COMPREHENSIVE ATLAS OF SURGICAL TECHNIQUES
The tumor is represented on the smaller curvature of the stomach.
The greater omentum is elevated from pylorus to esophageal hiatus opening the omental bursa.
The duodenum is tranversally stapled.
The smaller omentum is now opened along its hepatic insertion. The celiac axis is exposed and and the left gastric artery is ligated at its origin.
The stomach is now completely mobilized. The abdominal esophagus in transversally opened on its anterior circumference and a pursestring running suture is started on this cut border. The anvil of the circular stapler is introduced in the distal esophagus.
The section of the esophagus is completed. The stomach is removed and the pursestring is applied along this posterior border of the sectioned esophagus. The pursestring is tight.
Situation after specimen removal.
The D2 lymphatic dissection is carried out. It starts along the vertical portion of the common hepatic artery, clears the tissue surrounding the middle hepatic on the spine of the pancreas and reaches the celiac trunk. It also can follow the splenic artery to retrieve a maximal number of nodes and thus has a therapeutic value and is not only a sampling maneuver.
Hunt-Lawrence reconstruction. The proximal jejunum is stapled and the distal loop is brought in the upper mesocolic space through the transverse mesocolon. An inverted U-shaped reservoir is contructed with the linear stapler.
The circular stapler is entered through the enterotomy and its axis perforates the tip of the reservoir on its antimesenteric side. The axis is solidarized with the anvil and the stapler is fired thus constructing the esophagojejunal anastomosis.
Sixty cm distal to this anastomosis the Roux-en-Y jejunojejunostmy is carried out and the transverve mesocolon is loosely closed arounf the efferent loop leaving only the reservoir in the upper mesocolic space.
The abdomen is closed on a Jackson-Pratt drain.