Open Distal Gastrectomy

CHAPTER 1

Hi I'm Dr. Mullen. I'm a surgical oncologist at the Massachusetts General Hospital. I specialize in the treatment of gastric cancers and today we're going to operate on an 80-ish-year-old gentleman who has a distal gastric cancer. He initially presented with anemia, which led to an upper endoscopy. The endoscopist noted an area of inflammation in the distal stomach. That then prompted some biopsies which showed very early intramucosal adenocarcinoma. Patient was then referred for an endoscopic ultrasound, which showed a more obvious tumor invading the muscle of the stomach, and so we staged as T2. There were no suspicious lymph nodes, and so the regional lymph nodes were staged as N0. Scan showed no signs of metastatic disease so he presents today for a potentially curative distal gastrectomy. In this procedure, we're going to remove the distal 2/3rds of the stomach. We'll also a dissect out the D1 lymph nodes adjacent to the stomach. But furthermore, we’ll take out what I refer to as the D1 plus lymph node. So those nodes in the D2 station immediately in the central arterial system So celiac axis, common hepatic artery, and proximal splenic artery. And then we'll probably reconstruct him with a loop gastrojejunostomy in a Billroth II fashion.

CHAPTER 2

So, clearly we're making an upper midline incision. The important thing here is to try to stay on the midline and not expose the rectus muscle on either side. We are doing a nice job here of staying in the midline. The fat here is the preperitoneal fat. When you do forget surgery, I do think it's important to carry your incision all the way up to the xiphoid and at times will come around the xiphoid as we are in this case. So the xiphoid is right here. He has a very prominent xiphoid. We're just going to come around that a little bit just to give us better exposure in the upper abdomen. Okay, DeBakey forceps.

Now when one enters the peritoneal cavity, you have a choice to do so either bluntly or sharply. We're going to do so sharply here that - that is through the preperitoneal fat. Now this is the peritoneum, which has much greater tentsile strength. Make it slightly larger so one can put your finger in and then use the cautery to open up the remainder of the peritoneum. Can I have my headlight on - is it Kathy - who's here? Kelly. There are often times small vessels in the preperitoneal fat, so it's worthwhile to take the time just to cauterize those as you go, so that you don't have bleeding into your field during the case. Great.

So the first step is to do an exploration of the abdominal cavity to make sure there's no sign of metastatic disease. If gastric cancer is going to metastasize, it most commonly does so to the liver or to the peritoneal surfaces. So we're examining the surface of the liver. If a patient has a more advanced cancer such as a T3 or T4 cancer or a node positive cancer or has a very high-risk histology like a poorly cohesive type cancer or a linitis plastica, then I will commonly do a diagnostic laparoscopy at a separate operative sitting, but since he had a T2 and N0 cancer the risk of metastatic spread is very low, so I usually do not do a staging laparoscopy and indeed there's no sign of metastatic disease on exploration here. What's this little thing? That's a diverticulum. Oh, okay.

CHAPTER 3

Great, so our first step is to take the omentum off of the colon. Oftentimes patients will have adhesions of the omentum as he does. We'll take that abdominal wall retractor. Okay. These can be a nuisance because often times these adhesions can be deep in the pelvis. For smaller cases like this, I find a Bookwalter retractor to be perfectly fine. It's a small incision - and yes Yeah give us one second cuz I think the wound protector will be tricky with this. Once we take the omentum down, then we'll put that in. Is that okay? Let's come across this way. Okay. Mhmm. I know it's hard to see. He's probably had a bout of diverticulitis in the past and his omentum did its job by coming down here to seal the perf or inflammatory process. Maybe right up here - yep. Maybe right there - can you see that? Yeah Great. It's important to take the omentum out in a patient with gastric cancer - DeBakey forceps - because we're going to devascularize it in this case, as we ligate both the right and left gastroepiploic arteries which are the source of blood supply. Furthermore, the station four lymph nodes live along the greater curvature in the omentum, and so for an adequate lymph node harvest we want to take out the entire omentum. Okay, great, we're all set, Lauren. So now we have our omentum into the field. This is another common sight of metastasis. This is a nice glistening normal omentum. There's no sign of metastatic disease here.

