Laparoscopic Gastric Resection



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 unproven.

References at the end of this chapter give details of alternative approaches, including hand-assisted techniques and totally intracorporeal anastomoses.

SCORE™, the Surgical Council on Resident Education, did not classify laparoscopic gastric resection.

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 the 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 arteries and veins


  • Short gastric vessels


  • Spleen


  • Pancreas


  • Gastropancreatic folds



Laparoscopic Gastric Resection—Mobilizing the Stomach (Fig. 64.1)


Technical and Anatomic Points

The extent of resection will determine the amount of mobilization required. Trocar sites are shown in Figure 64.1A.

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 (Figure 64.1B; see also Figure 85.1B in Chapter 85). Enlarge this window proximally and distally to mobilize fully the greater curvature of the stomach (Fig. 64.1C). Elevate the stomach and sharply divide the avascular gastropancreatic folds.

Open the avascular portion of the lesser omentum (Fig. 64.1D). Pass a short segment of Penrose drain into the abdomen. Pass it through the windows in the greater and lesser omenta, behind the stomach, and use this as a sling to elevate and retract the stomach atraumatically (Fig. 64.1E).

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Sep 14, 2016 | Posted by in GENERAL SURGERY | Comments Off on Laparoscopic Gastric Resection

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