Total Gastrectomy

1.Prep and square drape, ensure NGT
2.Upper midline incision
3.Place a fixed retractor such as omnitract to aid in retraction of the liver. You may need to mobilise left lobe of liver by dividing the left triangular ligament
4.Conduct a laparotomy to confirm resectability.
Place a pack behind the spleen to bring it forward and help mobilise the spleen
5.Dissect the greater omentum off the transverse colon in order to include it with the specimen. At this point inspect the posterior surface of the stomach to ensure resectability.
6.Divide the gastro hepatic ligament to enter into the lesser sac of the abdomen and double ligate the right gastric artery sweeping nodes en bloc with the stomach.
7.Perform a truncal vagotomy (legacy). This is performed by incising the peritoneum over the abdominal oesophagus and identifying the crura. Insert your right finger aroung the back of the oesophagus to encircle it. There are often 1-2 anterior vagal (left) trunks. Divide and ligate these between artery forceps. The posterior vagal trunk is identified by encircling the oesophagus deeply across the front of the aorta to the deep surface of the right crus and then flexing the finger around. The posterior trunk should then be contained (i.e. it is often much posterior to the right surface of the oesophagus). It can also be found by inserting a finger above the left gastric artery and drawing it downwards, pulling the posterior vagus taut. A selective vagotomy (legacy) refers to a vagotomy just beyond and conserving the hepatic branch of the vagus. A highly selective vagotomy (legacy) refers to selective division of all the vagal branches to the stomach along with the branches of the left gastric artery, barring those to the distal antrum and pylorus. You need to identify the crow’s foot to determine the correct level. Pay attention to the criminal nerve of Grassi, which is a branch given off from the posterior vagus higher to the posterior cardia. Oversew the gastric lesser curve if performing a selective vagotomy only. Send a segment of the nerves for histological confirmation in order to confirm vagotomy. An endoscopic congo red test can also be performed by administering SC pentagastrin and 20 min later lavaging the stomach with 200ml congo red (vagally innervated parietal cells will turn black).
8.Divide the gastrosplenic ligament, the short gastric and left gastro-epiploic vessels.
9.Lift the stomach upwards to gain access to its posterior wall and divide the right gastro-epiploic vessels between it and the pancreas.
10.Divide the left gastric artery at its origin as well as its ascending branch to completely devascularize the stomach.
11.Divide the distal resection margin (duodenum) with a TA60 (3.5mm staples) linear stapler/scalpel division on the proximal side between an Allen clamp (this is aided by partially Kocherizing the duodenum that may also require mobilizing the hepatic flexure). Divide the proximal resection (having withdrawn the NGT) similarly between a TA60/right angled clamp with scalpel division on the proximal side of the stapler. You may re-inforce the duodenal stump closure with 3/0 PDS.
12.Place a pursestring at the distal oesophagus of 3/0 PDS and secure the anvil of a CEEA 28mm circular stapler
13.Create a roux limb by division of jejunum between a TA60/Allen clamp (dividing the bowel distal to the stapler and bring it up in an antecolic fashion.
14.Insert the circular stapler through the open cut end of the roux limb after placing a soft bowel clamp distally on the roux limb and fashion an end to side oesophago-jejunal anastomosis. Use a linear stapler to resect the redundant jejunum to complete the anastomosis. Oversew all staple lines with 4/0 PDS. A hand sewn end to end anastomosis can also be fashioned using interrupted 3/0 PDS. Place the posterior wall sutures first and parachute them down, then tie, completing the anterior layer subsequently. Be sure to pass a nasogastric tube down to the jejunum across the anastomosis.
15.Place soft bowel clamps at the site of intended jejuno-jejunal anastamosis (ensuring a 75cm roux limb). Create an end to side anastomosis using interrupted 4/0 PDS.
16.Haemostasis, drain the duodenal stump and oesophago-jejunal anastomosis.
17.Closure with 1/0 nylon and staples.

Complications
Early HIDA (Overall per-operative mortality 5-10% with an overall 50%5YS)
1.Haemorrhage
2.Intra-abdominal sepsis
3.Duodenal stump leak
4.Anastomotic leak

Late post-prandial sequelae SDHDB
1.Satiety
2.Dumping
3.Hypoglycaemic attacks
4.Diarrhoea VDOS due to vagotomy (mechanism unknown), as part of a dumping syndrome, bacterial overgrowth, steatorrhoea.
5.Bilious reflux.

Nutritional problems
1. Malnutrition
2. Specific deficiencies – Fe/Vit C supplements for 12 months, B12, Calcium (Vit D malabsorption) in post-menopausal and over 70