Most patients ask the same thing when surgery is advised for stomach cancer: how much of my stomach will be taken out? Put simply, there are two answers. Either all of it (total gastrectomy) or a part of it, usually the lower part (subtotal gastrectomy). Which one you get depends mostly on where the tumour is, how big it is and how it’s behaving. Doctors would rather save some stomach, because it helps with eating and nutrition later. But removing all the cancer always comes first. This is how total vs subtotal gastrectomy is decided.

According to Dr. Sandeep Nayak, a surgical oncologist in Bangalore, says you can’t name the exact operation from a diagnosis alone. The endoscopy, CT scan and biopsy come first, and even then the plan can still change during surgery, if the cut edge shows cancer.

Surgery is a big part of stomach cancer treatment. Here is what each operation actually takes out.

• Total gastrectomy: Here the whole stomach goes, top to bottom, cardia and pylorus included. The food pipe is joined directly to the small intestine.
• Subtotal gastrectomy: A good part of the lower stomach is taken out together with the pylorus. What remains, a small upper pouch, is joined to the intestine.
• Lymph nodes: Neither operation is only about the stomach. The glands lying along its curves are cleared as well, since that is where the disease tends to travel first.
• Reconstruction: The intestine has to be reconnected after the stomach is out, otherwise food has nowhere to go. How? That depends on how much stomach is left.
• Proximal gastrectomy: Ever heard of a proximal gastrectomy? Only the upper stomach is removed. It is rare. Only a few early tumours high up are suitable for it.

What does the oncology team look at? A few things, and always together.

• Tumour location: Low in the stomach? Then a subtotal gastrectomy is often possible. Middle or upper stomach? You’re more likely to need a total gastrectomy.
• A clear margin: The cut edge must be free of cancer. If a clear margin cannot be reached by removing only the lower stomach, the surgeon moves to a total gastrectomy. A frozen section, reported while you are still on the table, is sometimes sent to check.
• Size and depth: Big tumours need a wider cut, and so do tumours that have grown deep into the wall. Sometimes that leaves too little healthy stomach worth keeping.
• Pattern of spread: Some cancers, the diffuse type for instance, spread along the stomach wall. What you see on the surface may not show how far they have gone. So a larger resection may be needed.
• Nearby organs: If the tumour has reached the pancreas and surgery needs to remove part of it along with the spleen, a total gastrectomy is advised, wherever the tumour began.

When cancer spreads to the peritoneum, the lining of the abdomen, the surgical team needs an objective way to measure it. The peritoneal cancer index (PCI) does that by scoring how much disease is present and how widely it has spread. It is one of the first things assessed when deciding whether cytoreductive surgery with HIPEC is a realistic option, though it is never the only factor.

According to Dr. Sandeep Nayak, a surgical oncologist in Bangalore, the number alone doesn’t settle anything. The scans, the type of cancer, how fit the patient is and what can actually be removed all go into the decision, and the final score is often confirmed only once the surgeon looks inside.

Before anyone talks about HIPEC treatment, the first question is how far the disease has gone. The PCI is how that gets answered.

Thirteen regions: The surgeon divides the abdomen into 13 areas. Nine cover the abdomen and pelvis, and four cover the small bowel.

Lesion size score: Each area gets a score from 0 to 3, based on the biggest tumour deposit in it. Zero means nothing visible. A 3 means deposits bigger than 5 cm, or disease that has joined up into one sheet.

Total score: Add the 13 scores together and you land somewhere between 0 and 39. More disease, higher number.

How it’s measured: A scan gives you an estimate. The most reliable PCI is the one the surgeon sees with their own eyes at the start of the operation.

Completeness score: Once the surgery is done, a separate CC score records how much disease was left behind. The aim is CC-0 or CC-1.

No single number decides this. The oncology team looks at several things together.

Where the cancer began: Cancers of the appendix, colon, ovary and the peritoneum itself are the usual ones considered. Stomach cancer comes into it in selected cases.

The PCI range: In colon and rectal cancer, a PCI above about 20 is usually seen as too high for surgery. Other cancers use different cut-offs, and in ovarian cancer the PCI isn’t a fixed rule.

Can it all come out? This is the real question. Can the surgeon remove all the visible disease and finish with a CC-0 or CC-1 result? If not, the operation usually doesn’t go ahead.

Fitness: It’s a long, major operation. How active you are day to day matters, and so do your heart, lungs, kidneys and liver.

Spread outside the abdomen: Disease that stays within the peritoneum is the ideal. Spread to distant organs, or deposits in places that can’t be removed, can rule surgery out even when the PCI is low.

