Transabdominal total gastrectomy

Transabdominal total gastrectomy for the treatment of gastric cancer. Total gastrectomy is an important method for surgeons to treat benign and malignant diseases. It is often used in the treatment of cardiac cancer, gastric upper and middle cancer, and diffuse invasive gastric cancer. As an important part of radical gastrectomy, the operation of total gastrectomy and lymph node dissection is performed simultaneously. Therefore, the method and procedure of total gastrectomy are introduced as an example of D2 (root 2) surgery of gastric cancer. Other gastrectomy for other malignant and benign diseases of the stomach, such as the operation of gastric cancer with D1 and D3, and the operation of certain pancreatic gastrinoma, may increase or decrease the scope and steps of surgical resection according to the condition of the disease. Treatment of diseases: gastric cancer preoperative preparation 1. Patients with poor general condition and nutritional status should improve their general condition before surgery to correct malnutrition, anemia and hypoproteinemia. A diet high in protein and sufficient vitamins should be given. If necessary, transfusion or plasma transfer should increase the levels of hemoglobin and plasma protein. 2. Patients with dehydration and electrolyte imbalance should be properly infused and supplemented with electrolytes before surgery to correct water and electrolyte disturbances. 3. Patients with pyloric obstruction should start fasting, gastrointestinal decompression, infusion, daily gastric lavage 2 or 3 times before surgery, emptying the food and secretions in the stomach, reducing inflammation of the gastric mucosa. And edema to facilitate recovery after surgery and surgery. 4. Patients with ulcer bleeding should take various anti-shock measures before surgery to actively transfuse blood and try to make up the blood volume. 5. Patients undergoing elective surgery performed soapy water enema 1 day before surgery, and fasted in the morning on the day of surgery. Surgical procedure 1. Exploring the abdominal cavity Abdominal probing can be supplemented and corrected for preoperative diagnosis, which is the ultimate basis for determining the extent of gastric resection and the extent of lymph node dissection. Exploring the abdominal cavity should follow the principle of no tumor, and the location of the pelvic-infraorbital-liver-mesenteric root is closely related to the location of the pelvic-infraorbital-liver-mesenteric root. Those who need to undergo abdominal exfoliative cell examination can be performed after exploring the abdominal cavity. 2. Operation of the large curved side of the stomach The surgeon lifted the omentum to the left hand and separated the right hand. The assistant pulled the transverse colon downward with his left hand and assisted the separation with his right hand. Incision of the greater omentum along the transverse colon and removal of the anterior transverse mesenteric lobe, separated to the right, fully revealing the head of the pancreas and duodenum, under the pancreas can show the confluence of the colonic vein and the right vein of the gastric retina. Here, the right vein of the gastric retina is cut and ligated, otherwise it may cause residual lymph nodes under the pylorus. Continue to separate the inside of the duodenum, cut and ligation of the right artery of the gastric retina at the root. Complete removal of the pyloric lymph nodes. Continue to separate the omentum to the left to the spleen colon ligament, and remove the pancreatic capsule that continues in the anterior transverse mesenteric membrane while separating. 3. Cut off the duodenum First close to the liver to cut the liver and stomach ligament to the right side of the cardia, which is more conducive to confirm the right blood vessels. In some cases, there are parahepatic arteries in the liver and stomach ligament, which should be ligated. The serosal membrane of the duodenal ligament was cut open, and the right movement and vein of the stomach were cut at the root, and the loose tissue surrounding the lymph node was removed. The duodenum is fully dissociated and disconnected. The duodenal stump can be closed with a closure device and sutured with a silk thread. 4. Cleaning of the lymph nodes associated with the upper edge of the pancreas In the above steps, the tissue under the pancreas has been sufficiently freed, so that the stomach is turned upside down and the left upper abdomen is pulled up to fully reveal the tissue of each group of lymph nodes which are closely related to the metastasis of gastric cancer, and can be removed together. Firstly, the loose tissue in front of and above the common hepatic artery is removed. In this segment, the coronary venous venous flow returns to the splenic vein, and should be ligated at the confluence. Continue to separate to the left side, remove the loose tissue of the splenic artery root, and continue to dissect upward to reveal the left gastric artery, and ligature and cut it at the root, and remove the peritoneum and the loose tissue in front of it to the posterior side of the cardia. 