A Practical OR Guide for Surgical Nurses

Proximal gastrectomy is a gastric resection procedure in which the proximal portion of the stomach is removed while preserving the distal stomach and pyloric region.

The procedure requires careful dissection around the upper stomach, esophagus, spleen, pancreas, and regional lymph nodes. After gastric resection, reconstruction is required to restore gastrointestinal continuity.

A practical guide written from the perspective of an Operating Room Nurse.

The workflows, surgeon preferences, and nursing tips presented in this article are based on the author’s real clinical experience. Surgical techniques and operating room practices may vary depending on the surgeon, hospital, and institutional protocols.

📌Quick Facts

Item	Description
Procedure	Proximal Gastrectomy
Surgical region	Upper stomach / gastroesophageal junction
Main resection	Proximal portion of the stomach
Approach described	Open abdominal surgery
Key structures	Stomach, esophagus, spleen, pancreas, left gastric vessels
Lymph nodes	Regional lymph node dissection
Reconstruction	Esophagogastrostomy and other reconstruction methods
Important considerations	Vagal nerve preservation, reflux prevention, anastomotic technique

Indications

Early gastric cancer located in the upper stomach
Lesions confined to the upper portion of the stomach
Some advanced gastric cancers when the distal stomach can be preserved
Lesions involving the upper stomach where an adequate distal stomach remains

Why preserve the distal stomach?

One important theoretical advantage is preservation of the distal stomach and pyloric function.

The remaining stomach can continue to participate in food passage and digestive hormone secretion. However, emphasizes that disruption of vagal innervation may affect gastric emptying.

Preoperative Preparation

Antibiotic prophylaxis

Prophylactic antibiotics are administered before surgery to reduce the risk of surgical-site infection.

Starting antibiotics approximately one hour before skin incision. Additional administration may be required for prolonged procedures or significant blood loss.

Bowel preparation

Bowel preparation may be considered when bowel resection is anticipated.

Fasting

Fasting is required when general anesthesia is planned, according to standard preoperative preparation described in the source.

Patient Position

Patient positioning based on the location of the lesion and the extent of the planned operation.

The operative field is prepared to allow access to the upper abdomen.

For open surgery, the abdominal incision is made through an upper midline approach, with extension when necessary.

Surgical Exposure

After entering the abdominal cavity, the surgeon evaluates the peritoneal cavity and establishes adequate exposure.

Upper midline abdominal incision
Self-retaining retractors
Kent retractor
Gauze packing around the spleen
Abdominal exploration before proceeding with resection

The purpose of exposure is to provide adequate visualization while minimizing traction-related injury to surrounding organs.

🕒Proximal Gastrectomy: Surgical Workflow

The operative sequence can be broadly understood as:

Abdominal exposure → Gastric mobilization → Lymph node dissection → Esophageal mobilization → Gastric transection → Reconstruction

Let’s look at each stage.

Step 1. Mobilization of the Stomach

The stomach is mobilized to expose the area requiring resection.

The source describes dissection along the greater and lesser curvature and division of the relevant vessels and lymphatic tissue.

Attention is paid to structures around the:

Left gastric artery
Right gastric region
Greater omentum
Splenic area
Pancreas

Step 2. Lymph Node Dissection

Regional lymph node dissection is performed according to the planned extent of surgery.

Dissection involving lymph node stations around the gastric vessels, including stations such as No. 3, No. 4d, No. 8a, No. 9, and No. 11, depending on the operative field.

The surgeon proceeds carefully around the splenic vessels and pancreas.

OR Nursing Point

This part of the operation requires particularly good visualization of the vascular structures.

Esophageal Mobilization

The esophagus is mobilized after the upper stomach has been adequately exposed.

Mobilization of the abdominal esophagus and division of the surrounding tissue to allow the esophagus to be transected safely.

The esophageal mucosa is then prepared for reconstruction.

Gastric Transection

After adequate mobilization and lymph node dissection, the proximal portion of the stomach is removed.

Gastric transection using a linear stapling device.

The remaining distal stomach is preserved.

The basic concept is:

Remove the proximal stomach → Preserve the distal stomach → Restore gastrointestinal continuity

Reconstruction After Proximal Gastrectomy

Reconstruction is one of the most important parts of proximal gastrectomy.

