LAPAROSCOPIC CHOLECYSTECTOMY- OPERATIVE SURGERY
#surgicaleducator #operativesurgery #laparoscopiccholecystectomy #usmle #babysurgeon #surgicaltutor
Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• I have already uploaded videos on open and Laparoscopic Appendicectomy, Thyroidectomy, Modified Radical Mastectomy and Open Cholecystectomy.
• In this video today, I have discussed Laparoscopic Cholecystectomy- the flagship procedure for laparoscopic surgeries.
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you to watch real operative surgery videos as well and the links are:
• https://www.youtube.com/watch?v=VStEzI1jL8Y
• https://www.youtube.com/watch?v=O8j4kwpzd24
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links:
• surgicaleducator.blogspot.com
• youtube.com/c/surgicaleducator
This presentation gives a fine description about stoma and ostomy. This contains the details regarding types, complications and the advices that you should give to a patient with a stoma.
OPEN INGUINAL HERNIA REPAIR- OPERATIVE SURGERY
#surgicaleducator #operativesurgery #openinguinalherniarepair #usmle #babysurgeon #surgicaltutor
Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• I have already uploaded videos on open and Laparoscopic Appendicectomy, Thyroidectomy, Modified Radical Mastectomy and open and
Laparoscopic Cholecystectomy
• In this video today, I have discussed Open Inguinal Hernia Repair.
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you to watch real operative surgery videos as well and I will give a link for each surgery in the end of the video as end-cards, which I think will be very useful.
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links:
• surgicaleducator.blogspot.com
• youtube.com/c/surgicaleducator
• Thank you for watching the videos.
Anatomy of the stomach
Brief history of gastric surgery
Indications of Gastrectomy
The different types of gastrectomies.
The various reconstructions following a gastrectomy
Post Gastrectomy syndromes
LAPAROSCOPIC CHOLECYSTECTOMY- OPERATIVE SURGERY
#surgicaleducator #operativesurgery #laparoscopiccholecystectomy #usmle #babysurgeon #surgicaltutor
Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• I have already uploaded videos on open and Laparoscopic Appendicectomy, Thyroidectomy, Modified Radical Mastectomy and Open Cholecystectomy.
• In this video today, I have discussed Laparoscopic Cholecystectomy- the flagship procedure for laparoscopic surgeries.
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you to watch real operative surgery videos as well and the links are:
• https://www.youtube.com/watch?v=VStEzI1jL8Y
• https://www.youtube.com/watch?v=O8j4kwpzd24
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links:
• surgicaleducator.blogspot.com
• youtube.com/c/surgicaleducator
This presentation gives a fine description about stoma and ostomy. This contains the details regarding types, complications and the advices that you should give to a patient with a stoma.
OPEN INGUINAL HERNIA REPAIR- OPERATIVE SURGERY
#surgicaleducator #operativesurgery #openinguinalherniarepair #usmle #babysurgeon #surgicaltutor
Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• I have already uploaded videos on open and Laparoscopic Appendicectomy, Thyroidectomy, Modified Radical Mastectomy and open and
Laparoscopic Cholecystectomy
• In this video today, I have discussed Open Inguinal Hernia Repair.
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you to watch real operative surgery videos as well and I will give a link for each surgery in the end of the video as end-cards, which I think will be very useful.
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links:
• surgicaleducator.blogspot.com
• youtube.com/c/surgicaleducator
• Thank you for watching the videos.
Anatomy of the stomach
Brief history of gastric surgery
Indications of Gastrectomy
The different types of gastrectomies.
