Upper GI

Total Gastrectomy (Laparoscopic)

OPERATION: Laparoscopic Total Gastrectomy with D2 Lymphadenectomy and Roux-en-Y Oesophagojejunostomy
ANAESTHETIC: General anaesthesia with epidural
ANTIBIOTICS: IV at induction
POSITION: Supine, split-leg position with footpads. Urinary catheter. VTE prophylaxis.

INDICATION:
Gastric adenocarcinoma [location, Siewert type if applicable]. Preoperative staging: CT [staging], EUS [uT / uN stage], PET [if advanced]. [Neoadjuvant chemotherapy completed]. Laparoscopic staging with peritoneal washings previously confirmed negative for metastatic disease.

PROCEDURE:
WHO Checklist performed. Abdomen prepared and draped.

PORT PLACEMENT:
Five ports inserted across the lower abdomen: four 5 mm ports and one 12 mm port. CO₂ pneumoperitoneum at 15 mmHg. Nathanson liver retractor placed via 3 mm sub-xiphoid stab incision. Patient placed in steep reverse Trendelenburg.

GREATER CURVATURE / OMENTECTOMY:
Greater omentum elevated cephalad. Lesser sac entered via superior border of transverse colon. Posterior gastric wall visualised. Complete omentectomy performed without injury to mesocolon or splenic flexure. Short gastric vessels divided with energy device, providing access to the splenic hilar nodes. Greater curve mobilised to the level of the left crus.

PYLORUS AND DISTAL DISSECTION:
Right gastroepiploic vessels identified and divided at their origin with a vascular stapling device after en bloc dissection of level 6 lymph nodes. Pylorus confirmed from anterior and posterior views. Duodenum cleared 2 cm distal to pylorus. Duodenum transected with blue load linear stapler.

VASCULAR LIGATION AND LYMPHADENECTOMY:
Right gastric artery identified and ligated at origin with en bloc resection of level 5 lymph nodes. Lesser curvature mobilised with en bloc pericardial (levels 1, 3) lymph nodes. Left gastric artery and coronary vein identified. Level 7, 8, 9 lymph nodes dissected en bloc. Left gastric vessels ligated with vascular stapling device / endoclips.

OESOPHAGEAL TRANSECTION:
Oesophageal margin confirmed under direct vision above the GOJ. Linear stapling device used to transect the oesophagus. Frozen section of proximal margin confirmed — [clear / tumour — further resection performed until clear].

Specimen (total stomach, omentum, en bloc lymph nodes) placed in large retrieval bag and removed through slightly enlarged 12 mm right lower quadrant port site.

RECONSTRUCTION — Roux-en-Y Oesophagojejunostomy:
Ligament of Treitz identified. Jejunum divided 30 cm distally with blue load stapler. Roux limb prepared — vessels transilluminated and divided, preserving vascular arch. Jejunojejunostomy (biliopancreatic limb to Roux limb) constructed 60–65 cm from the planned oesophageal anastomosis using a 6 cm blue load linear stapler, enterotomy closed with running 2-0 silk. Roux limb brought up antecolic to the oesophageal stump.

OESOPHAGOJEJUNOSTOMY:
25 Fr circular EEA anvil (Orvil) passed transorally via orogastric tube, advanced into oesophageal stump and brought into abdomen. EEA circular stapler introduced into Roux limb via enterotomy. Anvil and stapler connected. Anastomosis fired. Both donuts confirmed intact — sent to histopathology as new proximal margin. Roux limb enterotomy closed with linear stapler. Anastomosis reinforced with interrupted 2-0 silk sutures.

Final inspection. Liver retractor removed. 12 mm port fascia closed. Skin closed subcuticularly.

FINDINGS:
Gastric [tumour / adenocarcinoma] at [location]. R0 resection. Proximal margin: [clear on frozen section]. D2 lymphadenectomy performed. No peritoneal disease. Both anastomoses patent.

SPECIMEN: Total gastrectomy specimen with en bloc omentum and lymph nodes to histopathology. Oesophageal and duodenal donuts to histopathology.
EBL: [Volume] ml. COMPLICATIONS: None.

POST-OPERATIVE INSTRUCTIONS:
Extubated in theatre. PCA analgesia. Ice chips day 1. Sips of liquid day 2. Postgastrectomy diet introduced day 3–5 with nutritionist review. CT surveillance alternating with endoscopy at 6–12 month intervals. Follow-up 1–2 weeks.