远端胃癌根治术（图文演示）

10. Major principles

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A D2 gastrectomy aims for a total (R0) resection of the cancer. The extent and type of lymph node dissection is determined by JGCA (1998) as follows:
D0: No dissection or incomplete dissection of Group 1 nodes
D1: Dissection of all Group 1 nodes
D2: Dissection of all Group 1 and Group 2 nodes
D3: Dissection of all Group 1, Group 2 and Group 3 nodes

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• UICC classification

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TX: Primary tumor cannot be assessed
T0: No evidence of primary tumor
Tis: Carcinoma in situ: intraepithelial tumor without invasion of the lamina propria
T1: Tumor invades lamina propria or submucosa
T2: Tumor invades muscularis propria or subserosa
T3: Tumor penetrates serosa (visceral peritoneum) without invasion of adjacent structures
T4: Tumor invades adjacent structures

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NX: Regional lymph nodes cannot be assessed
N0: No regional lymph node metastasis. pN0: Histological examination of a regional lymphadenectomy specimen will ordinarily include 15 or more lymph nodes.
N1: Metastasis in 1 to 6 regional lymph nodes
N2: Metastasis in 7 to 15 regional lymph nodes
N3: Metastasis in more than 15 regional lymph nodes

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MX: Distant metastasis cannot be assessed
M0: No distant metastasis
M1: Distant metastasis

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The location of the tumor is endoscopically tattooed with an india ink injection before the operation.
1. Tumor

12. Greater curvature

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The procedure begins with the preparation of the greater curvature of the stomach. Using laparosonic coagulating shears (LCS), the gastrocolic ligament is divided approximately 3 cm from the gastroepiploic vessels in order to harvest all lymph nodes along these vessels (No. 4d and No. 4sb).

• Gastroepiploic vessels

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The dissection of the gastrocolic ligament is continued towards the gastrosplenic ligament. The left gastroepiploic vessels are crimped with double clips and divided at their origins. To allow subsequent anastomosis, the greater curvature is skeletonized from the distal end to the proximal end using LCS.

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The division of the gastrocolic ligament is then continued towards the pylorus. At the head of the pancreas, the right gastroepiploic vein is isolated and divided at its origin. The infrapyloric lymph nodes (No. 6) are dissected, and the right gastroepiploic artery is exposed and divided at its origin with double clips.
1. Right gastroepiploic vein
2. Right gastroepiploic artery

13. Duodenal transection

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After the stomach is retracted with a grasper, the right gastric vessels are divided with double clips at their origin. This allows dissection of the suprapyloric lymph nodes (No. 5).

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The duodenum is divided with a laparoscopic linear stapling device approximately 1 cm from the pylorus.

14. Lesser curvature
• Dissections

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The common hepatic artery and the gastropancreatic fold, including the left gastric vessels, are then exposed by caudal retraction of the pancreas. The lymph nodes along the proper (No. 12a) and common hepatic arteries (No. 8) are dissected towards the celiac axis using LCS. Retraction of the common hepatic artery using a vessel loop facilitates this procedure.

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The lymph nodes along the proximal side of the splenic artery (No. 11p) are dissected. The left gastric vessels are exposed, allowing the dissection of lymph nodes (No. 7), and divided at their origin with double clips. The celiac vagal branch, which runs to the celiac ganglion along with the left gastric artery, taking position just behind this vessel, is also dissected to complete the dissection of lymph nodes around the celiac artery (No. 9).

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The lesser curvature of the stomach is skeletonized beyond the division line, allowing the dissection of the right paracardial lymph nodes (No. 1).

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A mini-laparotomy 5-6 cm in length is performed 10 cm above the umbilicus. The stomach is exteriorized through this wound with the dissected lymph nodes and neighboring fat tissue.

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The proximal side of the stomach is divided with a linear stapling device. The point at which this is done depends on the location of the tumor.

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The gastroduodenostomy is performed in 2 layers. A drain is placed at the epiploic foramen through the trocar incision at the right midclavicular line 2-3 cm above the umbilicus (E), and the abdominal wall is closed.

18. Postoperative management
a) Drainage from the epiploic foramen is maintained until oral intake is commenced on postoperative day 3 or 4.
b) The nasogastric tube is removed on postoperative day 1 or 2 after confirming that the gastric or enteric juice drained has not increased. A liquid diet is resumed on postoperative day 3 or 4 with gradual progression to normal food within a few days.
c) Normal physical activity is generally restored between postoperative days 7 and 10.

19. Conclusion
Advances in surgical skills and devices have contributed to the rapid evolution of laparoscopic surgery. Currently, the best indication for a laparoscopic gastrectomy is early stage cancer. Several publications confirm the feasibility of a D2 gastrectomy with extensive lymph node dissection (Uyama et al., 1999). However, this is yet to be accepted as standard procedure.