The various reconstructions following a gastrectomy
Post Gastrectomy syndromes
gastric resection, reconstruction and post gastrectomy syndromessanyal1981
discussion regarding history of gastrectomy, types of gastrectomy, billroth I, billroth II and roux en y gastrojejunostomy........discussion of post gastrectomy syndromes
tutorials in surgery, surgery training curriculum, residency in surgery, surgical education, principles of surgery, operative surgery, surgical anatomy, pathology and radiology, research methodology, surgery mcqs, surgery essay writing, part 1 exams, part 2 fellowship exams.
resident doctors. medical officers and house officers
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
2. OUTLINE
• INTRODUCTION
• HISTORY
• ANATOMY OF THE STOMACH
• TYPES OF GASTRECTOMY
• INDICATION
• PREOPERATIVE PREPARATION
• PROCEDURE
• – SUBTOTAL GASTRECTOMY
• - BILLROTH II
• COMPLICATIONS
• REFERENCES
3. INTRODCTION
• Gastrectomy is the surgical removal of part or the entire stomach.
• The earliest recorded operations on the stomach were performed for
penetrating injuries. Knife from the stomach of a knife thrower 1602
• Late 1800s: Experimental studies by Billroth confirmed the feasibility
of removing the pylorus.
• The last 20 years of the nineteenth century saw the introduction of
many gastric operations, some of which were to become established
and modified during the ensuing years.
4. • Billroth 1881: Performed the first successful pylorectomy –
Duodenum anastomosed to the lesser curvature of the stomach and
the greater curvature oversewn.
• Billroth 1885: Resection of a large pyloric carcinoma, using an anterior
gastrojejunostomy
• Several modifications of where seen over time
5. ANATOMY
PARTS OF THE STOMACH
It is usually J shaped and
located in the left upper
quadrant and epigastrium, and
its distal part can extend to the
level of the umbilicus.
The stomach is divided into;
Fundus,
Body,
Antrum
Pylorus.
6.
7.
8. ANATOMY
TYPES OF CELLS;
• Secretory epithelial cells cover the surface of the stomach;
• Mucous cells: secrete an alkaline mucus that protects the epithelium against
shear stress and acid.
• Parietal cells: secrete hydrochloric acid and intrinsic factor
• Chief cells: secrete pepsinogen, a proteolytic enzyme.
• G cells: secrete the hormone gastrin.
• Enterochromaffin cells- histamine
• D cells somatostatin
9. Arterial blood supply:
COELIAC TRUNK; 3Branches
Left Gastric Artery;
Supplies the cardia of the stomach and distal
esophagus
Splenic Artery;
Gives rise to 2 branches which help supply the
greater curvature of the stomach;
Left Gastroepiploic, Short Gastric Arteries
Common Hepatic ;
2 major branches Right Gastric- supplies a portion of
the lesser curvature
Gastroduodenal artery-Gives rise to Right
Gastroepiploic artery Helps supply greater curvature
in conjunction with Left Gastroepiploic Artery
12. ANATOMY
• LYHMPHATIC DRAINAGE
• The lymphatics of the stomach ultimately drain into the coeliac group.
• Zones
• Nodes
• Stations in D1-D4 resection
13. The lymphatics drainage
are grouped into 3 zones
Zone 1 drain via
Left gastric nodes
Right gastric nodes
Zone 2
Gastroepiploic
Suprapyloric
Subpyloric
Zone 3
Splenic, short gastric
Suprapancreatic
14. N1 – First tier – nodes within 3cm
from the primary tumour and are
station 1-6
1. Right cardiac
2. Left cardiac
3. Nodes along the lesser curvature
4. Nodes along the greater curvature
a.Along short gastric -4sa
b. Along left gastroepiploic 4sb
c. Along right gastroepiploic 4sc
5. Suprapyloric nodes
6. Subpyloric nodes
15. N2- Second tier nodes: Nodes
in main and intermediate
arterial trunk stations 7-11
7. Along left gastric artery
8. Along common hepatic artery
9. Along coeliac axis
10. At splenic hilum
11. Along splenic artery
16. N3 - Third tier nodes: Nodes at
stations 12-18 (para-aortic
and above)
12. At hepatoduodenal
ligament
13. Retroduodenal lymph
nodes
14. At root of mesentery
15. Around middle colic artery
16. Para-aortic nodes
17. Around lower oesophagus
18. Supradiaphragmatic
17. • D1—involvement of group I lymph nodes.
• D2—involvement of group I and II lymph nodes.
