腹腔镜远端胃癌D2根治术

Laparoscopic distal D2 resection for gastric cancer

先将大网膜向头侧翻起,于横结肠中部,大网膜与横结肠附着缘处超声刀离断大网膜,向右至结肠肝曲,左至结肠脾曲。在胰尾部分离出胃网膜左血管,血管夹夹闭并离断,之后离断脾胃韧带和胃短血管,清扫4d组淋巴结;暴露肠系膜上静脉,解剖胃结肠干,清扫14v淋巴结;分离并找到胃网膜右动静脉,夹闭、离断,清扫第6组淋巴结;将胃向头侧牵引,切除胰腺前被膜,分离、切断胃左动静脉。小心分离脾动脉,解剖血管周围淋巴结缔组织,向小弯侧剥离,清扫7、8、9、11p(脾动脉近端淋巴结)组淋巴结;将胃窦向头侧翻转,找到并解剖胃十二指肠动脉,再分离肝固有动脉、肝总动脉,在此处可清扫第12组淋巴结;解剖分离胃右动静脉,清扫第5组淋巴结;超声刀裸化胃小弯,清除第1、3组淋巴结。取上腹部正中切口,约5cm,将游离胃及大网膜提出腹壁外,行远端胃大部切除和毕Ⅰ式消化道重建。

Firstly, abdominal exploration was performed, including identifying the location and infiltration of tumor. Then dissection of the gastroeolie ligament （GCL） was continued from left to right side. The left gastroepiploic artery （LGeA） and short gastric： vessels（SGV） were divided from cauda pancreatis. The greater omentum was dissected from the greater curvature to the junction between gastric body and antrum in the right, and No. 4d LNs were reseeted. The division of the GCL was continued towards the pylorus. The superior mesenteric vein（SMV） was dissected to the inferior margin of the panereas neck for resection of No. 14v LNs. At the head of the pancreas, the right gastroepiploic vein （RGeV） was isolated and divided at its origin on the SMV. The infrapyloric, lymph nodes （ No. 6） were dissected proximal to the origin of anterior superior pancreatoduodenal vein, and the right gastroepiploie artery （RGeV） was exposed and divided at its origin with double clips;The celiac： artery （CA） and its main branches, the common hepatic＇, artery and the splenic artery, were dissected in the retropancreatic space at the superior margin of the pancreas body, with resection of No. 7,8,9, I lp LNs. No. 12a LNs was dissected along the vascular sheath of the proper hepatic artery in the hepato-duodenal ligament. No. 5 LNs were dissected by dividing the right gastric artery. Lymphadenectomy of No. l, 3, 5 LNs were performed in lesser curvature among lesser omentum. 5cm of the abdominal incision was made and incision protector were put up. Distal subtotal gastrectomy and Billroth I reconstruction of digestive tract were completed under direct vision.