用于胃良性病变：典型的胃大部切除术，变异：胃窦切除（图文演示）

中文版：用于胃良性病变：CLASSIC胃大部切除术，变异：胃窦切除（中文图文演示）

ASTRECTOMY   FOR   BENIGN   LESIONS:   CLASSIC   PARTIAL   GASTRECTOMY,   VARIATION:   ANTRECTOMY
Authors
D Mutter
Abstract
The description of the classic partial gastrectomy for benign lesions and its variation: antrectomy covers all aspects of the surgical procedure used for the management of benign gastric tumors.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: surgical approach, principles, mobilization of greater curvature, mobilization/transection, gastrojejunal anastomosis, gastroduodenal anastomosis, difficult duodenums, freeing of the curvature, transection of the stomach, restoration/continuity, Billroth I anastomosis, Billroth II anastomosis.
Consequently, this operating technique is well standardized for the management of this condition.

1. Introduction

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Historically, gastrectomy was indicated for benign lesions and in the radical treatment of gastric ulcers.
A significant decrease in the indications for gastrectomy has been observed in Western countries due to:
- the practice of vagotomy;
- the administration of anti-ulcer medications such as H2-blockers, proton pump inhibitors (PPI);
- the eradication of Helicobacter pylori with antibiotics.
Today, therapeutic failure for gastric ulcers is seen in less than 5% of the cases and gastrectomy represents less than 1% of surgical interventions for gastric ulcers.

Surgery is only indicated in patients who either do not respond to medical therapy or have a poor compliance record (Michot and Fraleu-Louer, 1996). Other indications are benign tumors and/or certain functional disorders.
Gastrectomy may be performed via the open approach and, more recently, via the laparoscopic approach.

2. Definitions/resection

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A partial gastrectomy (usually indicated for benign lesions) consists of the resection of a defined part of the stomach. Rarely, a proximal resection is performed, but more commonly performed is a distal resection with or without the pylorus, an antrectomy, or a two-thirds resection of the stomach.
The line of transection through the stomach is oblique.
It starts on the lesser curvature 2 fingerbreadths (4 cm) below the cardia at the level of the left gastric artery to finish at the level of the first short gastric vessel located in the avascular zone of the greater curvature.

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The line of transection through the stomach is oriented in a horizontal direction.
It starts one fingerbreadth (2 cm) above the angulus (junction between the horizontal and vertical regions of the lesser curvature), to finish on the midpoint of the gastroepiploic artery of the greater curvature.

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The correct landmark for the distal gastrectomy is also the landmark between the mobile part of the duodenum and the fixed duodenum. It is located below the pylorus, at the level of the duodenal bulb, 1 cm to the left of the gastroduodenal artery.

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Restoration of gastrointestinal tract continuity is established:
- with a gastroduodenal anastomosis (performed manually or by a mechanical stapler),
or
- with a gastrojejunal anastomosis where the remaining gastric stump is united to the first jejunal loop (as above).

3. General anatomy
• Anatomical description

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The stomach is a J-shaped sac located between 2 fixed anatomical landmarks:
1. the cardia: junction between the abdominal esophagus and stomach,
2. the pylorus: junction between the stomach and duodenum.

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The stomach is composed of 2 parts:
3. the vertical part inclines over the vertebral column to the left and is composed of both the fundus and the body of the stomach;
4. the horizontal part heads to the right beyond the linea alba.

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The duodenal bulb, often resected during gastrectomies due to its proximity to the stomach, is:
5. the first mobile segment of duodenum. It is separated from the pancreas by the omental bursa, which extends from the right to the gastroduodenal artery.

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From a physiological standpoint, the stomach is composed of:
6. a gastrin-producing zone called the antrum,
7. the fundus.
The junction between these functional regions does not correspond to the junction between the horizontal and vertical regions of the stomach.

4. Vascular anatomy

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Gastric arterial blood supply comes from the celiac trunk.
It divides into 4 pedicles, 2 each at the level of the:
1. lesser curvature,
2. greater curvature.
The pedicles then join a wide anastomotic network that supplants vascular blood supply when one of the main trunks is either obstructed or ligated.

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The celiac trunk supplies the stomach.
It originates from the anterior aspect of the aorta above the superior aspect of the pancreas.
The trunk is 1 to 3 cm long and divides into 3 branches:
1. the left gastric artery;
2. the common hepatic artery;
3. the splenic artery.

5. Lesser curvature
• Left gastric artery

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The left gastric artery originates from the celiac trunk in 90% of cases.

