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Complications - Total laparoscopic gastrectomy with D2 lymphadenectomy

general and visceral surgery
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Anatomy Perioperative management Technique Complications Evidence Total Video Medical Equipment

  1. Intraoperative complications

    Vascular injury
    Management: Oversew, vascular reconstruction

    Bile duct injury
    Management: Oversew, possibly T-drain; bilioenteric anastomosis

    Pancreatic injury
    Management: Oversew and extensive drainage

    Splenic injury
    Management: Coagulation with argon beamer, fibrin sealant patch, e.g., TachoSil®
    Last resort: Splenectomy

  2. Postoperative complications

    Failure of the esophagojejunostomy

      • Confirmation by endoscopy; sensitivity of radiological detection with water-soluble contrast agent is only 50%!
      • With early intervention and favorable tissue conditions, direct suture closure may still be possible in rare cases.
      • For smaller leaks: covered stent (prerequisite: bile-resistant cover, e.g., silicone)
      • For larger defects: Endoscopic negative pressure wound therapy (EsoSponge®)
      • In large defects otherwise unmanageable: Esophagus left in discontinuity with cervical diversion

    Suture line failure of duodenal remnant

      • Surgical revision with oversewing
      • If oversewing is not technically possible: drainage of duodenal remnant
      • If possible non-surgical approach; any resulting duodenal fistula may be drained secondarily via a jejunal Roux-en-Y limb

    Jejunojejunostomy suture line failure

      • Usually requires revision surgery

    Secondary intraluminal bleeding

      • Primarily endoscopic coagulation, if unsuccessful, revision surgery indicated

    Secondary extraluminal bleeding

      • Surgical revision, depending on bleeding intensity
      • Bleeding source spleen: Local hemostasis sparing the spleen, if possible; splenectomy as last resort
      • Note: Infection-induced erosive bleeding in duodenal remnant suture line failure!

    Intra-abdominal hematoma/abscess

      • Ultrasound-- CT-guided centesis and drainage
      • Often concomitant with suture line failure

    Lymphatic fistulas

      • Possible secondary to systematic (D2) or extended (D3) lymphadenectomy, rarely also chylous ascites
      • After removal of inserted drains, lymphatic fistulas usually resolve spontaneously
      • Temporary parenteral nutrition may be required in rare cases

    Pancreatitis

      • Most often edematous pancreatitis with good prognosis; nothing by mouth; nonsurgical treatment with medication
      • Hemorrhagic necrotizing pancreatitis, often resulting from iatrogenic pancreatic injury; multispecialty ICU treatment; also, surgical necrosectomy/lavage. Caution: High mortality!

    Esophagojejunostomy transit disorders

      • Causes: Edematous anastomosis, hematoma
      • Usually resolves within 10–14 days
      • Revision surgery indicated only in exceptional cases

    Secondary healing

      • Management: Reopening wound; wound debridement, secondary wound healing; negative pressure wound therapy of the abdominal wall