Transabdominal D2 gastrectomy for proximal gastric cancer

Transabdominal proximal gastric cancer D2 type gastric resection is used for the treatment of gastric cancer. Gastric cancer is divided into early and advanced stages. Early gastric cancer means that the cancer is limited to the mucosa or the submucosa, and has not invaded the superficial muscle layer. The size of the lesion, the presence or absence of lymph node metastasis, can not be used as a criterion for judging morning and evening. The only criterion is the depth of invasion. Advanced gastric cancer is relative to early gastric cancer. Where the cancerous lesion invades the muscle layer, regardless of size or lymph node metastasis, it is a progressive gastric cancer. According to the different range of lymph node clearance, the surgical methods of gastric cancer can be divided into three types: root 1, root 2 and root 3. Root refers to the complete removal of the cancer itself. 1, 2, 3 refers to the range of lymph node clearance, that is, clear the first, second or third station lymph nodes. Depending on the location of the primary tumor (gastric sinus, corpus corpus, and fundus), the range of lymph nodes to be removed from the corresponding station 1, station 2, or station 3 is also different. Treatment of diseases: stomach cancer Indication 1. Diagnosed as a cancer after gastroscopy and barium meal examination. 2. Clinical examination of the lymph nodes on the clavicle without a swollen lymph node, no ascites sign, rectal examination of the rectal bladder (uterus) fossa did not touch the mass. 3. There is no serious heart, lung, liver, kidney dysfunction, serum albumin above 3.5g / L. 4. Preoperative B-ultrasound and CT examination without distant metastases such as liver or lung. 5. There was no liver metastasis found in laparotomy, no peritoneal diffuse plant metastasis, tumor did not invade the pancreas, superior mesenteric artery, and no para-aortic lymph node metastasis. Contraindications 1. Clinically confirmed distant metastasis, such as supraclavicular lymph node metastasis, rectal examination touches the rectum bladder (uterus) fossa tumor, B-ultrasound, CT or chest radiograph confirmed liver or lung metastasis. 2. Exploratory laparotomy revealed that the abdominal wall has been diffusely implanted, the liver has metastasis, the tumor has invaded the pancreatic parenchyma or has affected the superior mesenteric artery, the pelvic cavity has been implanted, and there is lymph node metastasis along the abdominal aorta. Tumors with the above phenomenon are already in the scope of radical resection, and palliative surgery, including palliative partial gastrectomy or gastrojejunostomy, may be performed as appropriate. Preoperative preparation 1. Correct anemia, ascites and hypoproteinemia. Blood transfusion, plasma or human albumin, as well as short-term intravenous nutrition, can be used as appropriate to improve nutritional status. 2, for those with incomplete pyloric obstruction should be fasted or only into the liquid diet, while giving 3 to 5d gastric lavage. 3, routinely prepare for intestinal cleansing before surgery. 4, 1d preoperative routine cleansing of the upper abdomen and surrounding skin. 5. Place the nasogastric tube on the morning of the operation. 6. Intravenous administration of metronidazole 0.5g and antibiotics on the morning of surgery. Surgical procedure 1, surgical incision The upper part of the upper abdomen is the most commonly used incision from the left side of the umbilicus to the left side of the umbilicus to the lower part of the umbilicus. It can be freely extended to meet the requirements of full exposure. 2, laparotomy In addition to the above, focus on the extent of tumors at the esophagus in the Tuen Mun. If the lower esophagus is less than 2cm, it can be removed by abdominal abdomen; if the lower esophagus is more than 4cm, it is difficult to cut through the abdominal surgery, and it is necessary to consider thoracotomy. If the lymph node metastasis at the spleen is involved, and there is tumor involvement at the spleen and stomach ligament, it is necessary to consider the simultaneous removal of the spleen and pancreatic tail. 3, free stomach large curved side The gastric colon ligament was dissected from the upper edge of the middle part of the transverse colon, and the omentum was removed to the left until the spleen of the colon. The gastric spleen ligament was continued (Fig. 1, 5, 8, 2-1) until the left side of the cardia. Here, scissors can be used to cut the esophagus and the peritoneum on the left side. Generally, there is no blood vessel, and it is not necessary to use a clamp to break. 