1. Abdomen is opened from the Bilateral Subcostal incision or Midline Incision.
2. Omni retractor, Thomson's or similar retractor is used to lift up the rib cage. There should be good exposure of the stomach, lesser omentum, greater omentum and duodenum
3. Abdominal cavity is explored for metastasis especially liver, pouch of douglous, ovaries, base of mesentary, mesocolon, pelvis.
4. Note the site of tumor, extent and depth of the malignancy. Is there involvemnt of the adjacent organs
5. Bring down the hepatic flexure of colon and do a wide Kocher's maneuvre .
6. Omentum is now taken down from the transverse colon with the anterior layer of mesocolon. The dissection goes toward the right towards Right gastroepiploic artery and sweeping the sub pyloric group of lymph nodes up.
7. The hepatoduodenal ligament is cleared preserving the accessory left hepatic artery if present. Dissection in the porta might be done but not required because for D2 gastrectomy the other lymph nodes that need removal are
Hepatic artery, left gastric artery, splenic artery and coeliac artery group
8. Right gastric artery is ligated and duodenum cut and stapled and owersewn
9. Transected part of stomach and duodenum is now lifted up and tissue inferior to the common hepatic artery with the pancreatic capsule is taken off. Coeliac trunk will now need to be exposed
10. Splenic hilum will now be approached from below and all the lymphatic tissue will now need to be swept towards the Left gastric artery.
11.This will complete the lymphatic dissection and now stomach needs to be transected.
