Editing Oesophagectomy (section)

=== Abdomen: ===

** Midline laparotomy
** Check for metastases
** Prepare gastric tube
*** Start on greater curvature       - identify right gastroepiploic arcade near the midpoint of greater       curvature and start dividing the omentum 2cm peripheral, working towards       the fundus, preserving the arcade for the conduit
*** Divide short gastrics 1cm       off the stomach, and separate stomach from splenic hilum
*** Incise phreno-oesophageal       ligament
*** Identify left gastric       artery (elevate stomach towards hiatus and look for the band of fat       between retroperitoneum and lesser curvature. Left gastric dissected and       ligated (using EndoGIA tan 45mm), with resection of lymphatics around       it. Avoid splenic artery near origin of left gastric artery.
*** Lesser omentum opened
*** Divide hepatic branches of       the vagal nerves
*** Right gastric artery       divided close to pylorus
*** Identify resection margins       required - aim for 10cm distal to known tumour
*** Fashion a 4-5cm gastric       tube using linear staplers (narrower tubes have better emptying, whereas       wide tubes retain better perfusion). Start on greater curvature at level       of division, then work on an oblique line towards incisura/pylorus.
*** Kocher manoeuvre - pylorus       should reach caudate lobe when the conduit is pulled up
*** Consider       pyloroplasty/pyloromyotomy - Incise over pylorus, then spread muscle       fibres, trying to avoid using diathermy.
** Mobilise left hepatic lobe      (divide falciform ligament and left triangular ligament, and incise pars      flaccida)
** Finalise dissection of the      oesophagus - expose the junction of left and right crura posteriorly
** Suture the two halves of      stomach together with 3x interrupted, so they can be pulled up into the      chest.
** Remove all nodes from      coeliac axis, and along splenic artery to splenic hilum
** Clear common hepatic nodes      up to IVC and PV
** Place jejunostomy 40cm      distal to ligament of Treitz
** 24Fr Blakes drain alongside      pylorus