Total gastrectomy

ANATOMY
5cm margin from palpable edge of tumour
6cm margin if penetrated serosa
Total gastrectomy if within 7cm of GE junction (8 cm for serosa +ve)
D2 gastrectomy includes perigastric nodes and nodes along the main arteries of the stomach

PROCEDURE
Book Walter
Upper midline
Divide gastrocolic omentum diathermy (the bloodless plane between omentum and bowel will be about 1 cm from colon.
Mobilise splenic flexure and divide all adhesions between omentum and spleen so that capsule is not torn during dissection
Divide short gastrics: 2-0 vicryl tie loaded on roberts. Right angles to dissect and clamp vessels esp in LUQ near spleen
Divide lesser omentum along line of reflection of the liver capsule.
Divide right gastric (often insubstantial)
GIA 55 linear cutter stapler to 1st part of duodenum. Invert with seromuscular interrupted sutures
Divide left gastric: suture ligate
Mobilise oesophagus
Mobilise Roux loop: linear cutter stapler: can take loop retro or antecolic.
(Andrew Lowe: functional side:side anastomosis by making jejunotomy 5cm from end and oesophagotomy. Jejunal limb lies posterior then longitudinal linear cutter to anastomose. Close with 3-0 maxon interrupted.
End-side enterenterostomy 45cm down jejunum
Feeding jejunostomy