Several reconstruction methods:

Esophagogastrostomy
Jejunal interposition
Double-tract reconstruction
Gastric pouch reconstruction

The selection of reconstruction method depends on the surgical plan and the desired postoperative function.

Esophagogastrostomy

In esophagogastrostomy, the esophagus is connected directly to the remaining stomach.

The use of an anvil placed in the esophagus, followed by creation of the anastomosis with a circular stapling device.

Why is reflux an important concern?

Reflux esophagitis and anastomotic stenosis can occur after esophagogastrostomy.

It also describes that reflux may be more frequent compared with some alternative reconstruction methods.

Therefore, reconstruction is not simply about reconnecting the gastrointestinal tract.

The configuration of the reconstruction can influence postoperative function.

Double-Tract Reconstruction

In this technique, the jejunum is used to create an additional pathway between the esophagus and the remaining stomach.

Division of the jejunum approximately 20–30 cm distal to the ligament of Treitz
Creation of an esophagojejunostomy
Gastrojejunostomy
Jejunojejunostomy

The resulting reconstruction provides two routes for food passage.

Why use a double tract?

Double-tract reconstruction as one of the methods intended to address the functional limitations associated with direct esophagogastrostomy.

Gastric Pouch Reconstruction

Another method is gastric pouch reconstruction.

The technique creates a gastric pouch while maintaining a pathway between the esophagus and the remaining stomach.

Creating the pouch using a linear stapling device and emphasizes careful measurement of the pouch.

A pouch length of approximately 10–12 cm and notes that the pouch should not be made excessively long because postoperative food stasis may occur.

Vagal Nerve Preservation and Gastric Emptying

An important point is the relationship between vagal nerve preservation and gastric emptying.

If vagal nerve function is preserved, pyloric intervention may not always be necessary.

However, when vagal nerve function is compromised, gastric emptying can be impaired.

possible pyloric interventions, including:

Heineke–Mikulicz pyloroplasty
Finney pyloroplasty
Pyloric ring dilation
Finger bougie dilation

These techniques are presented in the context of maintaining gastric emptying when vagal innervation has been disrupted.

✅30-Second OR Checklist

Before the main resection begins, an OR nurse should understand the overall surgical sequence:

✅Exposure

Upper abdominal exposure
Adequate retraction
Protection of surrounding organs

✅Dissection

Gastric mobilization
Vessel control
Lymph node dissection
Careful dissection around the pancreas and spleen

✅Resection

Esophageal preparation
Proximal gastric transection
Specimen removal

✅Reconstruction

Esophageal preparation
Anastomosis
Reconstruction according to the selected technique
Final inspection

Common Surgical Considerations

① Pancreatic injury

The pancreas is located close to the operative field.

② Splenic vessel injury

Dissection around the splenic hilum and splenic vessels requires careful handling.

③ Vagal nerve injury

Vagal nerve disruption may affect gastric emptying, making nerve preservation an important consideration when possible.

④ Anastomotic complications

Reflux esophagitis and anastomotic stenosis as potential problems following reconstruction.

⑤ Pouch length

For gastric pouch reconstruction, the source emphasizes avoiding excessive pouch length because prolonged food retention can occur.

Surgical Reconstruction at a Glance

Reconstruction	Basic concept	Key point described in source
Esophagogastrostomy	Esophagus → remaining stomach	Reflux and stenosis are important considerations
Jejunal interposition	Jejunal segment between structures	Provides an alternative reconstruction route
Double tract	Esophagojejunostomy + gastrojejunostomy	Creates two pathways for food passage
Gastric pouch	Pouch created from remaining stomach	Pouch length and postoperative stasis are important

💎Operating Room Pearls

1. Know the anatomy before the dissection starts

Proximal gastrectomy involves several important structures in a relatively small operative field.

The left gastric vessels, splenic vessels, spleen, pancreas, and regional lymph nodes are closely related to the surgical field.

Understanding these anatomical relationships helps the OR team anticipate the next step of the procedure.

2. Pay attention to the splenic and pancreatic area

During lymph node dissection, the surgeon works around the pancreas, spleen, and splenic vessels.

For the OR nurse, this is an important point at which to anticipate vascular control and careful dissection.

3. Understand the reconstruction before the anastomosis begins

The reconstruction method can change the surgical workflow.

