Three other ports are placed as shown in Figure 3. The peritoneal cavity is then examined. Biopsies are taken of any abnormal sites. The service of the liver in an area that is difficult to note metastatic lesions on preoperative CT and MRI is then thoroughly examined. Using an laparoscopic retractor the liver is pulled away from the area of the lesser curvature of the stomach.
Lesser omentum is incised, avoiding injury to any large apparent blood supply to the liver.
The flexible endoscope is then passed and biopsies are taken of lymph nodes adjacent to the right and left crux. The lesser sack is then entered through the lesser omentum exposing the peripancreatic area and the celiac axis. Lymph node biopsies are taken from those regions as well. The biopsies are labeled according to the lymph node staging map, figure 2, and sent to the pathologist. The ports are then removed and all incisions are closed with vicral.