So step one of the operation, besides getting into the abdominal cavity, is to now enter the lesser sac through the gastrocolic omentum here. One trick I've found that's helpful is if you grab the stomach together with the omentum, that helps you get into the proper space and not come through the omentum. So now Andrea is going to enter this avascular plane between the transverse mesocolon and the back wall of the stomach. And here we can see the posterior wall of the stomach. This is the lesser sac. Now here we want to stay right in that avascular plane. If you’re little too far to the colon, you can get into either the mesocolon or these small appendices epiploicae and if you're a little too far this way, then you can get into the back wall of the stomach. In some patients, this procedure can be tricky, particularly if there's not a clear delineation between the two - the mesocolon and the back wall of the stomach. Thin patients, it can sometimes be tricky. In him, it's relatively straightforward. Small vessels can just be cauterized I prefer the LigaSure. Yeah, so you see now that's a nice plane there. You're going to want to... I'm just gonna fan it out. Yes. That vessel's going to go with the omentum. That's right. We’re carrying our dissection rightward now toward the mid-transverse colon, hepatic flexure. I do as much of this as I can without the retractor and then soon we're going to get to a point where it's going to become too deep and we'll have to put in our Bookwalter to complete the last bits of the dissection. The omentum can bleed throughout the case, and it becomes a bit of a nuisance, so I do like to control any little bleeders. So here's the appendices stuck to omentum. Now we should place the ring and the retractor as were getting a little bit deeper. The wound protector's designed to decrease your risk of superficial site infections.

One needs to be mindful of the falciform ligament here as one does not want to tear the liver so I'm going to just take the falciform ligament down just to minimize that risk with the LigaSure device. This can be done relatively simply with the LigaSure. You can probably do it - you can do it outside of it, it's okay. Yeah. For this case I like to use the the Maryland type LigaSure. I would think that the harmonic scalpel would be an equally good idea. The jaws are nice and small so when we do I lymph node dissection, this is a nice caliber in order to make that dissection more convenient Some of the larger devices, it can be challenging to to use those for the dissection I'll take this now to do this side. This will bring us down toward the first portion of the duodenum. I like to use a finer right angle instrument for the majority of my gastrectomy.

CHAPTER 4

So we're coming down now to the right gastroepiploic vein, which is this structure we see right here. And the right gastroepiploic vein, obviously, is going to go to the greater curvature of the stomach. We're going to ligate that. This is the middle colic vein and the middle colic vein joins the gastrocolic vein to form the gastrocolic trunk and the superior mesenteric vein is going to be deep to these branches here. So we're going to try to stay up high here - Well, not high here but we're going to stay obviously away from the colonic mesentery here and not injure these vessels. We're going to want to take the right gastroepiploic vein close to its junction with the gastrocolic trunk and harvest the station 6 lymph nodes, which live in this area here. Station 6 lymph nodes are perhaps the most important lymph nodes in a distal gastric cancer because they have the highest risk of metastatic involvement. Is that because they're usually right next to the tumor? Because they are next to the tumor, yes. Okay, 2-0 silk tie, please. I’m going to tie that one up, and I’ll clamp down. I'll grab the specimen for you. You certainly can use the LigaSure device for this. Sometimes for larger vessels I choose to clamp and tie them the old-fashioned way. It's good for the residents too, for training. Tie. Thank you. Gently now, these veins can be somewhat fragile. The next structure we're going to see is going to be the right gastroepiploic artery. This is just fatty and lymphatic tissue. I’m going to pinch burn that - might be a small vessel. That's a small vessel branch there that may be with the retraction - avulsed a little bit. This is carrying the dissection up to the first portion of the duodenum. D2 lymph nodes in this case would include stations 8, 9, and 11. The station 7 nodes importantly, which were formerly considered to be D2 nodes, are in fact D1 lymph nodes, and indeed the station 7 nodes at the left gastric artery, should be included in any gastrectomy as well Their metastatic rate is high on the order of at least 15 to 20%. That's higher than I'd expect. This patient has an early gastric cancer. He's elderly. One could argue not to do a D2 dissection at all in this case, so I'll probably just do sort of a D1 plus and take out the nodes at highest risk - maybe in stations 8, 9, and the proximal splenic nodes. Give me a Bovie here. Cause often, to take out all the splenic nodes, you have to do a splenectomy. Well I certainly wouldn’t go out to the distal splenic artery and the station 10 nodes. The likelihood of those being involved is incredibly low - and the morbidity of taking out those notes exceeds any benefit that you derive from taking them out.

