Open Distal Gastrectomy

1. Patient is positioned supine on operating table.

2. Anesthesia and antibiotic administration (usually a cephalosporin).

3. Upper midline incision (xiphoid process to below umbilicus).

4. Division of falciform ligament.

5. Abdominal exploration (for extent of locoregional disease and distant metastases).

1. Special attention: peritoneal surfaces and liver.

2. Evaluation of remote lymph nodes for metastases.

6. Mobilization of the greater curvature with omentectomy and division of the left gastroepiploic artery.

7. Infrapyloric mobilization with ligation of the right gastroepiploic artery and vein as it enters the gastrocolic trunk.

8. Superpyloric mobilization with ligation of the right gastric artery.

9. Duodenal transection.

10. Lymphadenectomy with dissection of the porta hepatis, common hepatic artery, left gastric artery, celiac axis, and splenic artery, and ligation of left gastric artery.

11. Gastric transection.

12. Reconstruction by Billroth II or loop of Roux-en-Y gastrojejunostomy.