gastrectomy.pptx

Gastric carcinoma management

1. Operative surgery - Gastrectomy Dr Suhas U

2. Anatomy Asymmetrical , pearshaped , most proximal abdominal organ of the digestive tract Fixed at upper cardioesophageal and lower pyloric sphinter

3. The organs abutting the stomach - liver, colon , spleen, pancreas, and occasionally the kidney. The left lateral segment of the liver usually covers a large part of the anterior stomach. Inferiorly , the stomach is attached to the transverse colon by the gastrocolic omentum . The lesser curvature is tethered to the liver by the hepatogastric ligament, also referred to as the lesser omentum or pars flaccida . Posterior to the stomach is the lesser omental bursa and the pancreas.

4. Blood supply

5. Nerve supply

6. History Earliest recorded operations on the stomach were performed for penetrating injuries In 1881 , Rydygier performed the 1 st successful pylorectomy , and in 1884 he performed the 1 st gastroenterostomy (peptic ulcer) In 1881, Billroth performed the 1 st successful pylorectomy for malignancy(duodenum and lesser curvature anastomosis ) In 1885, Billroth performed a resection of a large pyloric carcinoma, using an anterior gastrojejunostomy for the reconstruction

7. Common indications for gastric resections include peptic ulcer disease and tumors of the stomach Safe performance of surgery involves understanding The physiology of vagal innervation and gastric emptying; The surface and vascular anatomy of the stomach The principles of reconstruction following resection, specifically the Billroth I (B-I) gastroduodenostomy , the Billroth II (B-II) gastrojejunostomy , and the Roux-en-Y configuration The principles of surgical stapling techniques as well as hand-sewn suturing techniques The specific early and late postoperative complications that arise from different gastric resections and different forms of reconstruction

8. Degrees of resection Wedge resections and closure of gastric wall for ulcers, polyps, or tumors derived from neuroendocrine or submucosal tissues Distal gastric resection , focusing on antrectomy or hemigastrectomy (with or without vagotomy ) for peptic ulcer disease and when the major decision involves the choice of B-I or B-II reconstruction Management of gastric carcinoma , focusing on proximal, subtotal, or total resection, and the techniques of regional node dissection

9. Wedge resection Principles Minimum 2cm distance away from GE junction/ pylorus 2cm margin of resection Indications Peptic ulcers Polyps Tumors derived from neuroendocrine or submucosal tissues

10. Midline laparotomy Location of lesion Omental adhesions of tumour left in contact Omentum away are ligated 2cm scoring of serosa from base of tumour ( cautery ) Deepened through muscularis Submucosal vessels pop out(control)

11. Excision of tumour Closure in 2 layers

12. Tumour on the lesser curve Gastrotomy To stop bleeding from ulcer Excision from mucosal side Might require excising both nerves of laterjet and hence pyloroplasty Alternatively Distal gastrectomy with B1/B2 procedure / pauchet procedure

13. Distal gastrectomy Removal of the distal portion of the stomach According to disease (ulcer or carcinoma) and the location (duodenal ulcer, gastriculcer , high-gastric ulcer), they are classified as Antral Two-thirds Four-fifths High subtotal gastrectomy Distal partial gastrectomy is named according to the type of anastomosis between the small intestine and the gastric remnant

14. Indications Recurrent gastric ulcer after adequate antisecretory treatment and eradication of Helicobacter pylori . Prepyloric ulcer Complicated ulcers(perforation, bleeding, obstruction , intractable) Early carcinoma and Ca antrum Not recommended as standard treatment Early and well differentiated T1/T2 N0 lesions

15. Technique Position – supine Anaesthesia – GA +EA Incision Midline Transverse epigastric rectus muscle cutting Chevron incision Self retaining retractors

16. Entering lesser sac at middle of gastric curvature Incising the gastrocolic ligament Dissection made between gastric wall and gastroepiploic vessels Flimsy part of lesser omentum opened with blunt d issection and penrose drain inserted Dissection along greater curvature towards duodenum with ligation of vessels

17. Mobilsing the duodenum By Kochers maneuver By stretching the stomach , dissection proceeds along greater curvature to the medial duodnenal wall, then posterior wall and lateral wall( 3 -5 cm of posterior wall is exposed ) Transition between first and second part – entry of gastroduodenal artery

18. Dissection along lesser curvature Ligation of right gastric artery Selective vagotomy of gastric remnant Dissection proceeds along lesser curvature depending on the location of ulcer Left gastric artery(ascending branch ) should remain intact

19. Resection of specimen Cutting the duodenum after applying stay sutures (just distal to pyloric ring) Stomach resection Stapler (TA90/TL90) Angle of 45degrees to lesser curvature Clamp fitted at right angle to greater curvature The aboral end of greater curvature is cut after stay sutures Anastomosis is performed without clamps

