdomen at its antimesenteric aspect over 3 cm–5 cm. Follow this by preplacing the sutures for the posterior wall. Preplace all sutures of the posterior wall first, with the later knots resting on the inside. At the jejunum pass these seromuscular sutures from the inside out and then full thickness through the wall of the esophagus from the outside in. Use absorbable sutures size 4/0, e.g., Vicryl. With a sponge advance the jejunum along the preplaced sutures of the posterior wall toward the esophagus. Once the posterior wall of the esophagus has been aligned, tie the sutures of the posterior wall one by one. Construct the anterior wall also as a hand sewn single-layer anastomosis, but this time with the knots on the outside.

Note:

1. Before suturing the anterior wall, you may want to pass a nasogastric tube into the efferent jejunal limb (not shown in the video).

 2. Optionally, the anastomosis can be fashioned with a circular stapler (EEA, 25mm).

Plan the jejunojejunostomy about 40 cm–60 cm distad of the esophagojejunal anastomosis. The anastomosis between the short afferent and the transposed efferent Roux-en-Y limbs is end-to-side. Fashion the jejunojejunostomy as a hand sewn single-layer anastomosis with an absorbable running suture 4-0. These steps will have restored intestinal continuity. Close the mesenteric window (not demonstrated in the video).

The video finally shows the site at the end of the reconstruction phase. 

After drainage placement, close the abdominal wall with a full-thickness slowly absorbable running fascial suture size 0, e.g., PDS, and after satisfactory hemostasis close the skin with interrupted sutures.

Note: Drain the esophagojejunostomy to the right with the drain passing along the duodenal stump. Optionally, a second drain may be placed in the area of the suprapancreatic lymphadenectomy to prevent fluid retention from lymph fistulas. Both are not demonstrated in the video.