The three approaches differ mainly in the size of the cut and in how the surgeon sees and works inside the chest. Open thoracotomy uses one larger incision. VATS uses small cuts, a camera and long instruments, and RATS adds a robotic console with a three dimensional view. All three are used for lung cancer resections, including lobectomy. The right choice depends on the tumour, the patient’s health and the team’s experience.

According to Dr. Sandeep Nayak, a surgical oncologist in India, the choice between VATS vs RATS and open thoracotomy for lung cancer surgery depends on the tumour. “The approach is chosen to suit the tumour. Each one can remove a lung cancer completely when it is used in the right patient. Smaller cuts usually mean less pain and a quicker recovery. Some tumours still need an open operation to be removed safely. The route is only a means to the goal, and the goal is complete removal 

All three reach the lung through the chest wall, but the access and the tools differ.

Open thoracotomy: One larger incision between the ribs, with the ribs spread for access. The surgeon works looking directly at the lung.

VATS: A few small cuts between the ribs. A camera and long instruments are used, and the surgeon works from a screen. The full name is video-assisted thoracoscopic surgery.

RATS: Small cuts again, this time with a robotic console. The surgeon controls the instruments from the console and sees a magnified three dimensional view. The instruments bend and rotate more freely than straight VATS tools.

What they can treat: All three can be used for lobectomy, segmentectomy and wedge resection, depending on the tumour.

The same operation by a different route: In principle the tumour and the lymph nodes are removed in each case. Only the way in changes. Our page on lung cancer treatment covers the operations used.

The table sets out the main differences side by side.

VATS vs open: Trials found less pain and better quality of life after VATS, and long term survival wasn’t significantly different. Our blog on VATS surgery for lung cancer explains how it works.

RATS vs VATS: A pooled analysis of randomised trials found equivalent cancer and complication outcomes. RATS showed less blood loss and more lymph nodes removed, but that hasn’t translated into better survival.

Cost: Robotic systems generally cost more to buy and run, so RATS usually costs more.

Switching during surgery: Any keyhole operation can be changed to open surgery if it isn’t safe to continue. It’s a safety step, not a failure.

Most people hear “lung cancer surgery” and picture one operation. There are really three common ones, and what separates them is simple: how much lung leaves the body. A lobectomy takes a whole lobe. A segmentectomy takes a smaller piece of a lobe, a self-contained section with its own airway and blood supply. A wedge resection takes a small chunk around the tumour and doesn’t follow any of the lung’s natural lines.

Dr. Sandeep Nayak, a surgical oncologist in India, puts it this way: the operation should be cut to fit the tumour and the lungs, not the other way round. He won’t suggest a plan until the scans, the lymph node findings and the breathing tests are all on the table together.”

When the cancer hasn’t left the lung, surgery is usually the first option on the table in lung cancer treatment. Think of the lung as a tree. A lobectomy takes off a whole major branch. A segmentectomy prunes a smaller limb at the point where it joins. A wedge resection just cuts out the damaged part without worrying about where the branches split.

A lobectomy is the long-standing standard. The right lung has three lobes and the left has two, and the surgeon removes the one that holds the tumour. It’s the biggest of the three, and for years it was the default for any operable early cancer.

A segmentectomy is trickier to perform. The surgeon has to find that segment’s own bronchus, artery and vein, divide them one by one, and lift the segment out cleanly. The reward is that more healthy lung stays behind.

A wedge resection is the quickest and smallest. A stapling device cuts a wedge out and seals the edge as it goes. The catch is that nothing guarantees a generous rim of healthy tissue, so it depends heavily on where the tumour sits.

In all three, nearby lymph nodes are usually sampled or removed. What they show can change what happens next, so the surgeon doesn’t skip them.

And the technique is a separate question from the extent. Open surgery, VATS keyhole surgery or a robot can be used for any of the three.

Picture a typical case. A patient in their sixties has a 1.5 cm nodule near the outer edge of one lung, the lymph nodes look clear, and breathing tests are on the weak side after years of smoking. For that person, a segmentectomy often makes more sense than a lobectomy. Change one detail, say the nodule is 3.5 cm and close to the main airway, and the answer flips.

So what actually tips the decision?

Size and position matter most. Small tumours of around 2 cm or less in the outer lung are the best candidates for a smaller operation. Large ones, or ones near the centre of the chest, usually aren’t.

Lymph nodes come next. If they look involved on a scan, or turn out to be involved during surgery, the surgeon will often move to a lobectomy and clear the nodes more thoroughly.

