D2 Lymphadenectomy According to the Arterial Variations in Gastric and Hepatic Irrigation.

Abstract

D2 lymphadenectomy for gastric cancer is technically demanding and requires clearance of the lymph node stations along the main arteries that irrigate the stomach and the liver. As gastric and hepatic irrigation have a different pattern from the classic branching of the celiac trunk in approximately 25% of patients, acquaintance with these variations and knowledge on how to adequately perform the lymphadenectomy in different anatomic settings is of utmost importance for surgeons who manage gastric cancer.1 METHODS: This video demonstrates, step-by-step, how to perform D2 lymphadenectomy in accordance with gastric and hepatic irrigation. Illustrations of the arterial variation correlate with the corresponding computed tomography image and operative management of the lymph node stations. D2 lymphadenectomy is the standard of care in advanced gastric cancer.2 It implies clearing the lymph node stations along the celiac trunk, left gastric artery, and common and proper hepatic arteries. However, the celiac trunk and hepatic irrigation are highly variable and surgeons must be aware of how to properly and safely address the lymph node stations in all scenarios. Vessel anatomical variations increase the risk of vascular injuries and its complications, such as bleeding, necrosis, liver function impairment, liver necrosis, and conversion to open surgery.3-5 Additionally, the lymphadenectomy cannot be compromised if a variation is found.6 Preoperative knowledge of the gastric blood supply also shortens the surgical duration.7 CONCLUSIONS: The present video demonstrates how to recognize the most common variations found during D2 gastrectomy, and provides strategies to adequately approach them.