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Gastrectomy for benign lesions: modified partial gastrectomy
Authors
Abstract
The description of the gastrectomy for benign lesions: modified partial gastrectomy covers all aspects of the surgical procedure used for the management of benign tumors.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: surgical approach, gastrectomies/principles, proximal gastrectomy, modified resections/stapling device.
Consequently, this operating technique is well standardized for the management of this condition.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: surgical approach, gastrectomies/principles, proximal gastrectomy, modified resections/stapling device.
Consequently, this operating technique is well standardized for the management of this condition.
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2001-09
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E-publication
WeBSurg.com, Sept 2001;1(09).
URL: http://www.websurg.com/doi-ot02en168.htm
URL: http://www.websurg.com/doi-ot02en168.htm
Gastrectomy for benign lesions: modified partial gastrectomy
1. Introduction
The quality of medical imaging (ultrasonography, CT scans and MRI), along with recent progress in fibroscopy, has improved the detection of benign tumors.However, the lack of an exact histological diagnosis, the possibility of degeneration, the risks involved in repeated follow-up exams, and the anxiety of patients or their physicians can lead to the decision to remove these benign tumors. This is done by partial, or often modified, gastrectomies.
2. Definitions
Modified gastrectomies do not follow a strict procedure. Innumerable variations of a gastric resection are possible if certain rules are respected, eg a pyloroplasty must be performed if the vagus nerves cannot be preserved to avoid a gastric emptying disorder that could cause the sutures to give way too early.3. General anatomy
• Anatomical description
• Landmarks
The stomach is a J-shaped sac located between 2 fixed anatomical landmarks:1. the cardia: junction between the abdominal esophagus and stomach,
2. the pylorus: junction between the stomach and duodenum.
• Division
The stomach is composed of 2 parts:3. the vertical part inclines over the vertebral column to the left and is composed of both the fundus and the body of the stomach,
4. the horizontal part heads to the right beyond the linea alba.
• Duodenal bulb
The duodenal bulb, often resected during gastrectomies due to its proximity to the stomach, is:5. the first mobile segment of duodenum. It is separated from the pancreas by the omental bursa, which extends from the right to the gastroduodenal artery.
• Physiological description
From a physiological standpoint, the stomach is composed of:6. a gastrin-producing zone called the antrum,
7. the fundus.
The junction between these functional regions does not correspond to the junction between the horizontal and vertical regions of the stomach.
4. Vascular anatomy
• Pedicles
Gastric arterial blood supply comes from the celiac trunk.It divides into 4 pedicles, 2 each at the level of the:
1. lesser curvature,
2. greater curvature.
The pedicles then join a wide anastomotic network that supplants vascular blood supply when one of the main trunks is either obstructed or ligated.
• Celiac trunk
The celiac trunk supplies the stomach.It originates from the anterior aspect of the aorta above the superior aspect of the pancreas.
The trunk is 1 to 3 cm long and divides into 3 branches:
1. the left gastric artery;
2. the common hepatic artery;
3. the splenic artery.
5. Lesser curvature
• Left gastric artery
• Origin
The left gastric artery originates from the celiac trunk in 90% of cases.• Variations
Alternatively, it originates either:1. directly from the aorta;
2. from the inferior phrenic artery;
3. from the gastrosplenic trunk;
4. from the gastrohepatic trunk.
• Division
The left gastric artery forms an arch before joining and running along the lesser curvature 2 fingerbreadths below the cardia. It then divides into an anterior (1) and posterior (2) branch that both run down along the lesser curvature to join the terminal branches of the right gastric artery (or pyloric artery).• Other branches
The left gastric artery gives off several branches:1. the hepatic artery (present and functional in 30% of cases);
2. the anterior and posterior cardioesophageal arteries (that supply the cardia and abdominal esophagus).
• Right gastric artery
• Origin
The right gastric artery usually originates from the common hepatic artery.• Variations
Alternatively, it originates directly from:1. the gastroduodenal arteries;
2. the left hepatic artery;
3. the proper hepatic artery.
• Vascular arch
The right gastric artery approaches the pylorus, giving off one of its main terminal branches. It then divides into anterior and posterior gastric branches that join the terminal endings of the left gastric artery at the level of the angulus, the junction between the horizontal and vertical regions of the stomach.The right and left gastric arteries comprise the vascular arch of the lesser curvature.
• Gastroduodenal junction
The free duodenum is vascularized by branches mainly originating from the gastroduodenal artery.6. Greater curvature
• Definition
The greater curvature of the stomach is bordered by the greater omentum and gastrosplenic ligament. Each is composed of 2 layers in continuum with the gastric visceral peritoneum. The greater omentum spreads over the transverse colon and extends beyond it inferiorly at the level of the body and horizontal region of the stomach where it forms the gastrosplenic ligament at the level of the fundus. The right and left gastroepiploic arteries and the short gastric vessels form the vascular arch that runs through the anterior fold of the greater omentum.• Right gastroepiploic artery
The right gastroepiploic artery:1. originates from the division of the gastroduodenal artery at the inferior aspect of the duodenum;
2. runs along the greater curvature of the stomach from right to left at an average distance of 1 cm;
3. the branches originating from the right gastroepiploic artery run along the anterior and posterior aspects of the stomach and into the omentum.