So this is going to be the gastroepiploic artery. What’s our cautery on? Seems a little hot. 35. Can we turn it down to 30, Kathy? Sure. It's at 30. Great. Do you suture ligate this? No. Okay, 2-0 silk tie. We're gonna tie that one up - clamp below - with a little extra tissue here, but... Metz. Remember it’s a right angle so you have to - there you go. Okay. I'll take a tie on a pass. The right gastroepiploic artery comes off at the gastroduodenal artery right on the surface of the head of the pancreas. You want to take this artery close to its origin in order to fully resect the station 6 nodes.

You can hold that Andrea, and I'll take this. Just complete our dissection here in the infrapyloric area. Sometimes I try to get away with just buzzing things for speed, but then that leads to a little bleeding so…

Here's the cancer here I think - it’s very distal. Yeah there's a little thickening. Not super obvious. No. Sponge, please.

These are just some adhesions of the omentum to the gallbladder. Right angle. So now I'm clearing off the first portion of the duodenum. It’s just an omental adhesion to the anterior wall of D1 and distal to the pylorus. The tumor is located right here actually in the prepyloric antrum. It’s a subtle tumor, but it's easily palpable here. Measures maybe one and a half or two centimeters. So we're going to be able to do a fairly distal gastrectomy in this case.

CHAPTER 5

Right now I'm opening up the lesser omentum. And see how you can see that I'm circumferentially around the distal stomach and duodenum.

We’re going to do some of our superpyloric dissection here. We're going to take the right gastric vessels. Righties are station...? Right gastric vessels are the station 5 nodes. There are really very few lymph nodes in the station 5 location. In fact some autopsy studies have routinely found that there's no lymph nodes in station 5, but so I don't do a very aggressive proximal division of the right gastrics by the hepatics. I tend to take them fairly close to the stomach. I think we can probably just use the LigaSure device here. Okay. LigaSure? Thank you. And Heidi, do have the Endo GIA stapler? We're going to want a 60-mm tan load.

Maybe we'll clean this up just a touch here. Sorry Andrea.

CHAPTER 6

Okay, we’ll take that stapler. So we're dividing the duodenum now. I don't always do my gastrectomies in exactly the same steps. I kind of just go with whatever seems easiest at the time, so in this case, we entered the lesser sac, we mobilized the greater omentum. I didn't go leftward first. I went rightward. We took the right gastroepiploic vessels and the station 6 nodes. We then took down the lesser omentum, divided the right gastric vessels. We're now going to transect the duodenum distal to the pylorus. The pylorus is easily palpable as a ring. You want to make sure you take at least one to two centimeters of duodenum as a margin. His tumor is located here in the antrum, in the prepyloric space, so if we divide the duodenum there, that will give us at least a two- to three-centimeter margin. Articulate that. Your choice of stapler here is really personal preference. We've largely gone to the Covidien tri-staples. Do you want me to go in a little more there? Let's see, yeah, advance that slightly. Perfect. This fires three rows of staples on each side. Okay, ready? Go ahead. Yeah. No. 60 purple next.

