Partial gastrectomy with Roux-en-Y gastrojejunostomy - general and visceral surgery
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Freeing the greater omentum and transecting the gastroepiploic vessels
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)
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)
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)
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.
Transecting the duodenum
Taking down adhesions with the pancreas and removing the specimen
Closing the mesocolic window, Lembert sutures of the staple lines
Preparing the Roux-en-Y limb
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
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