• Left gastroepiploic artery
The left gastroepiploic artery originates from the division of the splenic artery. It supplies the middle part of the greater curvature and runs through the gastrocolic ligament to join the terminal branches of the right gastroepiploic artery.The right and left gastroepiploic arteries thus form the vascular arch of the greater curvature.
• Short gastric vessels
The short gastric vessels originate from the terminal branches of the splenic artery.Alternatively, they originate directly from the trunk of the splenic artery or from its terminal branches.
There are 2 to 6 vessels that run from the splenic hilum to the stomach via the gastrosplenic omentum.
The largest vessel - the posterior gastric artery - joins the posterior aspect of the stomach and divides to supply the fundus and the cardia.
• Vascular window
An avascular window consisting of 2 peritoneal folds is situated between the last short gastric vessel and the origin of the left gastroepiploic artery. These peritoneal folds split to form the omental bursa opposite the splenic artery.7. Indications
There are few indications for this type of resection, due to the major risks involved: removal of the pylorus and the resulting close proximity of the esophagus and duodenum cause bile reflux, which can lead to peptic esophagitis.For this reason, the indications for these procedures are debatable.
8. Operating room set-up
• Patient
The operation is performed under general anesthesia.The patient is supine. A single dose of systemic antibiotic prophylaxis is administered.
A nasogastric tube is inserted to fully decompress the stomach.
Padding (preferably inflatable) is set underneath the patient to obtain better exposure of the intra-abdominal anatomy. The operating table may be bent posteriorly at the level of the inferior angle of the scapula in order to obtain the same result. This angle must be straightened before parietal closure, at the end of the procedure.
• Team
1. The surgeon stands on the patient’s right.2. The first assistant stands opposite the surgeon.
3. The second assistant stands on the surgeon’s left.
4. The scrub nurse stands opposite the surgeon and on the first assistant’s left.
5. The anesthesiologist is at the head of the patient.
• Equipment
1. Anesthetic equipment2. Electrocautery
3. Operating table
4. Instrument table
9. Surgical approach
• Midline incision
The objective is a wide exposure of the stomach.The midline incision extends from the xiphoid process to the umbilicus.
The upper part of the abdominal incision extends to and exposes the xiphoid process and provides good visualization of the upper part of the stomach. In obese patients, the inferior part of the abdominal incision extends slightly to the left of the umbilicus. The round ligament is not disturbed, to facilitate exposure.
The parietal wall is protected using a plastic wound protector and a Gosset abdominal wall retractor is inserted.
Subcostal retraction is not necessary.
• Horizontal incision
A horizontal bilateral subcostal incision can also be used.10. Gastrectomies/principles
Tumors are resected with a minimum effective safety margin preserving the gastric pouch as far as possible. Usually at least one of the gastric curvatures is preserved to ensure a good vascular supply.The use of linear staplers make this a safe and rapid procedure.
11. Proximal gastrectomy
• Mobilizing the stomach
• Preservation/ gastroepiploic arteries
It is possible to create a gastric tube by resecting the lesser curvature and the superior part of the greater curvature.The left and right gastroepiploic arteries and their interconnecting vascular arcade on the greater curvature are preserved as this ensures adequate blood supply to the remaining stomach.
• Mobilization/ greater curvature
Short gastric vessels are ligated.• Ligation/ left gastric artery
The left gastric artery is ligated at its origin.• Mobilization/ esophagus
The distal esophagus is dissected and prepared before division is started.• Gastrectomy
• Linear stapler
The lesser curvature of the stomach is resected with successive stapling (several cartridges of the linear stapler) and division. The staple line is buried with a running suture.1. Staple line
• Division/ esophagus
The intra-abdominal part of the esophagus is divided and a purse string suture fashioned.2. Division of the esophagus
• Anastomosis
The anvil of a circular stapler is introduced into the esophagus and the purse string is closed around it.The gastroesophageal anastomosis is completed with the circular stapler prior to the final division of the resected specimen with a final line of linear staples. A pyloroplasty completes the procedure to prevent problems with gastric emptying.
12. Modified resections/stapling device
Any wedge-shaped resection performed with the use of one or several firings of the linear stapler permits the removal of a part of the gastric wall.The preservation of an intact vascular pedicle to the stomach is the only rule when resections are performed.
Note
The lesion may be localized with intraoperative endoscopy in order to preserve as much of the vascular supply of the gastric wall as possible.
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