Abdominal phase
Task 1: Abdominal access
1.1 Opening the abdomen
1.1.1 Obtain safe access to the abdominal cavity.
1.1.2 Confirm the absence of metastatic disease and the appropriateness of the planned procedure.
Task 2: Diaphragmatic hiatus
2.1 Diaphragmatic hiatus
2.1.1 Mobilise the oesophagus from the diaphragmatic hiatus to the gastro-oesophageal junction, resecting a cuff of diaphragm and right and left paracardial lymph (LN) tissue (LN stations 1 and 2).
2.1.2 Dissect along the pericardial adventitia to remove the pericardial fat.
2.1.3 Resect the right pleura to expose the right lung.
2.1.4 Resect the left pleura to expose the left lung.
2.1.5 Dissect along the pre-aortic fascia.
Task 3: Gastric mobilisation
3.1 Gastric mobilisation
3.1.1 Identify the right gastroepiploic artery, which will provide the blood supply to the gastric tube.
3.1.2 Divide the greater omentum, ensuring that the gastroepiploic artery is preserved.
3.1.3 Enter the lesser sac and continue the dissection along the greater curvature of the stomach towards the spleen, dividing the short gastric and left gastroepiploic vessels and resecting the associated LN tissue (LN stations 4sa and 4sb).
Task 4: Coeliac axis
4.1 Portal vein and coeliac axis
4.1.1 Retract the stomach and dissect LN tissue along the superior border of the pancreas, to expose the portal vein.
4.1.2 Sling the common hepatic artery.
4.1.3 Dissect LN tissue along the proper hepatic artery, common hepatic artery, coeliac artery, left gastric artery and proximal splenic artery (LN stations 7, 8a, 9, 11p and 12a).
4.1.4 Ligate and divide the left gastric vein at the portal vein.
4.1.5 Ligate and divide the left gastric artery at its origin from the coeliac artery.
4.1.6 Dissect LN tissue from the left side of the coeliac artery to the left crus at the oesophageal hiatus and left side of Gerota’s fascia.
4.2 Splenic artery
4.2.1 Continue the dissection along the anterior surface of the proximal splenic artery towards the splenic hilum.
4.2.2 Ligate the posterior gastric vessels at their origin from the splenic artery.
4.2.3 Dissect the remaining LN tissue along the distal splenic artery, clearing to the splenic vein inferiorly and the abdominal wall posteriorly, until the splenic hilum is reached (LN station 11d).
4.2.4 Clear the splenic hilum of LN tissue (LN station 10).
Note: This dissection should marry up with that performed in Task 3.
Task 5: Gastric tube
5.1 Gastric tube
5.1.1 Perform a lymphadenectomy along the lesser curvature of the stomach until the expected lower resection margin is reached (LN stations 3a and 3b).
5.1.2 Create the gastric tube.
5.1.3 Pyloroplasty, pyloromyotomy, other (e.g. botulinum toxin, Botox®, Allergan) or no action may be performed.
Task 6: Insertion of surgical adjuncts
6.1 Feeding jejunostomy
6.1.1 A feeding jejunostomy may be placed.
6.1.2 If the abdominal phase of the operation has been performed minimally invasively, a port site may be extended to an 8-cm incision to facilitate the placement of a feeding jejunostomy.
6.2 Abdominal drains
6.2.1 Abdominal drain(s) may be placed.
Task 7: Abdominal closure
7.1 Abdominal closure
7.1.1 Perform abdominal lavage.
7.1.2 Confirm haemostasis.
7.1.3 Close the abdomen.
7.1.4 Dress the wound.
Abdominal lymph node stations
Japanese Gastric Cancer Association. Japanese classification of gastric carcinoma: 3rd English Edition. Gastric Cancer 2011;14:101–12.
See table 5 in the above paper.
Thoracic phase
Task 1: Thoracic access
1.1 Thoracic access
1.1.1 Obtain safe access to the patient’s right chest.
Task 2: Thoracic lymphadenectomy
2.1 Thoracic lymphadenectomy
2.1.1 Mobilise the lower lobe of the right lung.
2.1.2 Ligate and divide the azygos vein at the azygos arch.
2.1.3 Dissect along the pericardium until the left lung is reached including the pleura of the left lung in the radial excision margin.
2.1.4 Perform a subcarinal lymphadenectomy (LN station 107).
2.1.5 Clear both bronchi of LN tissue until the hilum of each lung is reached (LN station 109).
2.1.6 Dissect along the right pulmonary veins, continuing posteriorly until the left pulmonary veins are reached.
2.1.7 Dissect the mediastinal pleura at the anterolateral border of the thoracic aorta.
2.1.8 Dissect along the pre-aortic fascia from the proximal resection margin towards the diaphragm (LN station 112).
2.1.9 Dissect LN tissue along the aorto-pulmonary window, clearing the arch of the aorta, pulmonary artery and recurrent laryngeal nerve as it hooks around the arch of the aorta.
2.1.10 Identify and ligate the thoracic duct at the proximal resection margin and at the level of the diaphragm such that it is resected with the specimen.
Task 3: Specimen excision
3.1 Specimen excision
3.1.1 Ensure that the thoracic part of the specimen is circumferentially free, from the previously completed diaphragmatic mobilisation (performed during the abdominal phase) to at least the level of the aortic arch (LN stations 108, 110 and 111).
3.1.2 Deliver the stomach into the right chest cavity, ensuring that the gastric tube can reach the site of anastomosis without tension or torsion.
3.1.3 Excise the specimen with a suitable distal resection margin.
3.1.4 Send the specimen to pathology as per protocol.
Task 4: Anastomosis
4.1 Oesophago-gastrostomy
4.1.1 Perform an oesophago-gastrostomy.
4.1.2 If performing a two-phase minimally invasive procedure, an incision of up to 5 cm may be made in addition to the existing ports.
4.1.3 If performing a three-phase minimally invasive procedure, a left cervical incision is permitted for the anastomosis to be made.
Task 5: Insertion of surgical adjuncts
5.1 Nasogastric/nasojejunal tube
5.1.1 A nasogastric or nasojejunal tube may be placed.
5.2 Thoracic drains
5.2.1 Thoracic drains should be placed prior to the closure of the thoracic incision.
Task 6: Thoracic closure
6.1 Thoracic closure
6.1.1 Perform lavage.
6.1.2 Confirm haemostasis.
6.1.3 Close the chest.
6.1.4 Dress the wound.
Thoracic lymph node stations
Japan Esophageal Society. Japanese classification of esophageal cancer, tenth edition: part 1. Esophagus 2009;6:1–25.
See page 12 in the above paper.
