total gastrectomy

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This operation is usually carried out for unresectable gastric carcinoma and as such it requires en bloc removal of stomach, spleen, greater omentum, body and tail of pancreas. After gaining abdominal or abdomino-thoracic access, the surgeon first assesses the operability of the situation: for example, widespread peritoneal seedlings would dissuade from continuation.

The greater omentum is first dissected away from the transverse colon and the duodenum is freed from its retroperitoneal covering. The right gastric artery is identified and divided. The duodenum is transected near the pyloric region and its stump is sewn over. A careful dissection is then made in the region behind the spleen - it is reflected forwards and its vessels are ligated. The lymph nodes in the coeliac axis are located and mobilised.

The pancreas is cleanly divided. Its duct should become visible and it is ligated to prevent leak of secretions. Now visible posteriorly, the left gastric artery is divided and ligated. The stomach is then resected from the oesophagus with an adequate margin of normal tissue. The en bloc mass of tissue with the stomach at its centre is then removed from the abdomen.

To reconstruct, the jejunum is assessed for a suitable section near to the duodenojejunal flexure. Its blood supply is pruned so as to permit mobilisation, and it is transected. A Roux-en-Y loop is formed between the proximal end and the side of the distal end. Finally, the distal section of the jejunum is sutured to lower end of the oesophagus, either by hand or by stapling machine. This type of procedure reduces the incidence of bile and pancreatic relux into the duodenum.

Oral solids are resumed over approximately a week in the presence of normal bowel function. Subsequently, frequent small meals high in protein and vitamin B12 are advised.

Last reviewed 01/2018

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