Steps of D2 gastrectomy.
For Post graduates, step by step learning of D2 gastrectomy
D2 gastrectomy is now the standard of care in carcinoma stomach. More over spleen preserving D2 gastrectomy has lower morbidity and same survival results as compared to d2 gastrectomy with splenectomy.
Principles of Surgery
- Proximal margin of 5-6 cm
- Distal margin of 2 cm
- Harvesting of 15 lymph nodes
Contraindications of D2 gastrectomy
- Distant metastasis
- peritoneal metastasis
- Malignant cells in ascites
- Para aortic lymph nodes
- Involvement of coeliac trunk and its branches
- Involvement of aorta
- Extensive tumor ingrowth to duodenum/pancreas
Preop preparation of the patient
1. Nutritional build up, Gastric lavage, correction of electrolyte abnormalities and adequate hydration
2. Prophylactic antibiotic
1. Abdomen is opened from the mid line incision extending from xiphoid to below the umbilicus. Self retaining re tractors are placed to get optimum space.
2. Abdominal cavity is explored for metastasis especially in liver, peritoneum, para aortic lymph nodes and resectability is assessed by seeing mobility and anterior and posterior fixation.
3. Greater omentum is removed from the left transverse colon (here mesentary is not fused) and go towards the right side in the avascular plane between the 4th layer of omentum and transverse mesocolon till the root of right gastro epipoic artery. This step will also expose the head of pancreas.
Division of right and left gastroepiploic vessels
Ligate all the veins over the head of pancreas (loop of henle) and right gastroepiploic artery is ligated here at the lower border of pancreas. Left gastroepiploic artery is the branch of splenic artery and is ligated at its origin at the upper border of pancreas on the left side.
Division of Right gastric artery
Right gastric artery is divided at the upper end of pylorus in the lesser omentum and the tissue in lesser omentum is divided on the liver side upto the GE junction.
In 15% of patients, accessory left hepatic artery may be present in the lesser sac and this has to be safeguarded.
4. Cattell braasch maneuver is the next step and hepatic flexure of colon is brought down completely expsoing the retroperitoneum and separating hepatic flexure of colon from the liver.
5. Superior Mesenteric Vein is seen passing from the mesentary to its course to join the portal vein.
Creation of Tunnel of Love
6. At this step attempt may be made to try and create the tunnel between the Superior mesenteric vein and pancreas but if it is problematic it may be attempted at the later stage. It is at this crucial time the resectability for Pancreaticoduodenectomy is decided.
7.Dissection is started at the free border of lesser sac and Common bile duct, Right hepatic artery and portal vein are identified. At this step special care is taken to identify and safeguard accessory or replaced Right hepatic artery. This artery is easily found posterolateral to the portal vein.
8. Gall bladder is dissected from the liver bed and followed onto the cystic duct, Common bile duct is divided at the junction with the cystic duct.
9. The Right hepatic artery is traced back and just above the duodenum Gastro duodenal artery is tied off.
10. The hepatoduodenal ligament is dissected easily as its a vascular and next after clearing the lesser curve of stomach and greater curve, stomach is usually transected with a linear cutter.
11. The portal vein is now seen clearly and the tunnel between it and pancreas is fashioned.
12. The pancreas is now cut and separated from the portal vein. There are many ways to do it and recently we have been doing it with a vascular stapler.
The resected specimen looks like this Whipple's Cut Specimen.
Pancreaticojejunostomy can be done duct to mucosa or pancreas can be dunked into the jejunum. Another technique is pancreaticogastrostomy. Both have similar results and comparable leak results. The choice depends on surgeon 's training and experience
Hepaticojejunostomy is next- Done in single layer and can be performed in interrupted or continuous fashion
Gastrojejunostomy is the final step of reconstruction
Feeding Jejunostomy is done because of high incidence of delayed gastric emptying (20%)
Drains may or may not be placed depending on surgeon's experience and abdomen is closed.