Total gastrectomy is a major gastrointestinal surgical procedure in which the entire stomach is removed. The operation involves extensive dissection around the stomach, regional lymph nodes, major blood vessels, the pancreas, spleen, and esophagus.
After the stomach is removed, gastrointestinal continuity must be restored. Reconstruction with a Roux-en-Y configuration, including esophagojejunostomy and jejunojejunostomy.
This article presents the total gastrectomy procedure from an operating room nurse’s perspective, focusing on the overall surgical workflow, important anatomical structures, vascular control, lymph node dissection, and reconstruction.
📌Total Gastrectomy: Quick Facts
| Category | Details |
|---|---|
| Procedure | Total Gastrectomy |
| Organ Removed | Entire stomach |
| Position | Supine |
| Anesthesia | General anesthesia with endotracheal intubation |
| Major Dissection Areas | Greater omentum, gastrocolic ligament, hepatoduodenal ligament, gastric vessels, splenic vessels, and esophageal hiatus |
| Important Lymph Nodes | LN #5, #6, #8, #10, #11, and #12 |
| Reconstruction | Roux-en-Y reconstruction |
| Main Anastomosis | Esophagojejunostomy and jejunojejunostomy |
Indications for Total Gastrectomy
Total gastrectomy may be considered when gastric disease involves a large portion of the stomach or when the extent of disease requires complete gastric resection.
Total gastrectomy in the context of gastric cancer and emphasizes evaluating the extent of disease before proceeding with definitive resection.
When advanced disease is suspected, exploration of the abdominal cavity is performed to determine whether definitive resection is appropriate.
Preoperative Preparation for Total Gastrectomy
Anesthesia
General anesthesia with endotracheal intubation is performed before surgery.
Patient Position
The patient is placed in the supine position and securely positioned for upper abdominal surgery.
Surgical Equipment
Preparation of equipment including a self-retaining retractor, electrosurgical device, Bovie, and energy device.
Stapling devices and equipment required for gastrointestinal reconstruction should also be prepared according to the planned surgical technique.
🕒Total Gastrectomy Surgical Procedure
1. Abdominal Exploration
For patients with suspected advanced disease, diagnostic laparoscopy may be performed before definitive laparotomy.
The abdominal cavity is evaluated for evidence of disease spread. The peritoneal cavity, mesentery, colon, and greater omentum are inspected.
Peritoneal washing cytology may also be performed when indicated.
2. Greater Omentum and Gastrocolic Ligament Dissection
The greater omentum is mobilized to expose the transverse colon and the underlying structures.
The gastrocolic ligament is dissected to enter the lesser sac. During this step, careful attention is required to the transverse colon, gastroepiploic vessels, and pancreas.
The operative illustrations demonstrate the relationship between the greater omentum, gastrocolic ligament, transverse colon, and gastric vessels.
3. Right Gastroepiploic Vessel Division
The right gastroepiploic artery and vein are identified and divided as the dissection progresses toward the pancreatic head and duodenal region.
Lymph node station #6 is located in this operative field.
Important structures in this region include the right gastroepiploic vessels, gastroduodenal artery, anterior superior pancreaticoduodenal vein, superior mesenteric vein, and gastrocolic trunk.
4. Duodenal Mobilization and Transection
The duodenum is mobilized before transection.
Division of the duodenum using a linear stapler. After transection, the duodenal stump is inspected for hemostasis and adequate mobilization.
5. Hepatoduodenal Ligament Dissection
The dissection continues toward the hepatoduodenal ligament.
The right gastric artery and surrounding lymphatic tissue are identified and dissected. The operative illustrations demonstrate lymph node stations #5 and #12 in this region.
This area is closely related to major structures including the hepatic artery, portal vein, bile duct, and gastroduodenal artery.
6. Common Hepatic Artery and Lymph Node Dissection
Lymphatic tissue around the common hepatic artery is dissected as part of the regional lymph node dissection.
The operative field includes lymph node station #8 and continues toward the celiac axis and left gastric artery.
Careful identification of the surrounding vessels is essential during this stage of the procedure.
7. Left Gastric Artery and Vein Division
The left gastric artery and vein are identified and divided as the gastric resection and lymph node dissection proceed.
Attention to the posterior gastric artery and its relationship to the splenic artery.
Because vascular anatomy can vary, careful dissection and identification of the vessels are important before division.
8. Splenic Hilum and Short Gastric Vessel Dissection
The dissection progresses toward the splenic side of the stomach.
