Subtotal Gastrectomy with D2 Nodal Dissection, Roux-en-Y Reconstruction for Cancer

Abstract

Indication • Carcinoma of the distal stomach Essential Steps 1. Make an upper midline incision. 2. Explore the abdomen. Confirm pathology and stage. 3. Separate the greater omentum from the transverse colon. 4. Infrapyloric nodal dissection and ligation of the right gastroepiploic vessels. 5. Suprapyloric nodal dissection and ligation of the right gastric vessels. 6. Divide the duodenum. 7. Dissect nodes along the common hepatic artery. 8. Dissect nodes around the celiac axis and the proximal splenic artery. 9. Ligate the left gastric artery at the celiac axis. 10. Dissect nodes along the lesser curvature toward GE junction. 11. Ligate the left gastroepiploic vessels. 12. Dissect nodes along the greater curvature. 13. Pull the nasogastric tube back into the distal esophagus. 14. Divide stomach at least 3 cm from the tumor for differentiated carcinoma or 5 cm for poorly differentiated carcinoma. 15. Trace jejunum to the ligament of Treitz; identify a mobile loop of the jejunum close to the ligament of Treitz. 16. Divide loop of the jejunum with a linear stapler. 17. Pass the distal jejunum antecolic/retrocolic for Roux-en-Y reconstruction and place adjacent to the gastric remnant. 18. Create gastrojejunal anastomosis. 19. Create a stapled jejunojejunostomy. 20. Check hemostasis. 21. Position nasogastric tube. 22. Close the abdomen without drainage. Note These Variations • Stapled or sutured duodenal stump closure • Stapled or sutured gastrojejunostomy • Billroth I or Billroth II reconstruction • En bloc resection of contiguous structures