COMPREHENSIVE ATLAS OF SURGICAL TECHNIQUES
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The stomach is approached with a supraumbilical incision.
The mobilization of the stomach starts at the lower part of the greater omentum. The latter is opened beyond the gastroepiploic arcade. The epiploic then the gastrosplenic vessels are ligated. At that stage the left crus of the diaphragm can be sectioned.
The right part of the greater omentum is opened unto the pylorus then the smaller omentum. The posterior wall of the stomach is freed from adhesions with the pancreas and the right crus is cut.
The Kocher maneuver.
A: The retroperitoneum is cut in front of the right kidney.
B: The duodenopancreatic block is elevated and can be held in the left hand.
C: At the end of the maneuver the duodenum can be retracted on the left thus discovering the IVC and abdominal aorta.
A: The left gastric artery is ligated at its origin from the celiac axis.
B: At this stage the D2 lymphatic dissection can be carried out from the common hepatic artery to the celiac axis. The hepatic and splenic arteries are freed from any lymphatic content on the spine of the pancreas. The posterior limit of the dissection is the nervous celiac plexus.
Pyloroplasty: the pylorus is sectioned longitudinally and sutured transversally with slow resorbing separated stitches.
The hiatus is manually enlarged for the upward gastric passage. At the end of the gastric mobilization the pylorus can be brought to the esophageal hiatus.
A: The stomach is stapled from the angle of the smaller curvature.
B: It is tubulized along the greater curvature so as the lengthen the stomach and to allow an easy ascent in the right pleural cavity.
The abdomen is closed leaving a Jackson-Pratt drain at the hiatus.
The patient is placed in left lateral decubitus for the posterolateral thoracotomy.
The thoracotomy is performed in the 5th intercostal space. The right lung is retracted anteriorly. The esophagus is located on the anterior aspect the spine and the parietal pleura is opened between the azyos vein and the diaphragm. It must stay attached with the esophagus and will be removed with it as well as the fat and lymphatic tissue around it. At this thoracic level the pneumogastric nerve often presents as a plexual structure. The thoracic duct, posterior to the esophagus is ligated.
The esophagus is dissected free in the cephalic direction. The pneumogastric nerve is clipped. The azygos vein is interrupted and hemostasis of stumps is performed with two running 5-0 Prolene R sutures. The descending aorta is now palpable and visible.
The posterior aspect of the tracheal bifurcation is prepared and the intertracheobronchial lymphatic tissue is completely removed with perfect hemostasis of the small bronchial arteries nourishing it. The right bronchial artery (not represented) from intercostal origin and vascularizing the middle part of the oesophagus is also ligated.
A: At the chosen level for the esophagogastric anastomosis the esophagus is transversally transected on its anterior aspect, a purse-string is started and the esophageal section is spread with fine forceps. The anvil of the circular stapler is introduced proximally. The posterior wall is cut and the purse-string is completed. The purse-string is tight around the axis of the anvil. The alternative is to place the purse-string with the automatic stapler, cut the esophagus below the purse-string, spread the proximal esophageal stump and introduce the circular anvil.
B: The anterior wall of the proximal stomach brought into the right chest is opened and the circular stapler introduced. Its axis perforates the upper posterior wall. The stapler is closed and fired. The stapler is removed and the donouts are verified.
The stomach is stapled proximal to the esogastric anastomosis with TAR linear device. The specimen is removed.
The stomach is sutured with 3 stitches to the prevertebral fascia in order to keep the esophago-gastric anastomosis without tension.
The right thoracotomy is conventionally closed on a 28-French chest tube.