5. Operation of the left side of the stomach The gastric spleen ligament was cut and ligated in turn until the left side of the cardia. After clearing the tail of the pancreas, the peritoneum and the lymph nodes in front of and above it should be more convenient to operate after cutting off the gastric spleen ligament. In some cases, the posterior gastric artery is dominated by the posterior stomach at 2/3 of the spleen to the root of the splenic artery. Wall blood supply should be cut off and ligated. Separate to the front of the esophagus, cut the anterior peritoneum, and insert the finger from the posterior part of the esophagus to make a blunt dissection. The vagus nerve can be touched and ligated before being cut and ligated. At this time, the lower part of the esophagus can be fully dissociated. The esophagus was cut at an appropriate distance above the cardia according to the location and growth pattern of the tumor, and the specimen was completely removed. Generally, the lower end of the esophagus is clamped with a non-invasive forceps, and the stapler can also be clamped by a purse clamp. 6. Digestive tract reconstruction At 20 to 40 cm from the ligament of the flexor, the vascular arch was cut according to the blood vessel, and the intestine was cut. The distal intestine is lifted in front of the transverse colon to anastomosis. The anastomosis of the jejunum and the esophagus is more secure. First, a purse-string suture is performed at the end of the esophagus. Generally, an appropriate stapler is selected according to the inner diameter of the jejunum. The staple anvil of the stapler is inserted into the end of the esophagus, and the purse string is tightened and ligated. Insert the stapler into the distal jejunum, insert the center rod out of the intestinal wall, and engage the nail anvil. Tighten the knob on the handle to close the lower end of the esophagus and press the firing handle to complete the anastomosis. In the process of approaching the lower end of the esophagus and the jejunum, the jejunum should be pulled down and flattened to avoid stenosis caused by clamping the contralateral intestinal mucosa into the anastomosis. The jejunal stump was closed with a closure and sutured with a silk thread. At the 50cm below the anastomosis, the proximal jejunum and the distal jejunum were anastomosed to the end-to-side. The side-to-side anastomosis was also performed, and the stump was closed with a closure. Intermittently suture the mesenteric rupture and complete the reconstruction of the digestive tract. There is also a method of jejunal esophageal anastomosis after the colon. The procedure is similar, but finally the transverse mesenteric hiatus is sutured intermittently with the jejunum that passes through it. complication 1. Postoperative anastomotic leakage If the patient has pyloric obstruction before surgery, long-term under-feeding, low nutritional status, a large tension in the anastomosis during operation, the suture is not accurate enough, and anastomotic leakage may occur after surgery. It usually appears 5 to 7 days after surgery. If the abdominal drainage tube has not been removed, the gastrointestinal contents can be discharged from the drainage tube, and there is a limited peritonitis phenomenon. The swallowing of methylene blue can be further confirmed. Once there is an anastomotic leakage, it should be fasted, the abdominal drainage tube should be changed to double cannula flushing and attracted, and treated with total parenteral nutrition support. Most cases can heal within 3 to 4 weeks after the above treatment. 2. Incision infection The operation is a contaminant operation. If the incision protection is not perfect during the operation, there is a gastrointestinal fluid overflow during the implementation of the gastrointestinal anastomosis, and a wound infection may occur. It usually appears around 1 week after surgery. Most of them are infections in the subcutaneous layer, and the incision of the infected part should be opened and fully drained. 3. Abdominal residual infection If the drainage tube placed after the operation is not well drained, or the drainage tube is removed too early, part of the exudate will accumulate in the local area, which may lead to local infection of the abdominal cavity. It is characterized by an increase in body temperature, an increase in the total number of white blood cells and a proportion of neutrophils, and may or may not be limited to abdominal pain or abdominal tenderness, which is generally difficult to diagnose. Multiple scans of the abdomen with B-ultrasound may reveal dark areas with localized fluid. Once diagnosed, it can be confirmed by B-guided puncture and then drained.