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Completion gastrectomy by laparoscopic approach for cancer of the gastric stump

This operative video demonstrates the performance of a completion gastrectomy in a patient who has had prior partial gastrectomy. This patient had a previous partial gastrectomy. To mobilize the distal esophagus, the author divides the phrenoesophageal membrane, and then frees the esophagus of all its attachments in the lower mediastinum. This aids in retracting the esophagus into the abdomen. The author then carries out dissection with the ultrasonic scalpel, dividing the posterior and the anterior vagus nerves. To perform partial division of the esophagus, he uses the linear Endo-GIA (Covidien, North Haven, CT) and uses the stomach as a lever.

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Completion gastrectomy by laparoscopic approach for cancer of the gastric stump

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摘要

This operative video demonstrates the performance of a completion gastrectomy in a patient who has had prior partial gastrectomy.
This patient had a previous partial gastrectomy. To mobilize the distal esophagus, the author divides the phrenoesophageal membrane, and then frees the esophagus of all its attachments in the lower mediastinum. This aids in retracting the esophagus into the abdomen. The author then carries out dissection with the ultrasonic scalpel, dividing the posterior and the anterior vagus nerves. To perform partial division of the esophagus, he uses the linear Endo-GIA (Covidien, North Haven, CT) and uses the stomach as a lever.

關鍵字

completion gastrectomy, laparoscopy, cancer, gastric stump, partial gastrectomy

媒體類型

手術影片

期間

11'20''

刊物

2008-02

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Feb 2008;8(02).
URL: http://www.websurg.com/doi-vd01en2274.htm

Completion gastrectomy by laparoscopic approach for cancer of the gastric stump

1. Operation commences with adhesiolysis 00'18''

The procedure starts with the removal of all adhesions between the hepatic hilum and the gastric stump.

2. Exploration of supra- and infra-colonic sectors 00'43''

Once this adhesiolysis is achieved, exploration of the supramesocolic and the submesocolic region are undertaken laparoscopically in order to obtain complete visualization of all surgical anatomical landmarks.

3. Coloepiploic detachment and division 01'05''

Then coloepiploic detachment is performed until the gastrosplenic ligament is opened. This ligament can then be divided along with the short gastric vessels up to the left diaphragmatic crus, which should be completely exposed.

4. Small bowel mobilisation and transection 01'59''

Then the transverse colon is lifted up, and using scissors without diathermy the jejunal loops are freed in order to expose the limb that has previously been anastomosed to the gastric stump. Once this loop has been isolated, a small window opening is created in the mesentery. Then using a mechanical linear stapler, the afferent loop is divided. This is followed by division of the efferent loop once this too has been adequately exposed and freed.

5. Mobilisation of prior gastrojejunal anastomosis 03'45''

The next step is to free the bloc of adhesions at the previous gastrojejunal anastomosis so that this can be positioned above the mesocolon. At this stage, the take down can proceed according to the conventional principles of total gastrectomy: thus, removal of the prepancreatic capsule at the level of the coeliac trunk,

6. Mobilisation of gastric remnant and lymphadenectomy 04'15''

along with lymph node resection starting from cephalad to caudad along the hepatoduodenal ligament can be performed in order to resect all nodal and fatty tissues lying anterior to the common bile duct and hepatic artery. Then lymphadenectomy can be performed from the common hepatic artery to the coeliac trunk while dividing the left gastric vein and the left gastric artery at their origin between clips. The panoramic view of the supramesocolic region that we obtain at all times helps us to control the lymphadenectomy with both skeletonization of both the proper and common hepatic artery, and at the coeliac trunk and at the proximal portion of the splenic artery. Now we can divide the gastrohepatic ligament right up to the right diaphragmatic crus. And hence, on an aortic plane, we can resect all residual lymph node and fatty tissue until the esophageal hiatus is reached.

7. Mobilisation of distal esophagus 08'47''

The phreno-esophageal membrane is then divided in order to better expose the anterior aspect of the esophagus. Then the esophagus is freed of all its attachments to the lower mediastinum. Such freeing is necessary in order to be able to retract the esophagus into the abdomen. This dissection is best performed using the ultrasonic scalpel. The posterior vagus nerve and the anterior vagus nerve are also divided.

8. Transection of esophagus 09'18''

The following step consists of the partial division of the esophagus using the linear Endo-GIA in order to use the stomach as a lever to exert traction on the esophagus into the abdomen.

9. Esophagojejunal anastomosis 09'34''

At this stage, the continuity of the digestive tract is reconstructed while checking that there is no tension at the level of the loop which will be anastomosed to the esophagus. A small window has been created at the level of the posterior aspect of the esophagus proximal to the division line and of the efferent jejunal loop. Through these openings, the two jaws of the linear stapler are introduced to perform a side-to-side jejuno-esophageal anastomosis. We then close the residual opening using interrupted sutures (Vicryl 2/0). This will be completed over a nasogastric tube which will be introduced into the efferent loop. The distal esophagus can then be completely divided. A reinforcement line of sutures is placed around this anastomosis.

10. Roux loop jejunojejunal anastomosis 10'42''

Then a jejunal loop is prepared 70cm inferior to the previous anastomosis.

11. Conclusion of surgery 10'56''

And a side-to-side jejuno-jejunal anastomosis is performed at the foot of the loop using a linear stapler. Closure of the residual opening is achieved again using interrupted sutures.