Laparoscopic Gastric Resection
Laparoscopically assisted gastric resection is used for benign disease or for palliation of malignancy. The laparoscopic portion may be limited to mobilization, with an extracorporeal anastomosis. Although totally intracorporeal anastomotic techniques are certainly feasible, difficulties with function and the need to create an incision to remove the specimen have rendered these less desirable alternatives, particularly after subtotal resection. In this chapter, laparoscopic subtotal gastrectomy with standard (open) reconstruction and laparoscopic total gastrectomy with intracorporeal anastomosis are described. Considerations of extent of resection, whether or not to resect omentum with the stomach, and type of reconstruction should not be altered by the use of a laparoscopic technique. Laparoscopic node dissection has also been described, but the use of laparoscopic gastrectomy for cure of gastric cancer is as yet unproved.
References at the end of this chapter give details of alternative approaches, including hand-assisted techniques and totally intracorporeal anastomoses.
Steps in Procedure
Obtain laparoscopic access and explore abdomen
Fully mobilize greater curvature by dividing gastrocolic omentum
Elevate stomach and divide gastropancreatic folds
Open avascular portion of lesser omentum and pass short segment of Penrose drain around stomach
Continue dissection proximal and distal, dividing vessels as needed
Mobilize pylorus and divide duodenum just distal to pylorus with endoscopic cutting linear stapler
If Subtotal Gastrectomy:
Divide proximal stomach with endoscopic linear stapler
Make a small midline or left paramedian incision to remove stapler and complete reconstruction in standard open fashion
If Total Gastrectomy:
Incise peritoneum over distal esophagus and mobilize
Divide short gastric vessels
Divide esophagus and remove specimen (as noted before)
Perform stapler reconstruction in usual fashion
Close Small Incision and All Trocar Sites Greater Than 5 mm
Hallmark Anatomic Complications
Injury to bowel or viscera
Inadequate resection
List of Structures
Esophagus
Stomach
Greater curvature
Lesser curvature
Pylorus
Duodenum
Greater omentum
Lesser omentum
Left gastric artery
Left and right gastroepiploic artery and vein
Short gastric vessels
Spleen
Pancreas
Gastropancreatic folds
Laparoscopic Gastric Resection—Mobilizing the Stomach (Fig. 55.1)
Technical and Anatomic Points
The extent of resection will determine the amount of mobilization required. Trocar sites are shown in Fig. 55.1A.
Begin by mobilizing the greater curvature. Elevate the stomach with an atraumatic grasper and divide branches of the gastroepiploic vessels along the greater curvature to create a window into the lesser sac (Fig. 55.1B; see also Fig. 72.1B in Chapter 72). Enlarge this window proximally and distally to mobilize fully the greater curvature of the stomach (Fig. 55.1C). Elevate the stomach and sharply divide the avascular gastropancreatic folds.
Open the avascular portion of the lesser omentum (Fig. 55.1D). Pass a short segment of Penrose drain into the abdomen. Pass it through the windows in the greater and lesser omentum, behind the stomach, and use this as a sling to elevate and retract the stomach atraumatically (Fig. 55.1E).
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