In recent years, a lot of importance is being attached to the restoration of the gastro-intestinal tract after total gastrectomies. We present a new method of reservoir reconstruction which has proven to be effective and simple. After a total gastrectomy, a section of the jejunum 40-45 cm in length, is cut out 14-15 cm from the lig. suspensorium duodeni (Treiz) along with its mesentery, one end of which is securely sutured. (photo-1, photo-2).
The intestinal loop is directed from behind the colon to the upper section of the abdominal cavity and at a distance of 20-22 cm (the middle of the loop) an oesophago-intestinal lateral stoma is formed and the continuity of the small intestine is restored through an end-to-end small intestinal anastomosis (photo-3).
A wide anastomosis is formed between the adducting and abducting loops of the section of small intestine moved to the epigastrium giving shape to a reservoir and the open end is anastomosed to the duodenum end-to-end (photo-4, photo-5, photo-6). The inter-intestinal anastomosis is secured to the mesocolon defect in order to prevent internal herniation (photo-7). All the above anastomoses can be formed both with the help of staples (which is quick but expensive) as well as with a single-row suture using an absorbable synthetic thread (which is also quick, but is significantly cheaper). (photo-8)
In patients who have undergone total gastrectomies, the passage of food through the duodenum is considered a major factor in the profilaction of post resection and dumping syndromes. For that reason we suggest a simple and quick method of reconstruction using a purse string, which closes the lumen of small intestine and controls the passage of food towards the duodenum.
After total gastrectomies, an anastomosis is formed between esophagus and small intestine (end-to-side), 25-30cm far from the ligament of Treiz (photo-1). The adducting loop, nearer to the anastomosis is closed with a purse string (Shalimov’s closure).
About 25-30 cm far from the esophago-intestinal anastomosis, on the abducting loop of small intestine, another stoma is formed between the duodenum and small intestine (side-to-end), followed by another Shalimov’s closure on the abducting loop of small intestine beneath the duodenal-intestinal stoma. (photo-2)
A final stoma, 3-4 cm beneath the second Shalimov closure, is formed between the adducting and abducting loops (Braun’s side-to-side anastomosis). The above mentioned reconstruction method, allows the passage of food through the duodenum without cutting the intestine and forming additional stumps, a factor which in turn will reduce the prevalence of bile reflux and dumping syndrome (photo-3).
The dissemination of gastric cancer in the regional lymphatic apparatus occurs in 75% of patients and is considered to be a bad prognostic sign. In some cases, the affected lymph nodes form large conglomerates, whose removal in the processes of gastrectomy is needed to handle the major vessels of the stomach. At the same time, the maximum dissection of lymph nodes increases the effectiveness of subsequent adjuvant chemotherapy and improves the quality of life of patients. However, conducting analogical dissection is very difficult because of localization around the major vascular trunks and the danger of damage to the latter. In this regard, we present our technique of removing large conglomerates of lymph nodes in gastrectomies.
Most often they occur in a small gland at the upper edge of the pancreas and in the greater gland, on the path of the right gastroepiploic artery (photo-01). After crossing the peritoneal wall - between the omental bursa and the proximal third transverse colon, not covered by the peritoneum, fatty tissue - is mobilized (manually) bluntly and assigned to the distal part of stomach. After attending to a few small vessels, the mobilization continues to the distal edge of the upper horizontal part of duodenum, then the fatty tissue covering the ventral surface of the head of the pancreas with a conglomerate of lymph nodes is assigned to the stomach. Here the right gastroepiploic vessels are crossed and intersected ( photo-02 ). The use of a harmonic scalpel is a great help in conducting this phase bloodlessly ( photo-03).
After crossing the right gastroepiploic vessels, ( photo-04, photo-05 ), the duodenum is mobilized, the right gastric artery is tied up and the duodenum is cut 1,5-2,0 cm more distal from the antral sphincter. Pulling the stomach up and left to a certain extent facilitates the mobilization of the conglomerate of lymph nodes along the upper edge of the pancreas ( photo-06 ). In this zone, the nodes are often directly adjacent to the major vascular trunks, infiltrating surrounding tissue, making it difficult to mobilize them, raising the possibility of damage to the vessels. In this regard, the harmonic scalpel provides definite assistance, which allows the processing of tissues in the immediate vicinity of the vessels without the risk of damage ( photo-07 ).
