Upper GI

Gastrectomy (Partial) (Open)

OPERATION: Partial (Subtotal) Gastrectomy (Open) with D2 Lymphadenectomy
ANAESTHETIC: General anaesthesia with epidural
ANTIBIOTICS: IV antibiotics at induction
POSITION: Supine. Urinary catheter. Nasogastric tube.

INDICATION:
Gastric carcinoma of the distal stomach, amenable to curative resection. Preoperative staging: CT, EUS, OGD. No evidence of peritoneal deposits, N3/N4 nodal involvement, or unresectable local invasion confirmed on staging.

PROCEDURE:
WHO Checklist performed. Long midline incision. [Xiphoid process excised if required]. Full exploratory laparotomy performed — pelvis, para-aortic nodes, root of mesentery, small and large bowel, liver, diaphragm, gallbladder, and upper abdomen systematically assessed. [Peritoneal washings taken.] Resection confirmed appropriate.

GREATER OMENTUM AND GASTROCOLIC DISSECTION (BURSECTOMY):
Greater omentum elevated and dissected from the transverse colon in the bloodless plane of fusion — anterior leaf of mesocolon preserved. Dissection continued to upper border of the pancreas, lifting the posterior peritoneum off the anterior surface of the pancreas to reach the coeliac axis.

VESSEL LIGATION AND LYMPHADENECTOMY:
Left gastroepiploic vessels isolated and doubly ligated and divided at their origin — level 4 nodes included. Right gastroepiploic vessels isolated and divided at origin — subpyloric (level 6) nodes included. Right gastric vessels identified above the pylorus and divided — suprapyloric (level 5) nodes included. Kocher's manoeuvre: duodenum mobilised from head of pancreas — 5-6 cm of first part exposed. Duodenum transected with mechanical GIA stapler. Peritoneum and connective tissue stripped from the hepatic artery to the coeliac artery in continuity. Left gastric vein identified and doubly ligated first. Left gastric artery isolated, doubly ligated and divided at the coeliac artery — level 7, 8, 9 nodes included. Stomach drawn caudally; lesser omentum divided to the cardia, keeping close to the liver — right cardial nodes (level 1) included. Lesser curve cleared to the transection line. Stomach transected with a mechanical stapling device at an appropriate level — ensuring 5 cm clearance from macroscopic tumour.