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Advanced therapy in thoracic surgery - part 10

Bóc tách proximally độ cong lớn hơn mở rộng để gián đoạn. Sau này, bóc tách được thực hiện distally, thận trọng trong việc ở ít nhất 2 cm bên và kém hơn so với động mạch gastroepiploic. Độ cong lớn hơn là nâng lên phía trước và dính giữa các tuyến tụy và dạ dày được chia bằng cách sử dụng đốt điện | 494 Advanced Therapy in Thoracic Surgery gastroepiploic artery. Using double clips ties or ultrasonic scalpel short gastric vessels are taken larger vessels being clamped and tied with 3-0 silk sutures. Elevation of the spleen with one or two moist lap pads may aid in exposure of the short gastric vessels. Dissection proximally on the greater curvature extends up to the hiatus. Following this the dissection is carried distally taking great caution in staying at least 2 cm lateral and inferior to the gastroepiploic artery. The greater curvature is lifted anteriorly and adhesions between the pancreas and stomach are divided using electrocautery. The left gastric artery is located and celiac nodal tissue is swept onto the specimen. Using a 30 mm vascular stapler the origin of the left gastric artery is clamped. After verification of an excellent pulse in the gastroepiploic arcade the stapler is fired Figure 41-5 . The remaining portion of the gastrohepatic ligament is divided using a combination of cautery and staples. Using a combination of careful electrocautery and blunt dissection a Kocher maneuver is performed mobilizing the duodenum to the midline. A pyloromyotomy or Heineke-Mikulicz pyloroplasty is performed. If a pyloroplasty is performed it is closed with interrupted 3-0 silk sutures in one layer carefully incorporating mucosa and muscular wall. A 6 cm left neck incision is made along the anterior border of the sternocleidomastoid muscle starting at the sternal notch. Dissection continues medial to the carotid sheath but lateral to the strap muscles and thyroid gland. The middle thyroid vein and omohyoid muscles are divided. Blunt dissection is directed toward the spine and the Penrose drain which had been placed around the cervical esophagus from the chest is grasped. The esophagus is gently and bluntly mobilized. The nasogastric FIGURE 41-4. The second Penrose drain is knotted and left in the abdomen for retrieval during the abdominal phase of the .