So there's the duodenal stump now. I do not routinely oversew the duodenal stump - that is a personal preference. In some patients, perhaps if they've had pre-op chemo radiation I might consider its - DeBakey forceps - but sometimes oversewing this stump with Lambert sutures and whatnot can be more meddlesome than helpful. So this is a well-perfused stump with three rows of staples. The incidence of leaks should really be quite low, so I'm going to leave that be. So now the stomach is divided. We've got our tumor here in the antrum.

We're going to complete our dissection leftward and then we'll be ready to do the completion of the gastrectomy. There is commonly congenital adhesions behind the stomach to the anterior capsule of the pancreas. We're taking these down now. The pancreas is coming into view quite nicely here. So now we need to make a decision - how far left we want to go. Again, we're going to preserve all the short gastrics in this case. We could consider just taking the left gastroepiploics. Cautery to me and a DeBakey. Just a second now. Here. Okay so now we want to make sure we pick up the stomach again just to follow our path. Hold that there. Oh my, quite a few adhesions here. Make sure that - that's hemostatic before it goes away. Looks good, huh? Okay. This part of the operation can frankly be quite a bit of a nuisance taking the omentum off of the splenic flexure. You certainly want to be careful not to injure the spleen, because as you know, the short gastric vessels derive their blood supply from the spleen and the splenic artery, and so if you injure the spleen then you have to convert the patient to a total gastrectomy if you have taken all the other named vessels. So really examining this - the tumor being so distal in this case, we really can do a fairly modest distal gastrectomy with more than an adequate distal margin. So I think we've done enough leftward dissection, and honestly, we could perhaps come through here. Alright, if you want to hold that up, I'm going to take LigaSure device, please. And I just come through the omentum and the gastroepiploic vessels with the LigaSure device For more proximal cancer, I would take some of the lower short gastric vessels but in this case given that this is such a distal cancer, I don't think that's necessary. DeBakeys. So let's come through here.

CHAPTER 7

Alright, so at this point, we're ready to divide the stomach, but I like having the stomach as a handle to do the dissection at the left gastric. We can tuck the colon away. One thing that can help with the dissection of the left gastric and the nodes is to place a moist lap pad. And a malleable gently on the pancreas. Oh his left gastric is a ways up there, isn't it? So the left gastric vein is located here. You always find the left gastric vein in front of the artery. And here's the artery. You can actually see a pulsating. He's nice and thin - it's not often that you see it so easily. And this is going to be the common hepatic artery here. It’s actually a bit calcified in him. You can feel that right there. So the station 8 lymph nodes live on top of the common hepatic artery, and then the station 9 nodes are going to be down here in the celiac axis. The station 7 nodes are here along the left gastric, and the station 11 nodes are going to be here along the splenic artery, okay? So we're going to open up the peritoneum here. We’re going to take the left gastric vein first, then we're going to take the artery and reflect the station 7 nodes upward with the specimen. Right angle.

So this is the peritoneum, which overlies the common hepatic artery. Oftentimes there's a large node here. Does it have a special name or just...? No. It's there. It’s just there. So this is part of the D1 plus lymph node dissection that we’re doing here now - taking the lymph nodes off of the anterior surface of the common hepatic artery. DeBakey. Bovie. Let's come here. Starting to see the left gastric artery come into view there, right here. Probably should be doing this with the LigaSure. As you can see, there's lots of little vessels to the nodes, which are a nuisance. Again for speed, I sometimes just try to get away with using the cautery, but then you have to be careful cause then you get into some bleeding and... Okay, go ahead. Convert to the pediatric sucker there. The caudate wants to come into view there. Looks like a little vessel in there... maybe. Cautery here, too. You can grab the node, here. Cautery. DeBakey. Baby sucker. Bovie. Suction. And, can you send that as a separate specimen labeled station 8 lymph node?

Let’s see if we can take our left gastric vein right here with the LigaSure device. This will help us a lot - get this out of our way.