The short gastric vessels are divided to mobilize the gastric fundus. The operative field includes the splenic artery, splenic vein, left gastroepiploic artery, and lymph node stations #10 and #11.
Dissection around the splenic hilum requires particular attention because vascular injury may result in significant bleeding.
9. Complete Gastric Mobilization
After the surrounding vascular structures and lymphatic tissues have been appropriately dissected, the stomach is progressively mobilized.
The operative illustrations demonstrate dissection around the celiac axis, common hepatic artery, left gastric artery, splenic artery, and splenic hilum.
The goal is to achieve adequate gastric mobilization while maintaining careful control of the surrounding vascular structures.
10. Esophageal Mobilization
After gastric mobilization, the distal esophagus is dissected.
The dissection proceeds around the gastroesophageal junction and esophageal hiatus to obtain adequate esophageal mobility for transection and reconstruction.
Careful dissection around the esophageal hiatus and surrounding tissues.
11. Esophageal Transection
The esophagus is divided after adequate mobilization.
A purse-string suture may be placed in preparation for reconstruction with a circular stapler.
The esophageal stump is prepared for the subsequent esophagojejunostomy.
12. Specimen Removal
Once the stomach and associated lymphatic tissue have been completely mobilized and divided, the total gastrectomy specimen is removed.
The specimen includes the resected stomach and the lymphatic tissue removed according to the planned lymphadenectomy.
Lymph Node Dissection in Total Gastrectomy
The operative illustrations demonstrate several lymph node stations surrounding the gastric vessels, common hepatic artery, splenic vessels, hepatoduodenal ligament, and splenic hilum.
Lymph Node Station #5
LN #5 is illustrated around the suprapyloric region near the right gastric artery.
Lymph Node Station #6
LN #6 is illustrated around the infrapyloric region near the right gastroepiploic vessels.
Lymph Node Station #8
LN #8 is demonstrated around the common hepatic artery.
Lymph Node Station #10
LN #10 is located around the splenic hilum.
Lymph Node Station #11
The operative illustrations demonstrate lymph node stations #11p and #11d along the splenic artery region.
Lymph Node Station #12
LN #12 is illustrated around the hepatoduodenal ligament.
Understanding the location of these lymph node stations helps the OR nurse anticipate the surgical field and recognize the major vessels encountered during dissection.
Roux-en-Y Reconstruction After Total Gastrectomy
After total gastrectomy, gastrointestinal continuity is restored using Roux-en-Y reconstruction.
Division of the jejunum approximately 15–20 cm distal to the ligament of Treitz, followed by reconstruction involving the esophageal stump and jejunum.
1. Jejunal Division
The jejunum is identified approximately 15–20 cm distal to the ligament of Treitz.
The jejunum is divided and prepared for reconstruction.
2. Esophagojejunostomy
The Roux limb is brought toward the esophageal stump.
The esophageal stump is prepared with a purse-string suture, and the anvil of the circular stapler is positioned according to the surgical technique.
The circular stapler is then used to create the esophagojejunostomy.
3. Inspection of the Anastomosis
After firing the circular stapler, the tissue rings, or donuts, are inspected.
The integrity of the anastomosis is assessed according to the surgeon’s standard technique.
4. Jejunojejunostomy
Creation of the jejunojejunostomy approximately 40 cm distal to the esophagojejunostomy.
The jejunal limbs are connected to complete the Roux-en-Y configuration.
5. Mesenteric Defect Closure
After reconstruction, the mesenteric defects created during the Roux-en-Y procedure are addressed.
Closure of these defects is important for completing the reconstruction safely.
🕒Total Gastrectomy: Surgical Workflow
The overall sequence can be summarized as follows:
- General anesthesia and supine positioning
- Abdominal exploration
- Greater omentum and gastrocolic ligament dissection
- Right gastroepiploic vessel division
- Duodenal mobilization and transection
- Hepatoduodenal ligament dissection
- Common hepatic artery and lymph node dissection
- Left gastric vessel division
- Splenic hilum and short gastric vessel dissection
- Complete gastric mobilization
- Esophageal mobilization
- Esophageal transection
- Total gastrectomy specimen removal
- Roux-en-Y reconstruction
- Esophagojejunostomy
- Jejunojejunostomy
- Mesenteric defect closure
✅Total Gastrectomy OR Nurse Checklist
✅Before Surgery
- Confirm general anesthesia and endotracheal intubation
- Confirm supine positioning
- Prepare the self-retaining retractor
- Prepare electrosurgical and energy devices
- Prepare linear stapling equipment
- Prepare circular stapling equipment according to the planned reconstruction
- Prepare purse-string sutures and related instruments
✅During Gastric Dissection
- Be familiar with the right gastroepiploic vessels
- Watch the gastroduodenal artery and pancreaticoduodenal vessels
- Identify the common hepatic artery
- Identify the left gastric vessels
- Pay attention to the splenic artery and vein
- Watch the short gastric vessels
- Maintain awareness of the pancreas and spleen
✅During Esophageal Transection
- Prepare the purse-string suture
- Prepare the circular stapler
- Confirm the anvil is ready
- Maintain the operative field for safe stapler placement
✅During Reconstruction
- Confirm the correct jejunal limb
- Prepare the circular stapler
- Check the stapler donuts after firing
- Prepare for jejunojejunostomy
- Confirm completion of the Roux-en-Y configuration
- Prepare for mesenteric defect closure
⚠️Common Pitfalls in Total Gastrectomy
Vascular Injury
Total gastrectomy involves extensive dissection around major gastric and abdominal vessels.