20. Anastomosis Two layered technique Outer seromuscular (3-0 silk ) Inner full thickness suture (3-0 vicryl ) Jammerecke (angle of sorrow) Junction of suture anastomosis and the staple line Site of leakage Triple seromuscular sutures at this angle Patency checked with fingers NG tube crosses the anastomosis

21. Alternative methods End to side gastroduosenostomy Stapler anastomosis (circular stapler) Laparoscopic B1 Gastrectomy

22. B2 gastrectomy Initial surgical steps Dissection of lesser and greater curvature Mobilising duodenum and circumferential dissection Ligating right epiploic vessels and right gastric artery Duodenum divided 2cm distal to pyloric ring with linear stapler

23. Gastric resection Transverse apllication of linear stapler Removal of specimen Selective vagotomy of gastric remnant Mobising the jejunum Tension free and retrocolonic fashion Placed oppsite to greater curvature Braun Jejunojejunostomy between ascending and descending loop

24. Anastomosis 4-5cm stapler line at greater curvature is incised Anastomosis done in 2 layers Before anterior layer closure , NG tube is passed into the descending jejunal segment

25. Roux en Y GJ Resection of specimen Mobilising the jejunum Identifying jejunum at ligament of Treitz Proximal jejunum , that reaches the stomach without tension is selected (15- 20 cm from treitz ligament) Jejunum transected with linear stapler

26. Mobilsing the distal jejunal segment End to side gastrojejunal anastomosis in two layers and isoperistaltic Proximal jejunal segment anastomosed to the jejunum around 45cm away from GJ as end to side anastomosis

27. Total gastrectomy Complete operative resection remains the only potentially curative modality for gastric adenocarcinoma Indicated when 4 to 6 cm of negative margins cannot be obtained from the primary tumor

28. Supine , with consideration given to the possibility of left or right thoracic approach Sandbag placed beneath left costal margin A split-lumen endotracheal tube is placed in all patients in whom thoracotomy is likely Incisions Midline / bilateral subcostal / left thoracoabdominal incision

29. Fixed retractors are placed. Dissection of the greater omentum from the colon and entering into the anterior leaf of the mesocolon The dissection is continued back to the inferior border of the pancreas, and the pancreatic capsule is dissected upward Branches to the right gastroepiploic vessels are divided just at the inferior border of the pancreas, and venous tributaries ligated . The dissection continued laterally , along the superior aspect of the pancreas, skeletonizing the splenic artery Division of short gastric vessels close to the spleen Dissecting the lesser omentum from the undersurface of the liver, extending back to the right crus and mobilizing the right aspect of the gastroesophageal junction .

30. Division of the duodenum two straight Kocher clamps /GIA stapler Invaginating the closure. Divided duodenum Elevated upward and forward Gaining easy access to the dissection of the node-bearing areas

31. Dissection in the porta Begin from above Isolating the bifurcation of the hepatic artery Bringing the node-bearing tissue inferiorly Dissecting the portal vein, to the left of the left hepatic artery and in the area between the common hepatic and the superior border of the pancreas This dissection moves towards celiac axis Picking up the dissection of the superior border of the pancreas at the junction of the splenic artery with the celiac. The left gastric artery is then divided at its origin

32. Dissection from above along the right crus allows the aortic junction of the celiac axis to be identified and cleared. The extent of the dissection of the splenic hilum depends on the extent of disease present. The short gastric vessels are identified and ligated close to the spleen

33. The left crus dissection downwards and all tissue reflected from it. The left adrenal gland should be clearly identified and preserved from harm. At this point, the entire stomach mobilized The left gastric artery can be divided at its origin Entire stomach lifted forward Paracardial lymph nodes are reflected inferiorly The gastroesophageal junction is mobilized and satinsky atraumatic vascular clamp applied

34. Anastomosis Roux-en-Y method end to side esophagojejunal anastomosis using 2 layered technique

35. Subtotal gastrectomy Indication When 4-6cm margin from the tumour is present Incision , position and anaesthesia same

36. Steps Mobilization of the greater curvature with omentectomy and division of the left gastroepiploic artery Infrapyloric mobilization with ligation of the right gastroepiploic artery and vein as it enters t he gastrocolic trunk Suprapyloric mobilization with ligation of the right gastric artery Duodenal transection

37. Lymphadenectomy with dissection of the porta hepatis , common hepatic artery, left gastric artery, celiac axis, and splenic artery and ligation of left gastric artery Gastric transection Reconstruction by loop or Roux-en-Y gastrojejunostomy

38. Gastric transection Point approximately 2 cm distal to the gastroesophageal junction on the lesser curvature Point at least 5 cm proximal to the upper border of the tumor on the greater curvature of the stomach .