Okay, right angle. Thanks. So here we see the splenic artery coming into view. So common hepatic artery, splenic artery, left gastric is going to be here. So we're going to dissect out this nodal packet here on the surface of the pancreas. Let’s get this little guy here. Bovie. Thank you. Okay. Right angle.

Let's open up the peritoneum here on the superior border of the pancreas. These will be the station 11 nodes. LigaSure device, I think. These are going to go as station 11 lymph nodes for permanent. Bovie. Next we're going to want actually a 45 tan. Really need to get this caudate out of our way. So here's our left gastric artery there. Cautery and get these nodes up with our specimen.

So to take the station 7 nodes, you do want to take the left gastric artery at its origin, which is what we're doing here. And we’re going to use this just as a handle to put the stapler. I like to take it with a stapling device. We’ll have to see if we have enough room. Yeah. If we don't, we can clear up a little bit more. Right angle. There you go. Let me take this off. Open. Can you see my tips, just to make sure... Yep. Okay, and now you make sure you haven't compromised the common hepatic or the splenic artery, which you haven’t. Okay, go ahead and fire. So this is a division of the left gastric artery at its origin. Scissors. Great.

CHAPTER 8

Alright, so now I think we can choose our site for division of the stomach. Can you pull your nasogastric tube back now? It’s a very important thing to remember of course - you don’t want to chomp through the nasogastric tube. How far back do you want it? All the way? I would pull it back to just the GE Junction - maybe 40 centimeters or so. So, that's at 38 right there.

Great. So before we do the division of stomach, let's just clear off the lesser curvature and these nodes we’ve worked so hard to get in station... So we’re going to take the LigaSure. These are the Station 3, and I don't go up as high as station 1, which would be all the way up to the GE junction. These are basically the branches - the more distal branches of the left gastric, up on the lesser curve of the stomach. In order to preserve the length of our stomach remnant, the amount of - of reservoir left, we strip these nodes down distally. So we still get the nodes, but we don't have to resect the actual stomach. There's our left gastric stump. So we're obviously going to take that with us - come through these nodes here. This is a bit time-consuming, but I think with patience it's worth taking out these extra nodes in many cases. We can always come back and get additional nodes that are... Can you put this with... You can put that with station 7, I think he's... Yeah. So next is going to be the 60 purple.

So now we're ready to do the gastrectomy. Can almost see a line of demarcation where this is ischemic. Okay, I'll take the stapler. So we typically with two firings of this - you want to hold down perhaps here on the stomach? Take one more of these in back. I do this in the manner of Hofmeister, so we have a transverse bite here, and now we'll take an angled bite up the lesser curve. And then we’ll do our anastomosis to the greater curved proportion of the stomach. And I - we may not make it. We'll see. We might need a - the other 45. I would get one ready. There’s a little itty bitty left. Yes, a 45. Hold that guy like this. Okay, and this is going to be distal gastrectomy, and I would like them to check the duodenal margin. Duodenal margin. Do you want to mark it? Let’s mark it with a stitch, just so there’s no doubt Laurie. Yes, right there. Was that going to be for frozen? Yes. Do you have a little irrigation, Endi. Grab this section before you start.

I’ll take a DeBakey, Endi. Alright, so now we’ll get hemostasis before we do our anastomosis - make sure there's no more nodes we want to take. Suction in here. See if we can get our caudate out of the way. It’s been a nuisance the whole case. All of the separate lymph nodes go for permanent. Or do you want to send it with it? What's your call? So this is a good example of a completed D1 plus lymphadenectomy the common hepatic artery here is exposed nicely, the proximal splenic artery here. This is the Celiac axis. Here's the left gastric artery divided at its origin. There’s still a bit of lymph node tissue. This is not a perfect dissection in which we've taken every node but certainly a very reasonable lymphadenectomy for an 80-ish-year-old gentleman with a T2 cancer.

