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Gastric Cancer Resection
upper endoscopy and biopsy. Surgical resectability was assessed Afterward, we dissected the adipose tissue over the anterosuperior
by multislice computed tomography abdomen (with IV and oral border of the pancreas and LNs along the splenic vessels (station 11).
contrast), where resectable tumors, according to TNM classification, In locating proximal tumors, the proximal resection margin
had to be T1-3, N0-1, and M0. All patients with infiltrating or involved the whole proximal gastric segment with 2 to 3 cm
metastatic cancer, peritoneal deposits, surgically unfit patient, or esophageal safety margin using linear endo GIA stapler, 45 mm,
pregnant women were excluded from the study. After the diagnosis blue cartilage and a distal resection line of 5 cm safety margin.
and assessment of eligibility, patients were randomized into two In tumors occupying a large area of the stomach, total
groups: group A had OG and group B had LG. Random assignment gastrectomy was done with the duodenum transected 1 to 2 cm
was done by the sealed envelope technique. distal to the pylorus and the esophagus transected 2 to 3 cm
All patients had signed an informed consent after a complete proximal to the stomach.
explanation of the risks and advantages of the surgery being Reconstruction was done by Roux-en-Y jejunal anastomosis
planned for them. for total and distal resection and esophagogastric anastomosis in
Baseline clinicopathological data were collected as age, sex, upper radical resection.
and tumor site. A nasogastric tube inserted at the start of the operation was
then advanced to cross the anastomosis, just beforehand sewing
Surgical Techniques the opening left after the side-to-side stapling. Finally, the resected
Laparoscopic Gastrectomy specimens after putting in a retrieval bag were taken out through
The patient was placed in supine position for the induction of a 6-cm vertical supraumbilical incision that starts at the umbilicus.
The specimen was then checked for safety margins. A subphrenic
general anesthesia with cuffed endotracheal tube and then placed tubal drain was then inserted and left until the patient starts
in French position. The operator stands between the legs of the semisolid meals without evidence of anastomotic leaks or bleeding,
patient. The cameraman stood on the patient’s right side, while usually for 3 to 5 days.
the first assistant stood on the patient’s left side and the tower is
placed near the patient’s head. Open Gastrectomy
A 10-mm camera port was created superior or inferior to the A 10–15-cm incision length from the xiphisternum till below the
umbilicus by open method, and pneumoperitoneum with carbon umbilicus was used. Abdominal exploration was routinely done
dioxide was induced to a pressure of up to 15 mm Hg. to assess the tumor and exclude metastasis before proceeding to
The peritoneal cavity was carefully checked for any secondaries. the radical gastric resection. In general, we used the same steps as
The table was turned into the steep reverse-Trendelenburg position, in the laparoscopic resection.
and four other trocars (one 12-mm and three 5-mm trocars) were
placed carefully using laparoscopic vision. Thereafter, laparoscopic Pre- and Postoperative Management
D2 gastrectomy was performed as follows. Pre- and postoperative management was the same for the two
We start by dividing the gastrocolic ligament along its groups. All patients received broad-spectrum antibiotics for
transverse colon attachment using ultrasonic shears (Harmonic 48 hours during their postoperative hospitalization. Feeding was
Scalpel TM; Ethicon Endo-Surgery Inc., Cincinnati, Ohio, United started after passage of flatus. When the patients have adequate
States). We started at the avascular plane to the left of the midline pain control, tolerance of oral intake, ability to mobilize and self-
and dissected toward the spleen till it reaches the left gastroepiploic care, and no abnormal physical signs or laboratory test they were
vessels that were divided. Division of the greater omentum was discharged.
continued in the direction of the first part of the duodenum, and Perioperative data such as operative time, estimated
the roots of the right gastroepiploic vessels were divided. The soft intraoperative blood loss, intraoperative organ injury, postoperative
tissues attached to the duodenum were dissected. complications, histopathology of the tumor, and clinicopathological
All LNs around the gastroepiploic vessels (stations 4d and 4sb) TNM stage (according to the International Union Against Cancer
were dissected followed by the infra-pyloric LNs (station 6), which staging 10) were recorded. Postoperatively, 30-day follow-up data
were dissected from the pylorus. At this stage, careful dissection were collected to assess any complications, hospital stay duration,
was usually done to avoid injury of gastrocolic trunk of Helen, and need for ICU admission.
which, if happened, will result in unnecessary bleeding. The lesser
omentum was then entered at the pars flaccida, and the origin of Data Management
the right gastric artery was divided. Data management including data entry and statistical analysis
In the case of distally located tumors, the distal resection margin were done by using IBM SPSS software, version 20. Quantitative
was the duodenum 1 to 2 cm distal to the pylorus using a COVIDIEN variables were presented in terms of mean ± SD, and qualitative
Endo GIA Ultra Universal Stapler, 12 mm. variables were expressed as frequency and percentage. Student’s
The left gastric vein and artery were exposed by raising the t-test and Chi-square test were used to compare the outcomes of
stomach upward and to the right, completing dissection till the two groups. The level of significance p-value was evaluated, where
origin of the left gastric artery from the celiac trunks, where the p-value <0.05 was considered statistically significant.
artery was divided at its origin (station 7) using both clips and the
ultrasonic shears. At this point, the LNs around the common hepatic
artery were exposed and dissected. The perigastric LNs were results
dissected along the lesser curvature reaching the esophagogastric During the study period, 73 patients were admitted to the
junction. At least a proximal 5-cm resection margin starts from department of general surgery at Assiut university hospital having
the grossly malignant margin is done using COVIDIEN Endo GIA GC and assessed for eligibility for possibility of curative resection.
Ultra Universal Stapler, 12 mm (according to gastric wall thickness). Twenty-seven patients were excluded as they were not meeting

World Journal of Laparoscopic Surgery, Volume 14 Issue 2 (May–August 2021) 107