• D3—involvement of group I, II and III lymph nodes.
• D4—involvement of group I, II, III and para-aortic nodes
• D4 is not commonly advocated. It is removal of stations 1-18.
18. TYPES OF GASTRECTOMY
• Base on the amount of stomach removed
• Total
• Near total >90%
• Subtotal 80-90 %
• Partial 65-75 %
• Hemigastrectomy 50 %
• Antrectomy (distal gastrectomy ) 35-50%
• Base on the method of reconstruction
• Billroth I
• Billroth II
• Roux en Y
19. BILLROTH 1
• Partial gastrectomy with gastro-duodenostomy. It is the most
physiologic type of gastric resection, since it restores normal
continuity.
20. Variations of Billroth I
A. Billroth (1881)
B. Billroth (1881)
C. Kocher (1890)
D. Kutscha-Lissberg (1925)
E. V. Haberer (1920)
F. V. Haberer (1920), Finney (1923)
G. Winkelbauer (1927)
H. Schoemaker (1911)
I. Harkins, Nyhus (1960
25. • Extent of lymphadenectomy
• D0 – incomplete D1
• D1; 1-6
• D2; 7-11
• D3; 12-14
• D4; 15, 16
• BASE ON THE RESECTION MARGIN
• R0
• R1
• R2
• BASE ON TECHNIQUE
• OPEN OR LAPAROSCOPIC
26. INDICATION
• PEPTIC ULCER DISEASE
• Intractable PUD
• Recurrent bleeding – for low risk patients
• Cicatrization- GOO
• Gastric ulcer type II and III
• Partial gastrectomy combine with vagotomy has shown less mortility disturbance
and marginal ulcers.
• TUMOURS; benign tumour of antrum, gastric cancer
• OBESITY- sleeve gastrectomy
• TRAUMA;
• STRICTURE
27. Choice for procedure
• Total gastrectomy
• indicated when the extent, or
• location, of the primary tumour is such that adequate margins
• of resection (i.e. 4–6 cm) are not possible by a subtotal
• gastrectomy. proximal gastric
• tumours and extensive lesions, including linitis plastica.
• Subtotal gastrectomy
• particularly suitable for
• small gastric tumours involving the pylorus and distal third
• of the stomach.
• Billroth I;
• benign gastric ulcer (proved by endoscopic biopsy),
• benign tumour of the distal stomach,
• trauma to distal stomach,
• recurrent or bleeding duodenal ulcer,
• if pyloroplasty is not feasible.
• Billroth II
• Gastric ulcer where Billroth I is not possible
• carcinoma pylorus and antrum as a radical or palliative procedure;
• recurrent ulcers;
• Trauma to distal stomach and duodenum.
28. • NB;
• In carcinoma distal stomach, Billroth I anastomosis is usually not done
as recurrence in bed when it occurs will cause obstruction due to
encasement of the relapsed (local) tumour;
29. • The advantage of a Billroth I gastrectomy over a Billroth II procedure
• maintenance of the physiological and anatomical gastroduodenal pathway.
Thus, it offers a lower incidence of post-gastrectomy syndromes.
• minimal disturbance of pancreatic function, and a
• possible lower incidence of late development of carcinoma in the stomach
remnant.
30. PREOPERATIVE PREPARATION
• History – symptoms, risk factor, co-morbidity
• Examination; Epigastric mass, features of advance disease
• UPPER GI ENDOSCOPY AND BIOPSY
• Abdominal CT scan; adjacent structures and liver metastesis
• ENDOLUMINAL USS; infiltration and local nodal involvement
• LAPAROSCOPY is useful for determining tumour spread in the peritoneal cavity and assessing any
fixation of the tumour to surrounding organs.
• Chest X-ray
• ECG, echo
• Optimize derangement; dehydration, dyselectrolytemia, anaemia, GXM, nutritional rehab
• CONSENT
• Preoperative antibiotics
31. PROCEDURE – SUBTOTAL GASTRECTOMY
• For small cancers limited to the distal antrum, the patient can be
offered radical distal or subtotal gastrectomy.
