GIST - distal gastrectomy according to Roux-Y

Anatomy Perioperative management Technique Complications Evidence Total Video Medical Equipment

Preoperative Assessment

The endoscopic examination reveals a submucosal tumor of the gastric wall obstructing the gastric outlet.
Explorative Laparoscopy

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The operation begins with a laparoscopic exploration of the abdomen to exclude peritoneal and liver metastases. In the course of this, an opportunistic cholecystectomy is performed independently of the tumor operation (not shown). After fenestration of the gastrocolic ligament with opening of the omental bursa, the posterior wall of the stomach becomes visible. The prepyloric tumor appears to be well resectable. Endosonographically, this tumor corresponds to an echo-heterogeneous 26 × 12 mm mass within the gastric wall.
Conversion to Laparotomy

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Due to the location of the tumor directly prepyloric, an atypical resection of the tumor is not possible, and there is an indication for distal gastrectomy. Therefore, conversion to an open procedure using a right-biased transverse upper abdominal laparotomy. After opening the abdominal cavity, the findings are inspected and palpated again.
Mobilization of the Duodenum according to Kocher; Preparation of the Stomach

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After mobilization of the descending part of the duodenum, the dissection of the proximal resection margin at the lesser and greater curvature is performed first. The preparation of the stomach can be done close to the stomach wall, as neither large safety margins nor lymph node dissection are necessary.
Postpyloric Stomach Resection

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Continue the dissection distally step by step at least 2 cm beyond the pylorus, severing the right gastric artery at the lesser curvature and the right gastroepiploic artery and vein near the gastric wall at the greater curvature. Once the duodenum is circumferentially mobilized postpylorically, it is transected with the stapling device.
Oversewing of the Duodenal Stump

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Oversewing the staple line of the duodenal stump with seromuscular interrupted sutures.
Transection of the stomach proximally; Removal of the specimen

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The transection of the stomach is performed with a stapler, after which the specimen can be removed. Partial oversewing of the staple line with interrupted sutures, leaving a section approximately 5 cm long intended for the anastomosis.
Formation of the Roux-Y Loop

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Approximately 30 cm aboral to the duodenojejunal flexure (Treitz's ligament), selection of a jejunal loop is performed under transillumination of the vascular arcades. Vascular-free portions of the mesentery are incised with the cautery, and the crossing vessels are divided between clamps. The intestine is transected with the stapler. The staple line of the efferent loop is oversewn in an inverting manner.
The mesocolon is incised in a vascular-free region, and subsequently, the efferent jejunal loop is relocated retrocolically into the upper abdomen and approximated to the gastric stump. Care must be taken not to twist the mesentery.
Gastrojejunostomy – Posterior Wall Suture

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The anastomosis between the stomach and jejunum is performed end-to-side. The posterior wall suture is executed using a two-layer technique. After placing two lateral holding sutures, the anastomosis begins with a continuous seromuscular suture. Subsequently, the staple line in the area left free on the stomach is removed, and the opposite jejunum is opened to the same length. The second suture line is then completed as a continuous full-thickness suture with a monofilament thread.
Gastrojejunostomy – Anterior Wall Suture

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After stenting the anastomosis by advancing the gastric tube into the efferent jejunal limb, the anastomosis is completed with a single-layer suture using extramucosal interrupted sutures.
Footpoint Anastomosis

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The afferent jejunal loop is anastomosed end-to-side with the efferent jejunal loop 40 cm aboral to the gastrojejunostomy. Both loops are approximated with knotted corner sutures, followed by the resection of the staple line of the afferent loop and the antimesenteric opening of the afferent loop using an electrosurgical knife.
The anastomosis technique corresponds to the technique shown in steps 9 and 10 for the gastrojejunostomy. It is performed in two layers in the area of the posterior wall and as a single-layer extramucosal interrupted suture in the area of the anterior wall.
Abdominal Wall Closure

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After placing a drain at the duodenal stump, a two-layer fascial closure is performed, along with a subcutaneous suture. The skin suture is performed as an intradermal suture with absorbable thread.

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