Particular attention is required around the hepatoduodenal ligament, common hepatic artery, left gastric artery, splenic artery, splenic vein, and gastroepiploic vessels.
Pancreatic Injury
The pancreas is closely related to several operative fields during total gastrectomy.
Careful dissection around the gastrocolic ligament, greater curvature, and pancreatic region is therefore important.
Splenic Vessel Injury
The splenic hilum and splenic vessels are encountered during the dissection of the proximal stomach and regional lymph nodes.
Vascular anatomy should be clearly identified before vessel division.
Inadequate Esophageal Mobilization
Adequate esophageal mobilization is necessary before esophageal transection and reconstruction.
The esophageal hiatus and gastroesophageal junction should therefore be carefully exposed according to the surgical plan.
Reconstruction-Related Problems
During Roux-en-Y reconstruction, attention should be paid to the orientation of the jejunal limb, stapler positioning, anastomotic construction, and mesenteric defect closure.
💎Surgical Pearls for OR Nurses
Know the Vascular Anatomy
Total gastrectomy is not simply a procedure for removing the stomach. A significant part of the operation involves systematic dissection around the gastric blood supply and regional lymphatic tissue.
Watch the Pancreas
When the operative field moves toward the greater curvature, gastrocolic ligament, and pancreatic region, the pancreas becomes an important structure to keep in mind.
Pay Attention to the Splenic Side
The splenic artery, splenic vein, short gastric vessels, and lymphatic tissue are located within a complex operative field.
The surgical illustrations demonstrate the progression of the dissection toward the splenic hilum and splenic vessels.
Anticipate Reconstruction
Once the stomach has been removed, the procedure continues with gastrointestinal reconstruction.
The OR nurse should anticipate the sequence:
Esophageal stump → Anvil → Circular stapler → Esophagojejunostomy → Jejunojejunostomy → Mesenteric defect closure
Frequently Asked Questions About Total Gastrectomy
What is a total gastrectomy?
Total gastrectomy is the complete surgical removal of the stomach.
What reconstruction is performed after total gastrectomy?
Roux-en-Y reconstruction, including esophagojejunostomy and jejunojejunostomy.
What is Roux-en-Y reconstruction?
Roux-en-Y reconstruction restores gastrointestinal continuity after total gastrectomy by connecting the esophagus to a prepared jejunal limb and creating a jejunojejunostomy.
Where is the jejunum divided during the reconstruction?
Division of the jejunum approximately 15–20 cm distal to the ligament of Treitz.
What lymph node stations are illustrated in total gastrectomy?
lymph node stations including #5, #6, #8, #10, #11, and #12.
What is an esophagojejunostomy?
An esophagojejunostomy is the anastomosis between the esophagus and jejunum performed to restore gastrointestinal continuity after removal of the stomach.
Conclusion
Total gastrectomy is an extensive gastrointestinal procedure involving gastric mobilization, vascular control, regional lymph node dissection, esophageal transection, specimen removal, and gastrointestinal reconstruction.
For an OR nurse, understanding the procedure as a continuous surgical workflow can make it easier to anticipate the next step and prepare the appropriate instruments and equipment.
The overall sequence can be remembered as:
Explore → Mobilize → Dissect → Control Vessels → Transect → Remove → Reconstruct
The reconstruction consists of Roux-en-Y reconstruction with esophagojejunostomy and jejunojejunostomy, followed by management of the mesenteric defects.
This article is intended for educational purposes. Surgical techniques, lymph node dissection, instruments, stapling methods, and reconstruction techniques may vary depending on the surgeon, institution, patient anatomy, and clinical situation.