Distal Gastrectomy

In general perform a laparoscopy first if cancer operation. No need if if clear indication for palliative resection ie bleeding etc.

Resection provides better relief for obstruction than bypass

Distal gastrectomy for benign disease (Bilroth I or II)
1.Supine position
2.Upper midline incision. (Consider rooftop if wide xiphisternal angle)
Thorough laparotomy
3.Incise the gastro-hepatic omentum and place a hand behind the antrum to lift it off the mesocolon and the middle colic artery. The plane is easier to find on the left
4.Begin to mobilize the antrum by dividing the branches of the right gastro-epiploic as close to the anterior surface of the pancreas as possible (so as to include the infrapyloric nodes) staying within the arcade for its preservation up to a point half way up the stomach. The left side of the omentum is separated from the spleen dividing the gastrosplenic ligament including the left gastro-epiploic vessels
5.Divide the left gastric artery about halfway along the lesser curve leaving a stump of the left gastric artery at least 1cm in length (a small accessory left hepatic artery may be ligated, but a larger one may need preserving to prevent hepatic necrosis. Lesser omentum is divided along the left side of the hepatoduodenal ligmaent.
6.At the proximal margin, divide the stomach using a GIA80 (4.8mm staples) stapler over the right half and between two Allen clamps over the left half, the length of which is the approximate diameter of the duodenum. Make sure you have withdrawn the NGT prior to division. Oversew the staple line or hand sew the whole thing if thickened.
7.Identify and ligate the right gastric artery from the anterior aspect where it originates from the proper hepatic artery. Reflect antrum rostral and to the left. Do not divide short gastrics along proximal greater curvature.
8.Apply traction on the specimen to display the posterior wall of the duodenum and dissect out 1.5cm to allow anastomosis. There are often some vessels coming up from the pancreas that will require ligation.
9.To perform a Bilroth I anastomosis, divide the duodenal resection margin between Allen clamps and fashion an end to end hand-sewn anastomosis using 3/0 PDS if there is at least 1.5cm of duodenum to suture to.
10.To perform a Bilroth II (Polya), use a TA60 (3.5mm staples) to divide the duodenal resection margin and perform a gastro-enterostomy using a retrocolic (may also be antecolic, but limb will need to be longer) loop no more than 15cm from the ligament of Trietz in two layers using 3/0 PDS in the standard manner. Advance the NGT down the afferent limb (one book says don't need to do this). Oversew the previous staple line and re-inforce the angle of sorrow.(this is the angle of the lesser curvature which is prone to ischaemia. Note Hofmeister variation (only anastomosing jejunum to greater curvature half of stomach of Bilroth II (Polya) picture above.
11.Oversew and drain the duodenal stump, lavage and close.


Subtotal or distal gastrectomy for malignancy (Bilroth II or Polya)
1.Conduct a laparotomy and confirm resectability.
2.Start with mobilizing the greater omentum off the transverse colon (the blood supply of the gastric remnant is to be from the short gastric arteries). Can either take the omentum or not: no difference has been shown in recurrence. The right gastro-epiploic artery is divided at its origin while sweeping all nodes towards the specimen. Similarly ligate the left gastroepiploic artery while mobilizing the left side of the greater omentum along the line of gastric transection.
3.Lift the stomach upwards and to the right to identify the left gastric artery and the adjacent coronary vein at the top end of the lesser curvature via the undersurface. Doubly ligate this with vicryl and divide. All nodal tissue is not only swept upwards towards the specimen, but if involved followed to the celiac nodes. Can then skeletonise the coeliac, splenic and common hepatic artery to perform D2 lymphadenectomy. This also involves dissecting the proximal lesser omentum to harvest the right cardia nodes.
4.Replace the stomach down and incise the lesser omentum down to the pylorus. Identify the ascending branch of the left gastric artery and ligate it at the cardia.
5.Extend the incision over the left gastric artery along the hepatic artery in the posterior wall of the lesser sac in order to identify the origin of the right gastric artery. Ligate and divide the right gastric artery.
6.Perform a Kocher maneuver and mobilize the duodenum off the pancreas for a distance of 5cm.
7.Use a TA60 stapler or scalpel between Allen clamps to divide across D1 and a GIA80 (4.8mm staples) to divide across stomach having withdrawn the NGT. Consider frozen section to ensure tumour margins clear. 5cm proximal margin for cancers. 5cm distal margin not always possible.
8.Reconstruct using a handsewn Bilroth II gastrojejunostomy with 3/0 PDS (or a stapled gestro-enterostomy using the GIA80 and oversew the staple line using 3/0 PDS) using an antecolic roux loop. May need to re-inforce the angle of sorrow.
9.Feed a nasogastric tube down the afferent limb of the gastroenterostomy prior to completing the anastomosis as far as possible to drain the duodenal stump. Lavage, drain and close.

Post op care
NG out on first or second day
Evidence that oral (500-750mcg) B12 is sufficient
Need iron replacement
Adjuvant chemotherapy should be considered routinely
No advantage to frequent follow up to detect recurrence
CT when symptomatic
Gastroscopy for stump cancer in long term survivors

Principles
Inspect posterior surface of stomach before ligating an vessels to confirm resectability