1. Introduction

2. Incision and Access to the Abdomen

3. Abdominal Exploration

a. Divide Right Gastric

4. Entry into Lesser Sac and Division of Omentum

a. Divide Gastroepiploic Vessels

5. Infrapyloric Dissection

6. Suprapyloric Dissection

7. Duodenal Transection

a. Open Peritoneum

b. Divide Left Gastric Pedicle

c. Divide Short Gastrics and Left Gastroepiploics

8. Greater Curvature Dissection

a. Divide Anterior and Posterior Vagus Nerves

9. Intra-abdominal Esophageal Dissection

a. Double-Check Z-Line

10. Esophageal Transection

11. Purse-String Suture for Esophageal Opening

a. Measure 60-cm Roux Limb

12. Jejunojejunostomy

a. Results from Pathology

13. Esophagojejunostomy

14. Excision of Open End of Roux Limb

15. Inspection and Hemostasis

a. Close Defect in Diaphragm

b. Reapproximate Transverse Mesocolon to Roux Limb

16. Closure

17. Post-op Remarks

The Hereditary Diffuse Gastric Cancer (HDGC) syndrome is due to a mutation in the CDH-1 gene that predisposes patients to a high lifetime risk of developing gastric cancer. As such, a total gastrectomy is typically recommended for patients with this syndrome. In this case, the patient presented with an incidentally discovered CDH-1 mutation on genetic testing obtained after she was diagnosed with early-onset rectal cancer. She underwent a prophylactic total gastrectomy with a retrocolic Roux-en-Y esophagojejunostomy. Her postoperative course was unremarkable, and she was discharged on postoperative day 3. Her pathology demonstrated several foci of signet ring cell carcinoma limited to the mucosa. This video demonstrates an experienced surgeon’s technique for performing a prophylactic total gastrectomy with a Roux-en-Y esophagojejunostomy reconstruction.

Watch this full-length, narrated surgical video of Dr. Mullen at MGH performing a prophylactic total gastrectomy for a patient with the CDH1 gene mutation.

Massachusetts General Hospital