Total gastrectomy may be indicated in treating extensive stomach malignancies. This radical procedure is not performed when carcinoma with distant metastasis to the liver or pouch of Douglas or seeding throughout the peritoneal cavity is present. It may be performed in association with the extirpation of adjacent organs including the spleen, body and tail of the pancreas, or a portion of the transverse colon. It is also the procedure of choice in controlling the intractable ulcer diathesis associated with non-beta islet cell tumors of the pancreas when pancreatic tumor or metastases remain that cannot be controlled medically.

Electrolyte replacement and fluid resuscitation should be complete. If colonic involvement is anticipated, the colon should be emptied with appropriate mechanical preparation. Blood should be readily available for transfusion.

General anesthesia with endotracheal intubation is used.

The patient is placed in a comfortable supine position on the table with the feet slightly lower than the head.

The area of the chest from above the nipple downward to the symphysis is shaved. The skin over the sternum, lower chest wall, and entire abdomen is cleansed with the appropriate antiseptic solution. Preparation should extend sufficiently high and to the left on the chest for a midsternal or left thoracoabdominal incision if necessary.

A diagnostic laparoscopy is often performed first to rule out inoperable spread of a malignancy (Chapter 13). If this view is clear, then a limited incision is made in the midline (figure 1, a–a₁) between the xiphoid and umbilicus. The initial opening is only to permit inspection of the stomach and liver and to introduce the hand for general exploration of the abdomen. Because of the high incidence of metastases, a more liberal incision extending up to the region of the xiphoid and down to the umbilicus, or beyond it on the left side, is not made until it has been determined that there is no contraindication to total or subtotal gastrectomy (figure 1). Additional exposure is allowed by removal of the xiphoid. Active bleeding points in the xiphocostal angle are transfixed with 00 silk sutures, and bone wax may be applied to the end of the sternum. Some prefer to split the lower sternum in the midline and extend the incision to the left into the fourth intercostal space. Adequate exposure is mandatory for a safe anastomosis between the esophagus and jejunum.

Total gastrectomy should be considered for malignancy high on the lesser curvature if there is no metastasis to the liver or seeding over the general peritoneal cavity, particularly in the pouch of Douglas (figure 2). Before the surgeon is committed to a total gastrectomy, he or she must have a clear view of the posterior aspect of the stomach to determine whether the growth has extended into the adjacent structures including the pancreas, mesocolon, or major vessels (figure 3). This can be assessed by reflecting the greater omentum upward, withdrawing the transverse colon from the peritoneal cavity, and searching the transverse mesocolon for evidence of invasion. By palpation the surgeon should determine that there is free mobility of the growth without involvement of fixation to the underlying pancreas or major vessels, especially in the region of the left gastric vessels (figure 4).

The entire transverse colon, including the hepatic and splenic flexures, should be freed from the omentum and retracted downward. As the omentum is retracted cephalad and the transverse colon caudad, the venous branch between the right gastroepiploic and middle colic veins is visualized and ligated to avoid troublesome bleeding. The greater omentum in the region of the head of the pancreas and the hepatic flexure of the colon is freed so that it can be entirely mobilized from the underlying head of the pancreas and duodenum.

Following the exploration of the lesser sac, the surgeon further mobilizes the stomach. If the tumor appears to be localized, even if it is large and involves the tail of the pancreas, colon, and kidney, a very radical extirpation may be carried out. Resection of the left lobe of the liver may occasionally be necessary.

To ensure complete removal of the neoplasm, at least 2.5–3 cm of duodenum distal to the pyloric veins should be resected (figure 2). Since it is not uncommon to have metastasis to the infrapyloric lymph nodes, they should be included in the resection. This is accomplished by doubly ligating the right gastroepiploic vessels as far away from the interior surface of the duodenum as possible (figure 5).

The right gastric vessels along the superior margin of the first part of the duodenum are isolated and doubly ligated some distance from the duodenal wall (figure 6). Palpation for potentially involved lymph nodes in the portal area is performed. If dissection is to be done, the surgeon must carefully identify and preserve the common hepatic and gastroduodenal arteries as well as the portal vein and common bile duct. The gastrohepatic ligament is divided as near the liver as possible up to the thickened portion, which contains a branch of the inferior phrenic artery.