Surgical anatomy of the omental bursa and the stomach based on a minimally invasive approach: different approaches and technical steps to resection and lymphadenectomy

Abstract

Background: It is imperative for surgeons to have a proper knowledge of the omental bursa in order to perform an adequate dissection during minimally invasive surgery (MIS) of the upper gastrointestinal (GI) tract. This study aimed to describe (1) the various approaches which can be used to enter the bursa and to perform a complete lymphadenectomy, (2) the boundaries and anatomical landmarks of the omental bursa as seen during MIS, and (3) whether a bursectomy should be performed for oncological reasons in upper GI cancer.Methods: In this observational study, videos of 20 patients undergoing different MIS procedures were reviewed, and the findings were verified prospectively in 5 patients undergoing a total gastrectomy and in a transversely sectioned cadaver. A systematic literature review (PubMed) was performed on the additive value of bursectomy during gastrectomy for cancer. Results:The omental bursa can be surgically entered through the hepatogastric ligament, gastrocolic ligament, gastrosplenic ligament or through the transverse mesocolon. Anatomical boundaries of the omental bursa could be clearly identified, and new anatomical landmarks were described (gastro-omental folds). The cranial part of the omental bursa consists of two compartments (splenic recess and superior recess), separated by the gastropancreatic fold, communicating at the level of the pancreas, and extending distally as the inferior recess. There is no clear evidence regarding beneficial effect of a bursectomy in upper GI oncology. Conclusions:The description of the omental bursa in this study may help surgeons perform a more adequate oncological dissection during MIS. Bursectomy should not be routinely performed during oncological resections.

Laparoscopic D2 plus complete mesogastrium excision using the "enjoyable space" approach versus conventional D2 total gastrectomy for local advanced gastric cancer: short-term outcomes.

“…The entire surgical plane was preliminarily divided into two regions: the superior region and the inferior region. Due to the presence of the GPF, the superior region was divided into two compartments: the superior recess in the right, and the splenic recess in the left [16]. For better understanding, we divided the surgical plane into three parts: the inferior region, the superior recess and the splenic recess.…”

The Peritoneum: Beyond the Tissue – A Review

“…Serosal cavities were described by Bichart in 1827 ( Herrick and Mutsaers, 2004 ; Mutsaers, 2004 ), and Minot (1890) described two mesodermal tissues: the mesothelium as the epithelial lining of the embryonic serosal cavity (caelom), and mesenchyme as the non-epithelial mesoderm ( Minot, 1890 ). The anatomic organization of the abdominal cavity is consequence of the complex embryologic development of the gut and the peritoneum ( Coffey and O’Leary, 2016 ; Brenkman et al, 2017 ).…”

“…An example of this is the omental bursa, the space formed from the left movement of the abdominal organs during embryogenesis, which is limited anteriorly by the lesser omentum and stomach’s posterior wall (see Figure 3 ). Access to this space is of great importance for lymphadenectomy and bursectomy in gastric cancer surgical treatment ( Kayaalp, 2015 ; Brenkman et al, 2017 ). The fact that the digestive tube and the peritoneum are formed as contiguous structures, explains why all these subspaces are connected (e.g., Winslow foramen) allowing free peritoneal fluid flow through the entire cavity ( Bricou et al, 2008 , 2009 ) (see Figure 4 ).…”

Cholecystectomy, porta hepatis stripping, and omental bursectomy

“…Between the two layers of the lesser omentum, bordering on the right free margin, is the hepatic artery proper. Attached to the lesser curvature of the stomach are the right and left gastric arteries, and the gastric vein (7).…”

“…Vital structures including major vessels and organs are densely positioned, and mistakes during the procedure can lead to lethal hemorrhage or damage to adjacent major organs. Therefore, thorough knowledge of the adjacent anatomical structure is imperative for safe lesion dissection (6)(7)(8)(9). In this review, we will discuss the surgical approach of each procedure, focusing on the related anatomy for safe operation.…”