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Alternatively, it originates either:
1. directly from the aorta;
2. from the inferior phrenic artery;
3. from the gastrosplenic trunk;
4. from the gastrohepatic trunk.

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The left gastric artery forms an arch before joining and running along the lesser curvature 2 fingerbreadths below the cardia. It then divides into an anterior (1) and posterior (2) branch that both run down along the lesser curvature to join the terminal branches of the right gastric artery (or pyloric artery).

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The left gastric artery gives off several branches:
1. the hepatic artery (present and functional in 30% of cases);
2. the anterior and posterior cardioesophageal arteries (that supply the cardia and abdominal esophagus).

• Right gastric artery

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The right gastric artery usually originates from the common hepatic artery.

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Alternatively, it originates directly from:
1. the gastroduodenal arteries;
2. the left hepatic artery;
3. the proper hepatic artery.

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The right gastric artery approaches the pylorus, giving off one of its main terminal branches. It then divides into anterior and posterior gastric branches that join the terminal endings of the left gastric artery at the level of the angulus, the junction between the horizontal and vertical regions of the stomach.
The right and left gastric arteries comprise the vascular arch of the lesser curvature.

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The free duodenum is vascularized by branches mainly originating from the gastroduodenal artery.

6. Greater curvature

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The greater curvature of the stomach is bordered by the greater omentum and gastrosplenic ligament. Each is composed of 2 layers in continuum with the gastric visceral peritoneum. The greater omentum spreads over the transverse colon and extends beyond it inferiorly at the level of the body and horizontal region of the stomach where it forms the gastrosplenic ligament at the level of the fundus. The right and left gastroepiploic arteries and the short gastric vessels form the vascular arch that runs through the anterior fold of the greater omentum.

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The right gastroepiploic artery:
1. originates from the division of the gastroduodenal artery at the inferior aspect of the duodenum;
2. runs along the greater curvature of the stomach from right to left at an average distance of 1 cm;
3. the branches originating from the right gastroepiploic artery run along the anterior and posterior aspects of the stomach and into the omentum.

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The left gastroepiploic artery originates from the division of the splenic artery. It supplies the middle part of the greater curvature and runs through the gastrocolic ligament to join the terminal branches of the right gastroepiploic artery.
The right and left gastroepiploic arteries thus form the vascular arch of the greater curvature.

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The short gastric vessels originate from the terminal branches of the splenic artery.
Alternatively, they originate directly from the trunk of the splenic artery or from its terminal branches.
There are 2 to 6 vessels that run from the splenic hilum to the stomach via the gastrosplenic omentum.
The largest vessel – the posterior gastric artery – joins the posterior aspect of the stomach and divides to supply the fundus and the cardia.

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An avascular window consisting of 2 peritoneal folds is situated between the last short gastric vessel and the origin of the left gastroepiploic artery. These peritoneal folds split to form the omental bursa opposite the splenic artery.

7. Operating room set-up

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The operation is performed under general anesthesia.
The patient is administered antibiotic prophylaxis (systematically) and put in supine position.
A nasogastric tube is inserted to fully decompress the stomach.
Padding (preferably inflatable) is set underneath the patient to obtain better exposure of the intra-abdominal anatomy. The operating table may be bent posteriorly at the level of the inferior angle of the scapula in order to obtain the same result. This angle must be straightened before parietal closure, at the end of the procedure.

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1. The surgeon stands on the patient’s right.
2. The first assistant stands opposite the surgeon.
3. The second assistant stands on the surgeon’s left.
4. The scrub nurse stands opposite the surgeon and on the first assistant’s left.
5. The anesthesiologist is at the head of the patient.

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1. Anesthetic equipment
2. Electric device
3. Operating table
4. Instrument table

8. Surgical approach

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The midline incision extends from the xiphoid process to the umbilicus.
The upper part of the abdominal incision clearly reveals the xiphoid process and provides good visualization of the upper part of the stomach. In obese patients, the inferior part of the abdominal incision extends slightly to the left of the umbilicus. The round ligament remains undisturbed to facilitate exposure.
The parietal wall is protected using a plastic “skirt” and a “Gosset” abdominal retractor.
Subcostal retraction is not necessary.

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A horizontal bilateral subcostal incision can also be utilized.

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1. Dissection of the greater curvature
2. Dissection of the duodenum
- Billroth II operation (closed duodenal stump)
- Billroth I operation (opened duodenal stump)
3. Dissection of the lesser curvature
4. Transection of the stomach
5. Restoration of the gastrointestinal tract continuity
- Billroth II anastomosis
- Billroth I anastomosis