CHAPTER 9

Alright let's oversew the lesser curve staple line. Can I have that Babcock back? We’ll take a 3-0 PDS and some bowel forceps. 1 hour. Thank you, Keith. Thank you. Alright, so let’s start here and... No. Thank you. So now we're getting ready for our anastomosis. We first oversew the staple line along the lesser curvature. It's probably not essential, but it makes me feel a little better to imbricate that. I do it in a running Lembert fashion with PDS. You're going to cut the shorter end about 6 mm or so. I'll take forceps too. Stray staples. So Dr. Mullen, for the anastomosis, how do you decide between Billroth I and II? That’s a good question. So - the main limitation for most cancers I see is that many of the cancers are too proximal. So you end up having to do a fairly large gastrectomy such that the ability of the duodenum to reach the gastric stump without tension is limited. There are some purported benefits to having a Billroth I because you maintain the normal physiologic flow of food through the duodenum, but you know it has the troubling side effect of bile reflux - perhaps worse than you'd see with a Billroth II. So - they both have their advantages and disadvantages. I rarely do a Billroth I although it's much more common in Asia because they have a lot of early gastric cancers in the distal stomach in Asia, so they have greater experience with it. We in the United States almost exclusively do Billroth II’s or Roux reconstructions. The reason I would do a Billroth II is he has a reasonably good-sized gastric remnant. If he had a really small gastric remnant, I'd be reluctant to bring up a loop cause you'd have really bad bile reflux. So in that case I would do a Roux reconstruction. But - the advantage of a Billroth II over Roux is that you only have one anastomosis instead of two so it's less time consuming and you can always convert a Billroth II to a Roux. Once you do a Roux, it's hard to go back and do much else. Cut the needle off. This you'll cut some 6-7 mm.

Okay, let's go get our loop of the jejunum. I like to do mine retrocolic. It probably doesn't really matter at the end of the day. The key here is to not injure the middle colic vessels, which you can see coming up here nicely. So we're going to come to the left of the middle colic vessels. There is typically a bare area here, which is where we're going to bring our jejunal loop through, so you can take the cautery and vertically incise the mesocolon. Right through the bare area there. Come up a little more north here. Yeah, that should do. And then you're going to find your jejunum now at the Ligament of Treitz. Here? Yeah, so we’ll bring up the loop of jejunum. You don't want your - this is going to be the afferent limb - it's the limb that brings the bile and pancreatic juices to the stomach. You don’t want your afferent limb to be too long cause it can kink and give you the afferent limb syndrome. So typically what I do and you can bring it up in isoperistaltic fashion or antiperistaltic fashion. Peristalsis goes in this direction, right? From the Ligament of Treitz distally. So the stomach contracts in this direction, so to bring it up isoperistaltic, you want to orient it this way. If you bring it up this way, it’s antiperistaltic, and truthfully, it's been studied - how you orient it really doesn't matter very much. And so I tend to just do it the way that it tends to lay nicely. And I make sure that the the limb is not too - redundant, so there's some snugness to it. Now we can take the colon away. Okay, Babcock. Now we have to go find our stomach remnant. So we decided - I want to make sure we check how we've got this oriented. This is afferent limb. This is the efferent limb. I think this will lay nicely almost here in antiperistaltic fashion.

Okay, before we do, let's place our corner stitches. So why don't you place your corner stitch there - antimesenteric portion of the jejunum. Now get a good bite. And now the stomach. Far behind - further behind the staple line - maybe not quite that far, but yeah - good. Cause when you excise the staple line, you don’t want to cut your stitch. Okay, snap. Alright and now let's do our other corner. So we’ll do it to there. Just come right under the staple line - great, snap. Need another. Snap, please. Right now we can get Mr. Colon out of the way. Put this in a little tension - see like that. Do you have a Ray-Tec?