In case of apparent infiltration of surrounding tissues, especially of pancreas, it is safer to separate the tissues from under the capsules of the pancreas dissected in an unmodified portion at a certain distance from the removed tissue, using a dissector and harmonic scalpel ( photo-08, photo-09 ). Traction of the tumor conglomerate with the capsule of the pancreas upwards allows the harmonic scalpel to separate it bloodlessly from the prostate and to expose the trunk of the common hepatic artery ( photo-10 ). Separating the division of the removable conglomerates is achieved by treating the lesser omentum, by abducting fatty tissues to the stomach ( photo-13 ). The complete treatment involves the removal of fatty tissue from the duodenum, common and proper hepatic, splenic artery (photo-14, photo-15). At the end, the left gastric artery is handled and cut ( photo-16, photo-17 ).
Surgery of gastric cancer remains the main option, allowing the achievement of sustainable long-term results and a satisfactory quality of life in patients. The approaches to the volume of regional lymph node dissection are still an issue of discussion in the specialized literature, although more surgeons are inclined to believe the necessity of performing extended lymphadenectomy (photo-02).
It is believed that it allows to improve long-term results of treatment and to achieve more accurate staging of the tumor process. The experience of the recent years shows that with certain skills the frequency of postoperative complications after extended lymphadenectomy is not higher than after standard resection when only perigastral lymph nodes are removed (photo-01).
At present, dissection along with the main trunks of the stomach is carried out not only to achieve adequate ablastics of the surgical intervention (curative resection) but also to facilitate the treatment and section of gastric vessels during palliative gastrectomies. We usually start the dissection of lymph nodes after crossing the duodenum and forming its stump. Often on the upper edge of the pancreas and in the gastro-pancreatic bundle, there is a defined enlargement of the lymph nodes ( photo-01, photo-02).
Dissection starts from the intersection of the capsule of the pancreas along the course of the common hepatic artery and the allocation of fatty tissue with lymph nodes (photo-03). Using the harmonic scalpel accelerates dissection, making it more bloodless ( photo-04, photo-05, photo-06, photo-07). Separated fatty tissue is abducted to the stomach (photo-08). Continuing to mobilize fatty tissues with nodes in the proximal direction we distinguish the left gastric artery ( photo-09). Here it is treated and intersects the left gastric vein, flowing into the splenic vein behind the pancreas (photo-10, photo-11, photo-12).
Separating the fatty tissue from the stump of the duodenum to the liver along the hepatic artery allows to excise the liver lymph node hilus, which then together with the fatty tissue of the small gland also is abducted to this mass, baring the right foot of the diaphragm (photo-13). Next, the capsule of the pancreas intersects with the splenic artery (photo-14). The fatty tissue with lymph nodes is assigned to the stomach (photo-15) together with the peritoneum lining the left leg of the diaphragm. We had а case of an anatomic variant of the passage of the splenic vein over a common hepatic artery (photo-16), which must be kept in mind to prevent its damage and possible bleeding.
After finishing the extended lymph node dissection in gastric cancer patients, what remains in the operating field is the cleaning from fatty tissue and lymph nodes the diaphragm legs, splenic, common and proper hepatic artery, and also in some cases, the initial division of gastro-duodenum artery (photo-17). In all gastroectomies that are considered to be curative, we conduct a mandatory extended lymphadenectomy.
The problem of correction of complications associated with the spread of tumors remains one of the most complicated in surgery. The above fully applies to cases of mechanical jaundice, especially when there is no possibility of forming a biliary-enteric stoma bypass. In some cases, the way out of the situation is a hepatic-intestinal anastomosis, allowing the diversion of bile through the peripheral ducts into the lumen of the small intestine.
