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Subtotal
Gastrectomy
Generally, the first maneuver in
gastric resection is to enter the lesser sac. This is
achieved by dividing an avascular portion of the greater
omentum. The hand elevates the stomach to facilitate this
maneuver. The extent of omental resection will depend upon
the malignant potential of the lesion. For benign disease,
once the lesser sac is entered, the omentum is detached
directly along the greater curvature outside the
gastroepiploic arcades by electrocautery, clips, or
ultrasonic scalpel. For more extensive omental resection,
the omentum is detached from the transverse colon along
the fusion plane either sharply or with electrocautery to
again enter the lesser sac. The most distal region of
greater curvature is then approached for the
identification of the right gastroepiploic artery.
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laparoscopic instruments in the left hand introduced
through the 12 mm port, the artery is dissected, and
ultimately divided between endoclips. The hand, throughout
the initial and subsequent stages of dissection, is a
constantly active participant. The hand can provide blunt
dissection, tactile feedback, and a wide range of grasping
and retraction options, which can continuously change the
exposure, and presentation of the tissue to the
laparoscope and laparoscopic instruments.
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The
first goal of laparoscopic gastric resection is to
pedicalize the stomach by dividing the pylorus. Once the
right gastroepiploic is divided, the retroduodenal
dissection is facilitated by upward retraction on the
stomach by the right hand. Small feeding vessels to the
pylorus can be divided with electrocautery. The hand can
feel and choose a site distal to the pylorus for distal
transection margin.
A linear stapler is introduced through the 12 mm port to
transect the duodenum |
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The
hand can then be placed behind the distal stomach segment
that is elevated and retracted downward. Dissection along
lesser curve (lesser omentum) is carried out. The right
gastric artery is identified and then divided between
endoclips. |
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The
lesser omentum is divided along the lesser curve to the
site of the proximal resection margin. Descending branches
of the left gastric will need to be clipped and divided
While
advancing up the lesser curvature, the left lobe of the
liver will require retraction. Occasionally this is simply
accomplished by using the back of the hand or one extended
finger, while the palmar side of the hand can still be
engaged in the act of retraction and palpation. Usually,
an assistant may hold up the left lobe with a blunt probe
introduced through the 5 mm port.
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