• At initial exploration, determine the resectability.
32. ANAESTHESIA
• General anesthesia with cuffed endotracheal intubation and
adequate muscle relaxation.
POSITION
• As a rule, the patient is laid supine on a flat table, the feet being
slightly lower than the head
34. INCISION
• A midline incision extending from the xiphoid skirting the umbilicus
• Additional exposure can be obtained by excising the xiphoid. Bone
wax is applied to the sternal end to control bleeding.
• Further exposure can be obtained by splitting the sternum with a
sternal knife.
• Chevron incision; the exposure provided by midline incision is usually
not as adequate as that provided by a chevron incision.
38. EXPLORATION
• Do not immediately palpate the stomach.
• Note any ascites and peritoneal deposits.
• Start your complete exploration from the pelvis and work towards
the stomach in order not to disperse malignant cells.
• Examine the greater omentum for deposits and then raise it to feel
the para-aortic nodes and those around the root of the mesentery,
and the right colic and middle colic arteries.
• Examine the full length of the small and then large intestine, seeking
peritoneal deposits on the bowel wall, the mesentery and the parietal
peritoneum.
• Look for incidental disease
39. • Now draw the omentum caudally to examine the upper
compartment.
• Feel both lobes of the liver and adjacent diaphragm, gallbladder and
free edge of the lesser omentum, the spleen, kidneys and adrenal
glands.
40. • Starting at the oesophageal hiatus and working distally, look and feel
for tumour involvement, fixity, glands and also incidental disease.
• Systematically move distally, avoiding handling or squeezing the
tumour if possible.
41. • Palpate the duodenum and feel the pancreas, then the region of the
coeliac axis just above the neck of the pancreas.
• If you are seriously in doubt whether to proceed, incise the lesser
omentum in an avascular area near the liver and examine the coeliac
axis and emerging arteries.
42. MOBILIZATION & RESECTION
• Lift the great omentum and dissect it from the transverse colon at the
bloodless plane of fusion between the folded omentum,
43. • Gently peel off the omentum, taking care not to damage the middle
colic artery
44. • At the left extremity of the greater omentum, Carefully dissect out the
lymph nodes at the origin of the left gastroepiploic artery, then doubly
ligate and divide the artery and vein.
45. • At the right extremity of the greater omentum Carefully isolate the
gastroepiploiec vessels and the subpyloric lymph nodes before doubly
ligating and dividing them at their origins
46. • Now draw the distal stomach caudally to put on stretch the free edge of
the lesser omentum.
• Carefully make a transverse incision in the anterior leaf above the
pylorus extend this towards the cardia, keeping close to the liver, it
reveals the right gastric vessels and the suprapyloric lymph nodes
• Dissect the nodes and doubly ligate and divide the right gastric blood
vessels.
47. • Perform Kocher's mobilization of the duodenum so that the first part
can be dissected from the head of the pancreas.
• Mobilize 5–6 cm of duodenum beyond the pylorus.
48. • Transect the duodenum-use GIA stapler or other mechanical stapler 2-
3cm of the first part.
49. • Elevation and cephalad traction on the stomach exposes the coeliac
axis, the left gastric artery, and the lymph nodes associated with
these vessels.
• The left gastric artery is doubly ligated divided near its origin with
division of the left gastric vein along the superior border of the
pancreas.
• The lymph nodes and fat along the branches coeliac axis, superior
border of the pancreas and infront of the portal veins are removed.
50. • Gastric division; subtotal gastrectomy (80-90%) by dividing the stomach
• 2 cm distal to OG junction along lesser curve and 5 cm distal along the greater
curvature. And at least 5cm resection margin otherwise a total gastrectomy is
done
• Straight occlusion clamp is placed along the greater curvature towards
remnant side and along lesser curve obliquely to create lesser curve.
• Crushing (Payr’s) or Kocher’s clamps are placed towards specimen side.
Stomach is cut using no. 15 blade.