However, the reliability of sutures on the liver, due to the peculiarities of its tissue, is not good and may cause the development of severe postoperative complications. We offer the method of formation of such anastomosis with longitudinal flaps of prolene mesh to increase the reliability of the anastomosis sutures. Such an operation is performed with extensive tumor lesion of the abdominal cavity ( photo-03) and the impossibility of forming a biliary-enteric anastomosis or external excretion of bile. Initially, on the left lobe an area is defined for the boundary resection and a loop of small intestine is applied for anastomosis ( photo-01, photo-02 ).
Boundary resection of the left lobe of the liver is performed ( photo-04, photo-05 ). Longitudinal scraps of prolene mesh with 1,5 cm width and appropriate length are fixed at the bottom and the front surfaces of the liver, resected along its edges ( photo-06, photo-07, photo-08 ). Fixing sutures are conducted through the entire thickness of the liver along its longitudinal axis, to avoid the capture of biliary ducts into the stitches. Then double-row anastomosis is formed, covering the seam edges of the prolene mesh ( photo-10, photo-11, photo-12, photo-13). In such an anastomosis, the jaundice reduces gradually, because of the small diameter of excretory biliary ducts. While using a prolene mesh, cases of anastomosis suture insufficiency have not been noted.
Surgical interventions in case of cancer of the pancreas are still relatively rare and are mostly performed in specialized clinics. The technique of their performance over the past two decades has undergone significant progress, which allowed to greatly reduce the number of postoperative complications, bringing them down to 3-4% and also lowered hospital mortality. Our experience in pancreaticoduodenal resection revealed their high level of tolerance by patients, low frequency of complications and mortality.
The average duration of surgery is about 4 hours, with minimal blood loss. Below is our method of pancreaticoduodenal resection. After laparotomy, to determine the relationship of the tumor to the upper mesenteric vessels, the mobilization of duodenum is performed according to Kokher, after which we go on towards the lower-horizontal division, with access to the upper mesenteric vein (photo-01, photo-02, photo-03, photo-04).
Cholecystectomy and further mobilization of the bile duct allows us to determine the relationship of the tumor to the common hepatic artery, portal vein and facilitates the treatment of the gastro-duodenal artery. The status of regional lymph nodes is also evaluated. At this stage, the dissection of fatty tissues with the lymph nodes is also performed in the hilus area of the liver and small gland (photo-05, photo-06). In the mobilization of the pancreas from the upper mesenteric vessels and its section to the line of resection it is convenient to use a harmonic scalpel, which provides for the bloodless resection of the pancreas (photo-07, photo-08, photo-09).
After removal of the mass, the rehabilitation phase of the operation begins with the formation of a submerged double rowed anastomosis between the pancreas and small intestine end to end. However, we do not drain the Virsungov duct (photo-10, photo-11, photo-12, photo-13, photo-14). Then single row choledochо-enteric and gastro-enteric anastomosis are formed with the use of continuous suture technique. Individual drainage of bile duct is performed only in patients with high levels of bilirubin (photo-15, photo-16). The operation is completed with the exclusion of the adducting loops of the small intestine according to Shalimov and the formation of additional interintestinal anastomoses according to Brown, which are then fixed to the peritoneum at the intersection of the Treyts ligament. (photo-17).
A 24-year patient was admitted and examined for a mass in the right lobe of the liver located in the V, VI, VII and VIII segments of the body. The sonography and computerized tomography interpreted the mass as a primary hepatocellular carcinoma, but examination of the hepatic markers did not detected any increase and a percutaneous puncture of the liver was not informative. Taking into consideration the absence of changes in the regional lymph system and distant metastases, it was decided to remove the right lobe of liver with the pathological foci.
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In recent years in operations of the organs of gastrointestinal tract the methods of single layer anastomosis formation are applied, which were facilitated by the introduction of new surgical suture materials in practice (vicryl, monocryl, the PDS, prolene, etc.). During the last 1.5 years we have been actively using single layer anastomosis in the department, using a continuous suture. During this period, more than 200 anastomoses were formed, with one case of insufficiency of thin-intestinal anastomosis after subtotal gastrectomy.
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