Okay, now you put your back row of Lemberts in. I'll take bowel forceps. Great. Grab that guy. Stitch. Needle back. Stitch. These are Lembert sutures. They’re seromuscular stitches. Not a strength layer. Not a strength layer but - certainly could do this anastomosis in many ways - single layer, stapled - this is a more traditional two-layer hand-sewn end-to-side gastrojejunostomy. Outer row of silk, inner row of some sort of absorbable suture - some use chromic, some use Vicryl, I use PDS. I like the PDS because it's monofilament. Laurie, do you know what is the strength layer in a bowel anastomosis? I mean I think it has to go across the entire bowel wall There’s a specific layer. What’s the strongest layer of the four layers? Well there's mucosa, submucosa muscularis, I think it's the submucosa. That’s right. Excellent. We should probably do it I think. What do you think? You want to put another one? Probably. Alright. One more. Residents always want to put in lots. Alright, why don’t you start tying the corner there. We'll re-snap that one. Do you have the Yankauer sucker now? Why don’t you take the cautery there, and I'll take a Schnidt.

So now we're making our enterotomies - Make a jejunotomy here and then we’ll excise the staple line on the stomach. Alright, that looks good. Here we stay close to the staple line just to make sure we don't get too close to our Lembert stitches - accidentally cut them. Almost there, huh? Maybe heavy scissors there, and amputate that guy. Alright, some like to use it as a handle. I'm with you, I just prefer to use my forceps. Alright 3-0 PDS.

That’s perfectly fine. Yep, approximately the middle. Make sure you get all layers. Great and tie that one. 6 knots. And we’re going to cut this one about 6 mm. Do you have a shod, Endi? We just need one, actually. Great, that’s nice. Make sure you get all the layers. It’s easy, when it retracts, to miss it, and then you end up not getting the serosa of the stomach. Lovely. Shods are little plastic booties on the clamp that doesn't fracture the suture. The problem is if you put a clamp directly on monofilament suture, you’ll weaken it, and it could crack. And when you're using it, it can break. So we try to put shods. You’ll see them commonly in vascular surgery. They use a lot of Prolene, and they'll put shods on all of the ends of their stitch - their stitches. You don't see those much in GI surgery. Okay we're going to run this way toward you full thickness. Nice. Push the mucosa down with your stitch. Yep. So the only reason I check the duodenal margin is because clearly the tumor was much closer to the duodenum than the stomach. We had a very wide stomach margin - grossly - but the duodenum margin was perhaps only two centimeters, so I had them freeze that. For cancers that are right in the middle, you know, it’s reasonable of course, or for certainly diffuse type cancers - this is an intestinal type cancer - I'd be inclined to test on frozen section both margins. You must be using the epidural key. We have an active - we have a busy jejunum. That’s okay. We'll get through it.

Have you seen a hand-sewn bowel anastomosis, Laurie? I have not, it's lovely. Okay, there you go. So the corners can be tricky. There’s a technique called Connelling. To help it. It everts the mucosa. And now you’re going to go inside out on this side. So essentially instead of going across like you were doing before, so I went outside in so now I go inside out. And now I’m outside, so I'm gonna go outside in. I’m going to shod you at this point and then bring mine around. Hold that stitch. Bowel forceps. All layers of the bowel wall - it’s important to see that. Come around the corner, 45-degree angle, flip your stitch, and a 45-degree angle back. Lots of serosa - not too much mucosa. I will try and come out with a 90-degree here. Flip your stitch. I think I got more mucosa than I needed there. It’s okay. And a 45. It's getting easier now. It's pooching back in - there you go. In a second, we're going to have you advance the nasogastric tube. One more - well, two more I guess. huh? Have to get to the other side. Grab the serosa, so you can pull the small bowel out. That’s mucosa there, yep. Yep. Okay, we'll take the scissors. Cut the needles off. Yep, great. Okay now we’ll take silks. And now we do what we did before.

As we get over towards the lesser curvature portion of the anastomosis, this is actually historically called the angle of death - or the angle of sorrow - because this used to be a frequent site of leak - because it is a site where there's a little more tension, so we're going to put a few extra stitches in here. That should do it I think. That is a lot of silk. Alright. Okay. Alright. Okay. Should I cut this too? Oh yes, yep, you have this one here. Shorter if you can.

