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Operative Technique |

D2.5 Dissection for Gastric Carcinoma

Vijay P. Khatri, MD; Harold O. Douglass, Jr, MD
Arch Surg. 2004;139(6):662-669. doi:10.1001/archsurg.139.6.662.
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Worldwide, gastric cancer ranks second only to lung cancer in mortality and accounts for 500 000 deaths annually. Since 1930, the incidence of gastric carcinoma in the United States has been declining steadily and plateaued during the 1980-1990 decade. Mortality rates for white males in the United States were approximately 40 per l00 000 in l930, compared with 5.4 per 100 000 in l994. For nonwhite males the rates were 23.7 per 100 000 in 1955 and 12 per 100 000 in 1985. In the United States in 2002, an estimated 21 600 new cases and 12 400 deaths were attributable to gastric carcinoma.1

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Figure 1.

Lymph node stations according to the Japanese Research Society for Gastric Cancer. A, Stations 1 through 6 (N1), 7, 9, 12, and 14 are seen. CHA indicates common hepatic artery; LGA, left gastric artery; SGA, short gastric arteries; LGEA, left gastroepiploic artery; SPA, splenic artery; RGEA, right gastroepiploic artery; RGEV, right gastroepiploic vein; SMA, superior mesenteric artery; SMV, superior mesenteric vein; MCA, middle colic artery; and MCV, middle colic vein. B, Second echelon (N2) lymph node stations 7 through 11 and third echelon (N3) lymph node stations 12 through 14 are seen. PV indicates portal vein; CA, celiac axis; SV, splenic vein. See Figure 2for the location of the stations.

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Figure 2.

Grouping of lymph node (LN) stations according to the location of the gastric cancer. CA indicates celiac axis; CHA, common hepatic artery; LGA, left gastric artery; MCA, middle colic artery; SPA, splenic artery.

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Figure 3.

With the stomach retracted upward, an omentobursectomy is performed by resecting the anterior leaf of the transverse mesocolon which is facilitated by hydrodissection (injection of a sterile saline solution).

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Figure 4.

With ligation and division of the right gastroepiploic artery, the subpyloric package of lymphoareolar tissue (station 6) is swept upwards to be included with the specimen.

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Figure 5.

A wide Kocher maneuver to expose retropancreatic (station 13) and para-aortic (station 16) lymph nodes.

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Figure 6.

The lesser omentum and the peritoneal lining overlying the hepatoduodenal ligament is incised from the left edge, across two thirds of its width, and then downward toward the superior border of the duodenum (Inset). The anterior peritoneal lining of the ligament is open and the hepatoduodenal lymph node dissection (station 12) begun by skeletonizing the hepatic artery proper.

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Figure 7.

The hepatic artery, celiac axis, and the proximal splenic artery have been skeletonized. A spleen-sparing lymphadenectomy at the splenic hilum (station 10) is shown.

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Figure 8.

A, Pancreas-preserving lymphadenectomy includes proximal ligation and division of the splenic artery after dissecting it from the superior border of the pancreas. B, Small tributaries from the splenic artery to the pancreas remain to be divided and ligated.

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