The Sterile Eye

The stomach exposed through the midline incision.

My last video in 2008, this total gastrectomy with Roux-en-Y reconstruction for stomach cancer, was published today on www.oncolex.no.

The video was recorded in February, and I wrote a post about the experience then. I’ve pasted the description of the operation below. Voice overs in Norwegian.

The patient had a large tumor in the upper part of the stomach, close to the cardia. The tumor had also grown very close to the spleen, so that would have to go too, together with the entire stomach.

The first part of the operation was pretty straight forward. The blood supply and nerves of the stomach was cut. Using an instrument called GIA, which places two double rows of staples and cuts between them in one move, the duodenum and stomach was divided below the pylorus. The esophagus was separated from the stomach the same way. The spleen was then dissected and the operation specimen was removed.

The surgical specimen with stomach (left) and spleen (right).

The second part took a little more thinking on my part before I understood the plumbing. No disrespect to the gastrointestinal surgeons, but this really was advanced plumbing. OK. Remember that both the esophagus and the upper part of the duodenum is closed. One could think that these ends were going to be joined together, but no. Most of the gastric juices enter the small intestine in the duodenum from the pancreatic duct and the common bile duct. If the duodenum was connected directly to the esophagus, bile could enter the esophagus and cause problems. So another solution has to be found.

First the surgeons separated the lower part of the duodenum from the jejunum with the GIA, sealing both ends. Then they made an anastomosis between the esophagus and the jejunum 40 cm below the ligament of Treitz. Finally they made an anastomosis between the bottom part of the duodenum and the jejunum 40 cm below the first anastomosis. The upper part of the duodenum was left closed. So the food would go directly from the esophagus to the jejunum, and join with the gastric juices from the duodenum after 40 cm. The surgeons explained it to me as they were working, but I didn’t really get it until I looked up an illustration in a book the next day (photo credit). Advanced plumbing indeed.