4, disconnected small omentum Cut the small omentum from the inside of the hepatoduodenal ligament, do not cut the left gastric artery, remove the small omentum as much as possible, the upper end to the right side of the cardia, use scissors to cut the peritoneum on the right side of the esophagus, so that it communicates with the left side. . 5, the corpuscle The two gastric retinal vessels are separated from the stomach wall distal to the avascular region corresponding to the large curvature of the stomach. Close to the stomach wall at the corresponding small curvature of the stomach, cut off the left branch of the left gastric artery to the distant branch at a distance of more than 6 cm from the lower edge of the tumor. The XF-type stapler was used to clamp and cut the stomach body on the large curved side. The small curved side was cut with a dental vascular clamp to cut the stomach. 6, treatment of the left gastric artery The proximal stomach of the disconnection is turned up and pulled upward, and the assistant gently pulls the pancreas to the other side by hand to expose the beginning of the left gastric blood vessel. Use the scissors to cut the anterior and posterior lobes, and dissociate the two vessels in the left venous and arterial roots, first ligature the left gastric vein, ligature the root of the left gastric artery and the distal side 1 cm, and then cut the left gastric artery. The residual end is inserted through a stitch. 7, disconnected esophagus The proximal stomach is turned up and pulled toward the head end, and the peritoneum is removed after the angle of the diaphragm is cut. There is no important blood vessel here, and the acute separation from the esophagus can be performed, and the vagus nerve trunk of the left anterior and right posterior esophagus can be cut off. The esophagus is free from 6 to 8 cm. Let the anesthesiologist withdraw the stomach tube to the upper part of the esophagus, clamp the esophagus 5 cm on the cardia with non-invasive forceps (or clamp the esophagus at 3 points on the cardia with a purse-string suture clamp), and clamp the distal end of the esophagus with a tracheal forceps or a large right angle clamp. , cut it off. The entire specimen of the excised proximal stomach was removed. Make a purse-string suture at the end of the esophagus. Insert the needle seat of the appropriate tubular stapler into the esophageal lumen, insert two tissue clamps to clamp the esophageal margin, and use a long flat file to clamp the front side of the esophagus. The rows are placed, and the rear side is rotated and all inserted, and the purse string is tightened and ligated. 8, the distal stomach and the esophagus do the anastomosis The vascular clamp of the distal curved side of the stomach was removed, and the blood vessels of the gastric wall were sewed. The anterior wall (or posterior wall) at 4 cm from the end of the tubular stomach formed on the large curved side of the stomach was sutured. In the middle of the center, the stomach wall is cut into a small opening, and the center rod of the stapler is inserted into the small opening, and the purse string is tightened and ligated. The body of the tubular stapler is inserted through the incision of the small curvature of the stomach, and the center rod of the needle holder is inserted into the center of the stapler body. After the center rod and the stapler are aligned, the spiral of the tail of the stapler is rotated to make the stomach and the esophagus close. At this point, the application of the hand to check whether the stomach and esophagus junction is smooth, no irregular tissue prominent. Open the insurance, grasp the cutting and matching tool, cut the anastomosis once to complete the loosening screw, and take the main body of the stapler together with the center rod to the needle seat (or separately), and check that 2 complete tissue rings have been cut. Generally, it is not necessary to reinforce the suture, the stomach tube is lowered, and the end 5 cm is left in the gastric cavity, and the incision of the small curvature of the stomach is interrupted by two layers of 3-0 non-absorbable lines. 9, placement drainage One cigarette and one latex drainage tube were placed under the left side of the anastomosis, and another puncture was made under the left costal margin. 10. Close the abdominal incision with the distal subtotal resection. complication 1, postoperative anastomotic leakage. 2. Incision infection. 3. Residual infection in the abdominal cavity.