Total Gastrectomy with Radical Systemic Lymphadenectomy (Japanese Procedure)
Mitsuru Sasako
Introduction
Historically, total gastrectomy with radical lymphadenectomy included distal
pancreatectomy and splenectomy and was favored by Brunschwig in 1948. Maruyama modified this procedure by preserving the distal pancreas, so-called pancreas preserving radical total gastrectomy. His initial report was published in Japanese in 1979. Initially he ligated both the splenic artery and vein near their origin, which often caused major congestion of the pancreas tail followed by massive necrosis. The first available English report was published in 1995 and described a modified technique of the original version.
There he obtained the splenic vein up to the tip of the pancreas tail to preserve venous return.
The technique of pancreas preserving total gastrectomy with radical systemic lymphadenectomy (D2) by preserving the splenic artery and vein as far as the branching-off of the major pancreatic artery (Sasako’s modification) is described.
Indications and Contraindications
Indications
■Gastric carcinoma (T2–T4, M0) involving the upper third of the stomach
Contraindications
■By invasion of the pancreas body or tail or macroscopically evident lymph node metastasis at the splenic artery, an extended total gastrectomy with pancreatico- splenectomy (en bloc resection) should be performed.
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Invasion of the distal esophagus
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Distant metastasis
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Severe cardiopulmonary insufficiency (relative)
Preoperative Investigations/Preparation for the Procedure See chapter on “Total Gastrectomy with Conventional Lymphadenectomy.”
Procedure
Access
Upper median incision or upper transverse incision with median T-shaped extension.
STEP 1 Exposure
Laparotomy and inspection are performed of the peritoneum, liver and, after mobiliza- tion of the duodenum by the Kocher maneuver, the para-aortic area. After cytological washings out of the Douglas space, one or two Kent type retractors with one or two octopus retractors are inserted for best overall view of the epigastric region, especially the diaphragmatic esophageal hiatus. Excision of the ensisternum is recommended.
Steps of the preparation of the gastrectomy are described in the chapter “Total
Gastrectomy with Conventional Lymphadenectomy.”
STEP 2 Omentectomy
The transverse mesocolon is stretched by the second assistant. Dissection of the greater omentum together with the posterior wall of the omental bursa is performed.
It is compromised by two membranes, one continuing to the anterior pancreatic capsule
and the other to the posterior duodenopancreatic fascia. Diathermy allows bloodless
transection.
STEP 3 Dissection of infrapyloric lymph nodes
Following the right accessory vein, Henle’s surgical trunk can be found. The origin of the
right gastroepiploic vein is ligated. Before going on to the third step, the dissection plane
should be changed from the posterior to the anterior capsule of the pancreas.
STEP 4 Ligation and division of the right gastroepiploic artery
By dissection of the anterior capsule of the pancreas towards the duodenum, the gastroduodenal artery appears on the anterior surface of the pancreas neck. Following this artery caudally, the origin of the right gastroepiploic artery can be found. After its ligation and division, the gastroduodenal artery should be followed cranially up to the bifurcation of the common hepatic artery.
STEP 5 Division of the lesser omentum
Close to the left liver lobe, the lesser omentum is divided from the left edge of the
hepatoduodenal ligament towards the esophagus.
STEP 6 Division of the right gastric artery
The lesser omentum is incised along the hepatoduodenal ligament up to the left side of the common bile duct and caudally to the duodenum. After ligation and division of the supraduodenal vessels, the gastric artery clearly displays in the ligament.
The tissue defined by this incision is dissected from the proper hepatic artery and
swept across to the patient’s left. The gastroduodenal artery is followed to its junction
with the proper hepatic artery, and the latter is cleaned until the origin of the right
gastric artery is found and ligated. The dissection to the left of the hepatoduodenal liga-
ment should go deeper than the proper hepatic artery and clear the nodes from the left
side of the portal vein.
STEP 7 Dissection of suprapancreatic nodes
Along the superior border of the pancreas the adipose tissue contains many lymph nodes. It is divided from the pancreas and the surface of the common hepatic, splenic, and celiac arteries. These arteries are surrounded by thick nerve tissue. It should be preserved in case of no adherence of suspect lymph nodes. The left gastric vein is visible and therefore ligated and divided. Caudally it crosses the origin of either the common hepatic or splenic artery before entering the splenic vein in about 30–40% of patients.
In the majority the left gastric vein passes obliquely behind the hepatic artery to join the junction of the splenic and portal veins.
STEP 8 Dissection around the celiac artery and division of the left gastric artery
The celiac artery is covered by the celiac plexus. All the tissue around these nerve
structures is dissected to visualize the celiac and left gastric artery. Ligation and
division of the left artery are performed near its origin.
STEP 9 Mobilization of the pancreas body/tail and the spleen
View from the patient’s feet. To carry out the dissection of the splenic artery and hilar
lymph nodes, the pancreas body/tail and spleen should be mobilized from the retroperi-
toneum, beginning at the pancreas body from the inferior towards the superior border
and then towards the tail and spleen. After total mobilization of the spleen, the retroperi-
toneum is incised lateral of the spleen and divided. The pancreas body/tail and spleen
are now completely mobilized for a meticulous dissection of lymph nodes around the
pancreas tail.
STEP 10 Division of the splenic artery
The splenic artery is divided near its origin but more distal in contrast to Maruyama’s procedure after branching-off of the great pancreatic artery in Sasako’s modification.
Sometimes preservation of the tail artery is possible.
STEP 11 Dissection of the splenic artery nodes
The distal portion around the splenic artery is removed from the anterior and posterior
way. To avoid venous congestion, the splenic vein should be preserved as distal as
possible. If there is a pancreas tail vein at the tip, it should also be preserved.
See chapter “Total Gastrectomy with Conventional Lymphadenectomy” for postoperative investigations and complications.
Tricks of the Senior Surgeon
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Avoid transecting the postpyloric duodenum to close to the pancreatic capsule, disabling oversew of the duodenal stump.
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