The several options:

Esophagogastrostomy
Jejunal interposition
Double-tract reconstruction
Gastric pouch reconstruction

Knowing which reconstruction is planned makes it easier to follow the procedure and anticipate the next surgical step.

4. Esophageal preparation is a key transition point

Once the gastric resection is completed, the operation moves into the reconstruction phase.

Esophageal preparation using an esophageal dilator, straight clamp, purse-string technique, and circular stapling device.

This is an important transition from resection to reconstruction.

5. Remember that vagal nerve preservation affects gastric emptying

The relationship between vagal nerve preservation and gastric emptying.

When vagal function is impaired, procedures such as pyloric dilation or pyloroplasty may be considered to help maintain gastric emptying.

6. Reconstruction is not simply about restoring continuity

The choice of reconstruction can affect postoperative function.

Reflux and anastomotic stenosis after esophagogastrostomy and presents alternative reconstruction techniques.

The key point:
The goal is not only to reconnect the gastrointestinal tract, but also to consider how the reconstructed pathway will function.

⚠️Common Pitfalls

1. Inadequate understanding of the surgical anatomy

The upper stomach is surrounded by important vascular and visceral structures.

Failure to recognize the relationship between the stomach, pancreas, spleen, and surrounding vessels can make the dissection difficult and increase the risk of injury.

Careful dissection around these structures.

2. Pancreatic or splenic injury during dissection

The pancreas and spleen are closely associated with the operative field.

Careful dissection is particularly important around the splenic vessels and pancreatic area.

3. Vagal nerve injury

Vagal nerve injury can affect gastric emptying.

Impaired vagal function may result in delayed gastric emptying and discusses additional pyloric procedures that may be used in selected situations.

4. Reflux after esophagogastrostomy

Direct esophagogastrostomy can be associated with reflux esophagitis.

Reflux as an important postoperative consideration and discusses alternative reconstruction methods.

5. Anastomotic stenosis

Anastomotic stenosis is another complication.

Therefore, the anastomotic technique and reconstruction configuration are important parts of the procedure.

6. Making the gastric pouch too long

For gastric pouch reconstruction, a pouch length of approximately 10–12 cm.

It warns that an excessively long pouch can make postoperative food stasis more likely.

OR Nurse Takeaway

Proximal gastrectomy is a procedure where anatomy and reconstruction are equally important.

The most important things to follow during the case are:

① Where the surgeon is dissecting
↓
② Which vessels and organs are nearby
↓
③ When gastric resection is completed
↓
④ Which reconstruction method is being performed
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⑤ How the final anastomosis is constructed

For an OR nurse, understanding this sequence makes it much easier to anticipate the next step of the operation.

FAQ

What is proximal gastrectomy?

Proximal gastrectomy is a gastric resection in which the proximal portion of the stomach is removed while the distal stomach is preserved.

Why is the distal stomach preserved?

Preservation of the distal stomach as a way to retain gastric function and maintain the passage of food through the remaining stomach.

What reconstruction methods can be used?

The source describes esophagogastrostomy, jejunal interposition, double-tract reconstruction, and gastric pouch reconstruction.

What is double-tract reconstruction?

It is a reconstruction technique using the jejunum to create an esophagojejunostomy and gastrojejunostomy, with a jejunojejunostomy completing the intestinal pathway.

Why is vagal nerve preservation important?

Vagal nerve disruption can contribute to delayed gastric emptying.

What is the purpose of a gastric pouch?

Gastric pouch reconstruction creates a pouch from the remaining stomach as an alternative reconstruction method. The source emphasizes appropriate pouch length to reduce postoperative food stasis.

Conclusion

Proximal gastrectomy is more than simply removing the upper part of the stomach.

From the OR perspective, the procedure can be understood as a sequence of:

Exposure → Gastric mobilization → Lymph node dissection → Esophageal mobilization → Gastric resection → Reconstruction

The most important anatomical areas to understand are the upper stomach, esophagus, left gastric vessels, splenic vessels, spleen, pancreas, and regional lymph nodes.

Just as important is the reconstruction strategy. Several options, including esophagogastrostomy, jejunal interposition, double-tract reconstruction, and gastric pouch reconstruction, each with different technical considerations.

For OR nurses, understanding what is being dissected, why the surgeon is moving to the next step, and which reconstruction is being performed makes the procedure much easier to follow in real time.