The nasogastric tube. Go slow. Okay. Yeah, I don’t feel you. Oh, there you are. Great. Keep going? A little bit more. That’s great. So I’d leave the nasogastric tube in the gastric pouch cause that's what you really want to decompress. It's not so important to put it down into the efferent limb, because you're not going to get anything out of there anyway I just try to keep the gastric remnant from blowing up and the risk of aspiration. And I usually leave that in for one or two days depending on how concerned I am with the anastomosis. I don't usually do a swallow. Probably just take it out on the weekend and start him on liquid.

CHAPTER 10

Hemostatic, a little juicy here - how about some warm irrigation? Maybe a... A DeBakey. Here you go. Grazie. I'll grab a DeBakey as well, please. Thank you. Aha, it's here! Those lymph nodes. I’ll take a longer DeBakey. Station 3 lymph nodes for permanent. These are some additional nodes - they’re sort of high up on the lesser curve - whether you call them 7 or 3, I don't know. Perhaps they’re better termed 7, but… Sometimes these are just easier to take out once the specimen is out. I think I would just amputate right there if you can I know it's not an angle on this but - Yes. Tiny bit more. Yes. No - that - that is the location. Yeah. Okay so here's the ligated left gastric artery at its origin, okay? This is the aorta here. This is the - so this is what we call the celiac axis cause it's the trifurcation - splenic artery here, common hepatic artery here, so the left gastric comes up. Additional station - you can call it station 8 lymph node. Yeah. Sorry, I - hate giving you to - these to you in bits, but... Bovie. So I just put it together with the first number, station 8 - Yes, that'd be great if it hasn't gone already, yeah. Thank you, beautiful.

Yeah we have to close this because if we don't, we get a hernia - we could get a hernia. Where the bowel will herniate up into the upper abdomen above the mesocolon. So we close this. This is a big problem in patients who have gastric bypasses who have done retrocolic, and if this defect isn't closed, they can have strangulated bowel that herniates through here. Okay, pop that off and tie it. You want to secure the cut edge of the mesocolon to the stomach, and that's just because you don't want to narrow your anastomosis or the efferent limb. So you pull the anastomosis below the mesocolon and then just with a few interrupted sutures. Needle. Thank you. Another stitch.

Actually, we have that - xiphoid is here, so there's the fascia of Wight. I want you to get up - just a second, sorry. Relax here - way up here. Good. What are the chances we’ll have to do a thoracotomy? Well I just think it’s so hard to get there in supine. You’re coming - you want to come out more. Yeah. Because your last stitch came out here. Yes. Better. If it were someone like thinner, do you think you could do it supine? Oh I could, for sure. Yeah. Well there were two reasons I wasn’t thrilled about doing it that way. One was that she has a big hernia, so then we’d have to fix her hernia - probably with mesh so that just adds complexity to the case And that doesn't bother her - she doesn't care if it's fixed, so I said fine. And then the second thing is - I told you, she's - the location of this tumor is terrible. Make sure there’s no purple there. Okay, good.

No, it's fine. Which way - can you staple from this way?

CHAPTER 11

I think in general the operation went well. As is common with the lymph node dissection, there a lot of little vessels to the nodes and that's where we got into some little bleeding - not significant, but enough to be a nuisance. So that adds time. I probably should have that little LigaSure device more frequently, but that takes more time cause you have to exchange instruments frequently. So I try to just go as much as I can with the cautery, but then sometimes you buzz through a vessel, it bleeds, and then it takes more time. So - that sort of is just the nuisance factor of taking out nodes in this area, and that’s why a lot of surgeons don't want to do it frankly, because it adds extra time and - and complexity. But it’s not necessarily hard - it just takes a little patience to do it. So I probably could have got a little better job with hemostasis there if I used the - the vessel sealing device more frequently.