• Specimen is placed in orientation grid. Intraoperative frozen section biopsy
is done to confi rm the clearance at margins.
52. POLYA METHOD
• Unit jejunum with open end of
the stomach.
• Anticolic or retrocolic
• Retrocolic; the jejunum is
brought through a rent in the
mesentry to the left of the
middle colic near the ligament
of treitz
• Grasp the jejunum with babcock
juxtaposition to the lesser
curvature of the stomach
• The jejunal loop is grasped in an
enterostomy clamp and
approximated to the posterior
surface of the posterior of the
stomach adjacent to the
noncrushing clamp by a layer of
closely placed interrupted 2-0
silk suture
53. This posterior layer
should include both
greater curvature and
lesser curvature of the
stomach , otherwise
subsequent closure of
the angle may be
insecure
Apply noncrusing
clamps several cm from
the line of staple on the
stomach – for stability
and prevent gross
soilage
54. Cut-off stapled line with
scissors and jejunum
open approximately
same size
Inner layer thru-and
thru approximating both
mucous membrane of
the stomach and
jejunum
55. • The corners are inverted with a Connell type suture tha is continued
anteriorly and the final knot is tied on the inside of the midline
• The anterior serosal layer are then approximated with interrupted 2-0
silk
• Finally at the upper and lower angles of the new stoma, additional
sutures are placed so that any strain exerted of the stoma is met by
these additional reinforcing serosal suture and not by the sutures of
the anastomosis.
71. POSTOPERATIVE CARE
• The patient is placed in a semi-Fowler’s position when conscious.
• Intravenous fluid, antibiotics, analgesics
• Correction of anaemia, electrolyte
• Chest physiotherapy
• Early ambulation, DVT prophylaxis
• NG tube
• Graded oral sips
• Feeding
72. COMPLICATIONS
• EARLY
• Intragastric hemorrhage
• Extragastric hemorrhage
• Duodenal blow out/ stump leakage
• Stomal obstruction
• Afferent loop obstruction
• Jejunal loop herniation
• Gastric remnant necrosis
• Postoperative pancreatitis
• Common bile duct injury or injury to ampula
• Omental infarction
74. FUTURE PROSPECTIVE
• SENTINEL LYMPH NODE BIOPSY
• Injection of isosulfan blue, indocyanine green
• Technetium 99m- radioisotope (standard)
• Intraoperative subserosal injection
• Injection is carried out in 4 quadrant of the tumour
75. • Estern studies node negative T1 and T2 and report accuracy of >98%
particularly in early stage
• Western countries included T3 and the accuracy was about 80%
• Complex lymphatics of the stomach and fear of skip metastesis –
make the selection of patient difficult
• Limited lyphadenectomy base on SLN is cautioned by several authors
and further studies are needed before this method can be introduce
into daily practice.
76. REFERENCES
1. Oliver M, Myles J. Classic operations on the upper gastrointestinal
tract. In; Farquharson's textbook of operative general surgery.
Edward Arnold publ. 9th ed. 272-279.
2. Robert M Z, Christopher E E. Gastrointestinal procedures. In;
Zollinger’s Atlas of surgical operation.Mc Graw Hill. 9th ed 64-79.
3. Winslet M C, Dawas K I. stomach and duodenum. In; Kirk’s General
Surgical operations. Churchill livingstone 6th ed 174-177.
4. SRB’s surgical operation text and atlas. Jaypee Brothers Medical
Publishers. 1st ed. 2014
77. REFERENCES
• 5. Robinson JO. History of gastric surgery. Postgrad Med J. 1960;
36;706-712
• 6. Songun I, et al. Lancet Oncol 2010; 11:439-49
• 7 . Tohru T, Hiromichi S, Masaji T. sentinel lymp node navigation for
gastric cancer: does it really benefit the patient? World J
gastroenterol. 2016 Mar 14; 22(10):2894-2899.
• 8. Arnold S G. The rationale of antrectomy and vagotomy for
duodenal ulcer. AMA Arch Surg. 1956;73(2):364-366