Open Gastrectomy - Radical

1. Abdominal cavity approach

Substep Structure Actions Specification

1A Midline incision Incision A midline incision is made from the xiphoid to the umbilicus.

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2. Stomach exposure

Substep Structure Actions Specification

2A Abdominal cavity Inspect Inspect the abdominal cavity for the location of lesion and possible distension of the intestine,
ingrowth, peritoneal deposits, palpable metastases in the liver, and distal nodal metastasis.

2B Greater omentum Retract Retract the greater omentum cranially.

2C Anterior coronary ligament Transect Transect the anterior coronary ligament of the liver while grasping the left lobe of the liver.

HAZARD: Left hepatic vein injury

Care should be taken to preserve the left hepatic vein while dissecting the anterior coronary
ligament.

HAZARD: Metastases
Because of the high incidence of metastases, a more liberal incision extending up to the region of
the xiphoid and down to the umbilicus, or beyond it on the left side, is not made until it has been
determined that there is no contraindication for a total gastrectomy.

TIP: Palpation
Determine if there is free mobility of the tumor by palpation, without involvement or fixation to
the underlying pancreas or major vessels as the portal vein, superior mesenteric artery and the
coeliac trunk.

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3. Lesser curvature mobilization

Substep Structure Actions Specification

3A Liver Retract Place a retractor over the liver and retract the liver laterally.

3B Hepatogastric ligament Incise Incise the hepatogastric ligament close to the liver, so the omental bursa will be opened.

3C Lesser omentum Transect Transect the lesser omentum along the lesser curvature of the stomach up to the
gastroesophageal junction.

3D Peritoneum Dissect Dissect the peritoneum overlying the esophagus.

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4. Greater curvature mobilization

Substep Structure Actions Specification

4A Greater omentum Lift Lift the greater omentum upwards.

Dissect Dissect the avascular plane between the greater omentum and the transverse colon.

HAZARD: Vascular connections

Care should be taken to preserve the vascular connections between the greater omentum and
the mesocolon.

4B Omental bursa Incise Incise and open the omental bursa.

4C Greater omentum Transect Continue the transection of the greater omentum towards the spleen.

4D Adhesions Transect Transect the adhesions between the greater omentum and the abdominal wall and release the
spleen from the adhesions.

HAZARD: Capsular ruptures spleen

Be careful not to create capsular ruptures due to traction.

Radical extirpation If the growth of the tumor appears to be localized, but it is large, involving the tail of the
pancreas, colon, and kidney, a radical resection may be carried out.

4E Greater curvature of the stomach Dissect Continue the dissection of the greater curvature of the stomach towards the gastroesophageal
junction.

HAZARD: Position tumor

When the tumor is near the greater curvature in the midportion of the stomach, it may be
necessary to remove the spleen and tail of the pancreas to assure ‘en bloc’
resection of the immediate regional lymphatic drainage zone.

4F Left gastroepiploic vessels Transect Transect and ligate the left gastroepiploic vessels

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4. Greater curvature mobilization

Substep Structure Actions Specification

HAZARD: Pancreas injury

Remain superior to the pancreas during the ligation of the left gastroepiploic vessels.

4G Short epigastric vessels Transect Continue the dissection along greater curvature of the stomach up to the gastroesophageal
junction by transecting the short epigastric vessels.

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5. Duodenal transection

Substep Structure Actions Specification

5A Greater omentum Dissect Dissect through the avascular plane of the greater omentum, along the anterior border of the
duodenum.

5B Duodenum Isolate Isolate a sufficient amount of the posterior wall of the duodenum from the adjacent pancreas,
especially inferior, where a few vessels may enter the duodenal wall.

5C Stomach Retract Retract the stomach cranially.

5D Retrogastric adhesions Transect Transect the retrogastric adhesions from the stomach to the pancreas.

5E Right gastroepiploic vessels Transect Isolate and transect the right gastroepiploic vein and artery, as they run from left to right along
the greater curvature of the stomach.

5F Right gastric artery Transect Isolate and transect the right gastric artery, as it passes from right to left along its lesser curvature
of the stomach.

5G Duodenum Transect Isolate the horizontal part of the duodenum and transect the duodenum with a straight stapler
about 5 cm distal from the pylorus.

Hepatoduodenal Be careful not to damage the hepatoduodenal ligament and inspect the transection area for
ligament injury hemorrhage after stapling.

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6. Esophageal transection

Substep Structure Actions Specification

6A Stomach Retract Retract the stomach cranially.

6B Left gastric vein Identify Identify the left gastric vein by dissecting towards the superior portion of the lesser curvature of
the stomach.

Transect Transect and ligate the left gastric vein.

6C Left gastric artery Identify Identify the left gastric artery after the dissection is extended towards the coeliac trunk.

