Laparoscopic radical gastrectomy puncture location

Once a disease like gastric cancer occurs, it is not easy to recover. For gastric cancer, we should pay more attention to early detection and early treatment, and do not delay the treatment time. I hope that every gastric cancer patient can stay away from the disease and get rid of the trouble as soon as possible.

1. Surgical steps

1. How can you make a midline incision in the upper abdomen to open the abdomen from the linea alba, without cutting the rectus sheaths on both sides beyond recognition? First, use the line connecting the xiphoid process and the umbilicus on the skin, and then observe carefully, you can find a row of thickened pores. The most difficult thing is how to know where the white line is after cutting the skin and subcutaneous tissue. I will tell you the safest method. Cut the anterior rectus sheath one centimeter horizontally one centimeter above the umbilicus to determine the position and width of the white line. If your sense of direction is poor, cutting upward will still deviate from the midline, so make another horizontal cut under the xiphoid process.

2. Do not rush to see what the tumor is like during the exploration. You should first explore the liver, spleen and pelvic cavity for metastatic nodules and then explore the stomach. The size and shape of the tumor are not very important for the operation. Pay special attention to the distance between the tumor and the pylorus and cardia. Pay special attention to the position of the cardia, which needs to be determined by a gastric tube. Then cut the avascular area of ​​the hepatogastric ligament and explore its relationship with the pancreas. For pyloric tumors, pay attention to the relationship with the hepatoduodenal ligament. Lift the transverse colon and observe whether the middle colic artery is invaded. If there are a large number of enlarged lymph nodes, pay special attention to the root of the left gastric artery and how much space is left. Based on the exploration results, determine whether the tumor can be removed, what the difficulty of resection is, and the range of lymph node dissection.

3. Sequence For doctors who have just started to perform radical treatment of gastric cancer, the most difficult thing is freedom. They feel that they have no idea where to start. After starting, they always feel that they are not as clear as their senior doctors. Where to start? Where to end? Therefore, sequence and organization are a problem! Simply put, it is from left to right, from bottom to top, and from front to back.

4. Resection of the omental bursa A complete and clear resection of the omental bursa gives people an artistic enjoyment, but if you do it yourself, you will know that it is not as easy as you think. First, separate the greater omentum from the transverse colon, which should be relatively easy. Then separate the anterior lobe of the transverse colon mesentery, which is the easiest to break. It should be combined with electrosurgical separation and blunt separation. Blunt separation is best done with a non-charged electrosurgical head that cuts horizontally from left to right. This saves time and ensures that the separation plane is parallel to each other, avoiding uneven force and tearing. It is best to separate the gastropancreatic ligament first when crossing the lower edge of the pancreas, and then separate from right to left.

5. Pylorus

Below the pylorus, there are the roots of the right gastroepiploic vessels, the subpyloric lymph nodes, and the pyloric vein.

In order to prevent pancreatic damage, many people cut off the blood vessels close to the pylorus. However, the result of this is that the branches of the subpyloric vein need to be ligated, which can easily cause tearing and bleeding of the veins between the branches during separation, leaving behind the subpyloric lymph nodes, and often requires the right main trunk of the omental blood vessels to be ligated twice.

The reasonable method is: first cut the peritoneum at the lower edge of the duodenum to expose the pancreas. At this time, you can find that the pancreas has an upward bulge, and the top of the bulge is the root of the right omental blood vessel. The artery is upward along the bulge, and the vein is downward. Since the right omental vein merges with the right colic vein into a trunk, it should be ligated first, and then the subpyloric lymph nodes should be sharply separated upward. Finally, at the lower edge of the duodenum, close to the duodenal wall, it can be stretched to the right, and the root of the right omental artery can be ligated at the root, while avoiding the dense subpyloric vein.

6. Duodenal stump

For pyloric tumors, the most important factor for resection is whether the duodenum can be completely closed in addition to determining whether there is pancreatic invasion. Special attention should be paid to how much duodenum, blood supply, and hepatoduodenal ligament can be retained. For cases where it is uncertain, it is best to first cut the peritoneum in front of the common bile duct to expose the common bile duct. Then cut the peritoneum at the upper and lower edges of the duodenum, separate the back of the duodenum, and determine the length that can be retained. And bidirectionally explore the relationship between the tumor and the pancreas with the opening of the avascular area of ​​the hepatogastric ligament.

After closing the stump, the length of the free stump of the duodenum should not be greater than 1 cm to ensure good blood supply. For cases with poor blood supply and leakage after closure, duodenostomy should be performed without hesitation. The stump must be observed again before closing the abdomen.

7. Small curved side cleaning

Since gastric cancer often occurs on the lesser curvature, the lesser curvature clearance is the focus of radical surgery. The scope of clearance includes all blood vessels, lymph nodes, and adipose tissues between the lesser curvature of the stomach and the liver except for the hepatic blood vessels and common bile duct. How can the clearance be completed smoothly? The most important thing is the order of clearance.

Recommended sequence: First, make a longitudinal incision in the avascular area of ​​the hepatogastric ligament to explore the posterior wall of the stomach. Extend the incision upward to the lower edge of the liver, which is the starting point of our cleaning. Note that before this, do not ligate or cut any tissue on the lesser curvature. Any advance operation will cause repeated labor and affect the next operation. Then cut the peritoneum to the right along the lower edge of the liver, directly reach the proper hepatic artery, cross the artery and go down in front of the common bile duct to the upper edge of the duodenum, and go left along the upper edge of the duodenum to the gastroduodenal artery. Free the anterior lobe of the hepatoduodenal ligament to the right to the left side of the proper hepatic artery, then go left along the common hepatic artery, ligate the right hepatic blood vessels that originate from it at the root, ligate and cut off the left gastric vein that crosses it, and reach the root of the celiac trunk. If there are enlarged lymph nodes next to the common hepatic artery, they can be sharply separated and adhered to the blood vessels, and then gauze can be used to compress and stop bleeding, and ligation is usually not required.

Ligate the root of the left gastric artery, and proceed from the original starting point along the liver to the left to the right side of the cardia. Then, proceed downward from the cardia to ligate and cut off the blood vessels along the lesser curvature of the stomach until the predetermined gastric resection position is reached, and the lesser curvature can be completely cleaned.