Subtotal gastrectomy is indicated in the presence of malignancy; in the presence of gastric ulcer that persists despite intensive medical therapy; and sometimes in the presence of pernicious anemia, suspicious cells by gastric cytology, or equivocal evidence for and against malignancy by repeated gastroscopic observation with direct biopsy. It may be utilized to control acid secretion in cases of intractable duodenal ulcer. A more conservative procedure should be considered in underweight patients with duodenal ulcer, especially females. Likewise, block excision of a gastric ulcer with multicentric frozen section studies should be made for proof of malignancy before performing a radical resection on the assumption the lesion may be malignant.

The preoperative preparation will be determined largely by the type of lesion presented and by the complication it produces. Sufficient time should be taken to improve the patient’s nutrition if possible, especially if there has been considerable weight loss in a patient with obstruction. The fluid and electrolyte normalization should be treated with intravenous fluids and electrolytes as necessary. The increased incidence of pulmonary complications associated with upper abdominal surgery makes it imperative that elective gastric surgery be carried out only in the absence of respiratory infection, and active pulmonary physiotherapy with possible bronchodilators, expectorants, and incentive spirometry should be started in all patients but especially those with chronic lung disease. Preoperative antibiotics should be given.

General anesthesia with endotracheal intubation should be used. Excellent muscular relaxation without deep general anesthesia can be attained by utilizing muscle relaxants. Epidural catheter placement may be considered for analgesia and after surgery.

As a rule, the patient is laid supine on a flat table, the feet being slightly lower than the head. If the stomach is high, a more erect position is preferable.

The skin is prepared in the routine manner.

A midline incision extending from the xiphoid to the umbilicus may be used. Additional exposure can be obtained by excising the xiphoid using electrocautery. Placement of a self-retaining retractor or a broad-bladed, fairly deep retractor placed against the liver down to the gastrohepatic ligament will aid in visualization.

The surgeon should focus his or her attention on the arterial blood supply (figure 1). Although the stomach will retain viability despite extensive interference with its blood supply, the duodenum lacks such a liberal anastomotic blood supply, and great care must be exercised in the latter instance to prevent postoperative necrosis in the duodenal stump. The blood supply to the lesser curvature of the stomach can be totally interrupted, and the retained fundus will be nourished by the small vessels in the gastrosplenic ligament in the region of the fundus. Importantly, if it is desirable to mobilize the stomach into the chest, its viability can be retained if only the right gastric artery is left intact. In such instances, however, the gastrocolic ligament should be divided some distance from the greater curvature to prevent interference with the right and the left gastroepiploic vessels.

The blood supply may also be used as landmarks in designating the extent of the gastric resection. Approximately 50% of the stomach is resected where the line of division extends from the region of the third large vein on the lesser curvature down from the esophagus to a point on the greater curvature where the left gastroepiploic vessels most nearly approach the gastric wall. Approximately 75% resection can be assumed when the line of resection includes most of the lesser curvature with extra gastric ligation of both the left gastric and left gastroepiploic vessel.

The surgeon likewise should be familiar with the major lymphatic drainage of the stomach in determining the presence or absence of metastasis if malignancy is suspected. Under such circumstances it is advisable to keep the dissection as far away as possible from both curvatures in order to retain all involved lymph nodes with the specimen. There is a tendency for metastases to involve distant lymph nodes of the lesser curvature (a) and the lymph nodes beneath the pylorus (b) as well as those of the greater omentum (c) (figure 1).

In general, it is desirable to move the greater omentum, most of the lesser curve to the esophagus, and about 2.5 cm of the duodenum (including subpyloric lymph nodes), and the greater curvature. It is rarely necessary to remove the spleen unless there is direct extension of a gastric cancer into the spleen. Extended radical dissection of the preaortic (Figure 1 d and Chapter 31 figures 2, 4 and 11) and portal area lymph nodes (not in the Chapter) has been shown to be beneficial in the Japanese experience; however, the utility of these dissections remains controversial.