Minimally Invasive Surgery for Upper Abdominal Cancer by Miguel A. Cuesta

Author:Miguel A. Cuesta
Language: eng
Format: epub
Publisher: Springer International Publishing, Cham

Right side dissection and duodenal division. After completion of left side, procedure move to right side and tissues around the gastrocolic trunk are cleared (Fig. 16.2b). right gastroepiploic vein is divided and the soft tissues above the pancreas are retrieved (#6). Right gastroepiploic artery is divided and dissection continues up to the root of gastroduodenal artery to mobilize the duodenum from the pancreas. In supraduodenal area, minor periduodenal vessels are divided and duodenum is transected by using linear endoscopic stapler.

Suprapancreatic dissection. Right gastric vessels are divided and soft tissues around the common hepatic artery are dissected (#5–8a) (Fig. 16.2c). For D2 dissection, soft tissues medial to the portal vein and proper hepatic artery are included in the specimen (#12a) (Fig. 16.2d). After left gastric vein division, soft tissues around left gastric artery are dissected on the right side (#7, #9), and splenic artery on the left side (#11p) (Fig. 16.2e, f). Retroperitoneal attachments of stomach including posterior gastric vessels if present are detached. Right diaphragmatic crus is reached and lesser curvature of the stomach is cleaned to remove #1 and some parts of #3 for distal gastrectomy (Fig. 16.2g, h).

Reconstruction. It is possible to perform anastomosis by either intra- or extracorporeally after gastrectomy. After distal gastrectomy, Billroth-I gastroduodenostomy, Billroth-II gastrojejunostomy, or Roux-en-Y gastrojejunostomy are the options to maintain intestinal continuity. For Billroth-I gastroduodenostomy, small full-layer incisions are created on the edge of greater curvature side of the stomach and on the edge of the posterior side of the duodenum. The 45-mm endoscopic linear stapler is inserted towards both intestinal lumens and the posterior walls of the stomach and duodenum are anastomosed (Fig. 16.3a). The entry hole is closed with another endoscopic linear stapler and Delta-Shaped Anastomosis is achieved (Fig. 16.3b) [11]. For Billroth-II gastrojejunostomy roughly 20 cm distal to the treitz ligament is brought up and anastomosis is performed by using two linear staplers (Fig. 16.3c, d). When jejenum is divided from same distance, it is possible to perform roux-en-Y gastrojejunostomy by using linear staplers and then jejunojejunostomy is added 25–30 cm distal to the gastrojejunostomy with similar stapling technique. After total gastrectomy, most common anastomosis type is Roux-en-Y esophagojejunostomy. For years, it has been performed by circular stapling technique which require mini-laparotomy, however, it is now possible to perform safely with side-to-side linear stapling technique (Fig. 16.3e, f). Linear staplers can also be used for esophagogastrostomy after proximal gastrectomy and for gastro-gastrostomy after pylorus-preserving gastrectomy to achieve all reconstructive process intracorporeally. For reconstruction, in addition to the techniques mentioned above, jejunal interposition and double-tract method are alternative options.

Fig. 16.3Intracorporeal anastomosis for Billroth-I gastroduodenostomy (a, b), Billroth-II gastrojejunostomy (c, d) after distal gastrectomy, and intracorporeal Roux-en-Y esophagojejunostomy (e, f) after total gastrectomy

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