Transect Transect and ligate the left gastric artery where it originates at the coeliac trunk.

6D Lymph nodes Dissect Dissect the lymph nodes following the splenic artery towards the spleen and towards the liver
along the lesser curvature of the stomach.

6E Stomach Retract Retract the stomach caudally and turn the attention to the gastroesophageal junction.

6F Distal esophagus Isolate Isolate the distal esophagus away from it’s surroundings.

6G Vagal nerves Transect Transect the anterior and posterior vagal nerves, lying directly over the distal esophagus.

6H Distal esophagus Fixate Fixate the distal esophagus with two anchor sutures. Since the esophagus is not covered in
mucosa, the longitudinal and circular muscle layers tend to tear when sutured.

HAZARD: Esophagus retraction

As the esophagus is divided from the stomach, it tends to retract cranially into the thorax.
Adequate and free exposure must be obtained to secure a safe anastomosis.

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6. Esophageal transection

Substep Structure Actions Specification

TIP: Anchor esophagus

The wall of the esophagus can be lightly anchored to the crus of the diaphragm on both sides, as
well as anteriorly and posteriorly, to prevent rotation of the esophagus or upward retraction.
Take care these sutures do not enter the lumen of the esophagus.

Position Position two blunt clamps between the upper part of the stomach and the suture line.

Transect Transect the distal esophagus between the two clamps.

HAZARD: Gastric tube damage

Do not forget to remove or withdraw the gastric tube into the esophagus, before transecting the
distal esophagus.

HAZARD: High tumor

In the presence of a very high tumor that reaches the gastroesophageal junction, several
centimeters of esophagus should be resected above the tumor. Leave at least 2,5 centimeter of
esophagus visable, in order to ensure a secure anastomosis without tension.

6I Stomach Remove Remove the specimen.

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Open Gastrectomy - Radical

7. Jejunojejunal anastomosis

Substep Structure Actions Specification

7A Transverse colon Retract Retract the transverse colon cranially and identify the ligament of Treitz.

7B Jejunum Transect Transect the jejunum 10 cm distal to Treitz, in the presence of a vascularized pedicle. This can be
done with a stapling device.

7C Mesentery Transect Transect the mesentery at the height of the jejunojejunostomy, to give enough length to the
jejunal loop.

TIP: Electrocautery usage

Electrocautery will give less hemorrhage.

Ligate Ligate the vascular arcade of the mesentery at the height of the jejunojejunostomy.

TIP: Transillumination
With the jejunum held outside the abdomen, the arcades of blood vessels can be clearly defined
by transillumination with a portable light.

7D Efferent jejunal loop Retract Retract the efferent jejunal loop over the mesocolon and the transverse colon (antecolic
manner).

Check Make sure the efferent jejunal loop can be approximated easily to the base of the diaphragm
behind the esophagus, with 5-10 centimeters reserve length.

Extend Extend the efferent jejunal loop

TIP: Mesentery transection

Additional mesentery is divided if the end of the jejunum does not easily extend upwards to the
esophagus.

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7. Jejunojejunal anastomosis

Substep Structure Actions Specification

Inspect Find a well vascularized place, where a side-to-side anastomosis can be made between the two
jejunal loops, approximately 40 centimeters distal to the efferent loop.

7E Jejunum Fixate Fixate the jejunal loops using a blunt clamp.

Anastomose Make a side-to-side anastomosis between the afferent and the efferent jejunum loops at 40 cm
distal from the jejunojejunostomy. There are various anastomotic options (see chapter
anastomosis).

Hand-sewn anastomosis In case of a hand-sewn anastomosis, suture inside-out / outside-in. The use of a double-armed
threat is advised.

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8. Esophagojejunal anastomosis

Substep Structure Actions Specification

8A Efferent jejunal loop Retract Retract the efferent jejunal loop to the distal esophagus.

Fixate Fixate the efferent jejunal loop to the distal esophagus, preferably with a double-armed thread.

TIP: Blood supply

Reconfirm if the blood supply of the jejunal limb is strong and adequate.

HAZARD: Angulation
When retracting the mesentery of the jejenum, take care to avoid angulating or twisting the
mesentery of the jejunum, when it is retracted cranially.

TIP: Antecolic vs retrocolic

There are two methods of bringing the efferent jejunal loop to the esophagus; The first way is
antecolic, what means over the transverse colon. The other option is retrocolic; through an
opening in the mesocolon of the transverse colon.

Anastomose Make an end-to-end anastomosis. There are various anastomotic options (see chapter
anastomosis).

HAZARD: Nasogastric tube

Do not place a nasogastric tube into the jejunal loop.

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9. Abdominal wall closure

Substep Structure Actions Specification

9A Vessels Check Make sure the hemostasis has been established.

Closure Closure of the abdominal wall is discussed in detail in the Course “Abdominal wall incisions”

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