Open surgical gastrectomy

Opening of the abdominal cavity via a median upper abdominal laparotomy with left circumcision of the navel. After inserting a protective sheet, an abdominal wall retraction system, in the case shown a cable hook system plus Mercedes retractor, is installed.

After assessment and palpation of the liver (both not shown), the left liver lobe is mobilized and the lesser omentum is transected near the liver. Then the esophageal hiatus is opened and the esophagus is looped.

Detachment of the greater omentum from the transverse colon by incision of the gastrocolic ligament, then also releasing adhesions between the posterior wall of the stomach and the pancreas.

The peritoneum is incised at the lateral edge of the duodenum, and it is freed from its retroperitoneal connections along with the head of the pancreas. Mobilization according to Kocher

Next, the short gastric vessels, which run in the gastrosplenic ligament, are transected between Overholt clamps.

Initially, the gastroepiploic vessels are located and transected below the pylorus, securing the vessel stumps with a transfixion ligature. After the connection to the hepatoduodenal ligament above the gastroduodenal junction is transected between ligatures, the duodenum is resected using a stapling device. The duodenal stump is then oversewn with interrupted sutures (Maxon 4-0), incorporating the pancreatic capsule and the anterior duodenal wall in a seromuscular manner.

The stomach is now moved upwards and to the right laterally, and then the left gastric artery is exposed and centrally divided. Now the specimen is only attached to the esophagus in the hiatus loop.

After the stomach is retracted, the hiatus is adjusted. Following the transection of the vagus branches (here depicted is the transection of the anterior branch) and notching of the diaphragmatic crura, the distal esophagus is opened halfway on its anterior side and secured with a proximally placed Allis clamp, which prevents thoracic retraction of the esophagus. Subsequently, the posterior wall of the esophagus is transected and the specimen is removed.

Placement of a purse-string suture (monofilament, non-absorbable thread of size 2-0, overcast) and gentle dilation of the esophageal lumen using a sponge forceps. Introduction of the pressure plate of a circular stapler, which is fixed with the previously placed purse-string suture.