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Minimally Invasive Total Gastrectomy

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Surgery for Cancers of the Gastrointestinal Tract

Abstract

The role of minimally invasive surgery for total gastrectomy is not well-established. This chapter describes the technical aspects of laparoscopic and robotic approaches for total gastrectomy for gastric cancer and discusses considerations regarding the learning curve and patient selection. The chapter also summarizes the current literature on minimally invasive approaches to total gastrectomy with focus on technique, outcomes, and cost.

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References

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Author information

Authors and Affiliations

  1. Division of Surgical Oncology, Thornton Hospital and Moores Cancer Center, University of California, San Diego, 3855 Health Sciences Drive, Mail Code 0987, La Jolla, CA, 92093, USA

    Kaitlyn J. Kelly M.D.

  2. Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA

    Vivian E. Strong M.D., F.A.C.S.

  3. Weill Medical College of Cornell University, 525 East 68th Street, New York, NY, 10065, USA

    Vivian E. Strong M.D., F.A.C.S.

Authors
  1. Kaitlyn J. Kelly M.D.
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  2. Vivian E. Strong M.D., F.A.C.S.
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Corresponding author

Correspondence to Vivian E. Strong M.D., F.A.C.S. .

Editor information

Editors and Affiliations

  1. Division of Surgical Oncology, City of Hope, Los Angeles, California, USA

    Joseph Kim

  2. Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA

    Julio Garcia-Aguilar

Electronic Supplementary Material

Below is the link to the electronic supplementary material.

In this video, the surgeon demonstrates her approach to minimally invasive total gastrectomy for gastric carcinoma. (WMV 246,113 kb)

Key Operative Steps

Key Operative Steps

  1. 1.

    Explore abdomen for adhesions and peritoneal carcinomatosis. Ensure that 2–4 cm of adequate proximal margin can be obtained.

  2. 2.

    If the lesion cannot be appreciated on the extraluminal surface, perform intraoperative endoscopy.

  3. 3.

    Dock the robot.

  4. 4.

    Dissect the omentum from the colon in the avascular plane proceeding towards the splenic flexure and enter the lesser sac.

  5. 5.

    Grasp the posterior wall of the stomach and retract anteriorly and to the right. Ligate the short gastric vessels with energy sealant device up to the left crus.

  6. 6.

    Incise the peritoneum over the left crus and expose the posterolateral aspect of the esophagus.

  7. 7.

    Retract the stomach to the left side and proceed with omentectomy towards the hepatic flexure. Place fully mobilized omentum in the left upper quadrant.

  8. 8.

    Divide the posterior attachments between the stomach and the pancreas sharply or with an energy sealant device.

  9. 9.

    Dissect the right gastroepiploic vessels at the level of the superior border of the pancreas near the point of origin from the gastroduodenal vessels. The linear stapler can be used for this maneuver.

  10. 10.

    Incise the gastrohepatic attachments near the suprapyloric region. Identify and ligate the right gastric artery.

  11. 11.

    Dissect the lymphatic tissues along the proper hepatic and common hepatic artery towards the specimen creating a window at the level of the pylorus.

  12. 12.

    Mobilize the posterior aspect of the pylorus and proximal duodenum and divide the duodenum with a linear stapler. Use a bioabsorbable staple line reinforcement.

  13. 13.

    Continue dissecting lymphatic tissues toward the celiac axis and proximal splenic artery.

  14. 14.

    Identify and ligate the left gastric vein and artery. Dissect all lymphatic tissues with the specimen.

  15. 15.

    Further incise gastrohepatic attachments to the level of the esophageal hiatus. Level 1 and 3 lymph nodes are dissected with the proximal stomach up to the right crus and esophagus.

  16. 16.

    Mobilize distal esophagus and divide it with a linear stapler.

  17. 17.

    Place specimen in a specimen bag and remove via the umbilical port site.

  18. 18.

    A Roux limb is prepared 30–40 cm downstream from the ligament of Treitz. Transect jejunum with a linear stapler.

  19. 19.

    Create jejunojejunostomy 60–70 cm downstream from the transected jejunum.

  20. 20.

    Perform esophagojejunostomy with a transoral anvil device and a circular stapler.

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Kelly, K.J., Strong, V.E. (2015). Minimally Invasive Total Gastrectomy. In: Kim, J., Garcia-Aguilar, J. (eds) Surgery for Cancers of the Gastrointestinal Tract. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-1893-5_8

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  • DOI: https://doi.org/10.1007/978-1-4939-1893-5_8

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  • Publisher Name: Springer, New York, NY

  • Print ISBN: 978-1-4939-1892-8

  • Online ISBN: 978-1-4939-1893-5

  • eBook Packages: MedicineMedicine (R0)

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