The look of the tumour on CT counts too. A hazy “ground glass” appearance often means slow growth, which can justify taking less lung.

Then there’s the patient. Weak breathing reserve, heart trouble or other illness can make a smaller operation the safer choice, even when a lobectomy would otherwise be on the cards.

The research backs this up for carefully chosen cases. A large randomised trial looked at tumours up to 2 cm in the outer lung with clear nodes, and patients who had a smaller resection did about as well on disease-free survival as those who had a lobectomy.

Whether surgery can cure the cancer at all depends on stage, which our guide on whether lung cancer can be cured explains.

Surgery is the first and main treatment for most oral cavity cancers, including cancer of the tongue. Radiation usually comes later, after the operation, if the pathology report points to a higher risk, and it takes the lead only when surgery isn’t an option. Speech and swallowing are affected because the tongue is central to both. How much changes depends on how much of it is removed, which part, and whether it’s rebuilt.

According to Prof. Dr. Sandeep Nayak, Surgical Oncologist at MACS Clinic, Bangalore, talks patients through what to expect after a glossectomy. “The first question I get before tongue surgery is almost always the same: will I be able to talk and eat afterwards? With a small tumour, usually yes, with only a mild and brief change. If a bigger part has to go, the road is longer and rehab matters a lot. We plan the surgery and the recovery together.”

 

That depends on the tumour: how big it is, how deep, and where it sits. The surgeon takes the cancer plus a small rim of healthy tissue around it, and tries not to take more than that.

Partial glossectomy: Most people with a small tumour on the side of the tongue need only this. A piece comes out and the rest of the tongue stays. Some of these small tumours can be reached through the mouth with robotic help, and our page on trans oral robotic surgery covers where that’s used.

Hemiglossectomy: Half the tongue. This is for larger or deeper tumours.

Total glossectomy: The whole tongue, or nearly all of it. Rare, and kept for advanced cancers.

The neck: Tongue cancer often spreads to the lymph nodes in the neck, so the surgeon usually clears those during the same operation.

Rebuilding: If a big part is taken, skin and tissue from the forearm or thigh can be used to build the tongue back up.

Almost every sound you make involves the tongue. So yes, speech changes. How much is the real question.

Small removals: Many people notice very little. Some are a bit slurred for a short while, and then it settles.

Bigger removals: Clarity can drop. Sounds like t, d, l and s need the tip of the tongue to touch the roof of the mouth, so those suffer first.

Straight after surgery: Swelling makes everyone sound muffled for the first few days. It passes.

A rebuilt tongue: The tissue used to rebuild it gives the tongue enough bulk to reach the palate, and that helps with clearer sounds.

Speech therapy: This starts early. Exercises, practice, patience. Over weeks and months most people get clearer, even if it doesn’t sound exactly as it once did. Speech is a large part of head and neck cancer care, and our page on head and neck cancer treatment covers that.

No two people recover alike. These are the things that shape it.

How big the tumour was: The more tongue that has to come out, the bigger the change.

Where it was: The tip and front mostly change how clearly you speak. The back mostly changes swallowing.

Whether it was rebuilt: And how.

Radiation afterwards: If you need it, it can leave you with a dry mouth and some stiffness, and that makes both speaking and swallowing harder.

The neck operation: In suitable cases, Dr. Nayak’s RIA-MIND approach to neck dissection is designed to cut complications and help function. You can read more on our expertise page.

Rehab: Early therapy and daily practice at home count for a great deal, and they’re as much your job as the surgeon’s.

Where you started from: Your age, your general health, and how you were speaking and eating before.

Key Takeaways

• The tongue plays a vital role in both speech and swallowing, so surgery can affect these functions.

• Smaller tissue removals usually cause milder changes, while larger surgeries may require longer recovery and therapy.

• Surgical planning, reconstruction and rehabilitation help improve speech and swallowing after surgery.

• Ask your care team what to expect based on your tumour and planned surgery.

• To discuss your treatment options, book an appointment or call the clinic at +91 9482202240.

References

National Cancer Institute (NCI) – Head and Neck Cancers: Side Effects and Rehabilitation https://www.cancer.gov/types/head-and-neck/head-neck-fact-sheet

 PubMed – Voice Rehabilitation After Tongue Cancer Surgery: A Cohort Study in Indian Population https://pubmed.ncbi.nlm.nih.gov/39559020/

Disclaimer: This blog is for informational and educational purposes only and is not a substitute for professional medical advice or diagnosis.