Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

3. CLOSING

The incision is closed in layers using 2-0 polyglactin in a running fashion. The subcutaneous tissue is reapproximated with a running 3-0 polyglactin suture. The skin can be stapled together or closed with a running subcuticular suture of 4-0 undyed absorbable monofilament and adhesive strips.

STEP 4: POSTOPERATIVE CARE

The patient should have already received a preoperative dose of a prophylactic antibiotic such as cefazolin. Two additional doses should be given after the operation. Hydration will be maintained with an intravenous infusion of a balanced dextrose and electrolyte solution. Intravenous analgesics are used until the patient resumes enteral feeds. The decision to decompress the stomach with a nasogastric tube is up to the individual surgeon, and the current tendency is to use these tubes sparingly. Certainly, if the repair was deemed to be tenuous, a nasogastric tube could prove to be very helpful. After 2 to 3 days (on average), enteral feeds can be slowly and gradually resumed. The presence of bile in the gastric aspirate does not necessarily represent a persistent postoperative paralytic ileus, because it could be the result of the pyloroplasty itself, and it should not be a reason for undue delays in resumption of enteral feeds. Pain, abdominal distention, tachycardia, and guarding should prompt the surgeon to order a contrast study to investigate for leaks in the suture line.

STEP 5: PEARLS AND PITFALLS

As mentioned previously, avoidance of tension on the suture line is essential. This is accomplished by a generous Kocher maneuver. Avoid approximating the antrum and duodenum in such a manner that both structures have to be excessively rolled inward to approximate the anterior layers. This can be achieved by placing the posterior seromuscular stitches as posterior as possible (taking care not to involve the ampulla of Vater in the suture line), giving ample room to perform the incisions in both the duodenum and antrum and complete the anastomosis with minimal tension.

As with any pyloroplasty, alkaline reflux, alkaline gastritis, and dumping syndrome can be problematic. Suture line leaks can result from undue tension or the approximation of acutely inflamed or poorly perfused tissues.

SELECTED REFERENCES

1. Mercer DW: Stomach. In Townsend CM, Beauchamp RD, Evers MB, Mattox KL (eds): Sabiston Textbook of Surgery, 17th ed. Philadelphia, Saunders, 2004, pp 1265-1317.

2. Warner BW: Pediatric surgery. In Townsend CM, Beauchamp RD, Evers MB, Mattox KL (eds): Sabiston Textbook of Surgery, 17th ed. Philadelphia, Saunders, 2004, pp 2097-2132.

C H A P T E R 25

JABOULAY SIDE-TO-SIDE

GASTRODUODENOSTOMY

Carlos A. Angel

INTRODUCTION

This bypass operation is indicated in the presence of marked inflammation or scarring of the pylorus that precludes a Heineke-Mikulicz pyloroplasty. The procedure can be performed using a standard handsewn technique or a stapler. The handsewn technique described in this chapter is a two-layer anastomosis with a running inner layer of 3-0 absorbable sutures and a seromuscular outer layer of interrupted 3-0 silk sutures.

STEP 1: SURGICAL ANATOMY

The pylorus sits at the distal end of the stomach and is marked by thickening of the circular smooth muscle layer, thus forming the pyloric sphincter, which acts as a valve between the stomach and the duodenum and regulates gastric emptying. The pylorus does not have independent blood supply; rather, it gets its blood supply from the vessels that perfuse the distal stomach and proximal duodenum. Innervation of the pylorus is through the terminal branches of the right and left vagus nerves. Any injury to these nerves or denervation of the pylorus will result in pylorospasm and delayed gastric emptying.

STEP 2: PREOPERATIVE CONSIDERATIONS

Confirmation of the diagnosis of peptic ulcer disease or delay in gastric emptying should be documented before the procedure with endoscopy, contrast studies, or technetium-99 sulfur colloid meals.

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Duodenum

Antrum

Layer of interrupted seromuscular stitches

FIGURE 25–7

STEP 5: PEARLS AND PITFALLS

As mentioned, avoidance of tension on the suture line is essential. This is accomplished by a generous Kocher maneuver. Avoid approximating the antrum and duodenum in such a manner that both structures have to be excessively rolled inward to approximate the anterior layers. This can be achieved by placing the posterior seromuscular stitches as posterior as possible (taking care not to involve the ampulla of Vater in the suture line), giving ample room to perform the incisions in both the duodenum and antrum and complete the anastomosis with minimal tension.

COMPLICATIONS

As with any pyloroplasty, alkaline reflux, alkaline gastritis, and dumping syndrome can be problematic. Suture line leaks can result from undue tension or the approximation of acutely inflamed or poorly perfused tissues.

SELECTED REFERENCES

1. Mercer DW: Stomach. In Townsend CM, Beauchamp RD, Evers MB, Mattox KL (eds): Sabiston Textbook of Surgery, 17th ed. Philadelphia, Saunders, 2004, pp 1265-1317.

2. Warner BW: Pediatric surgery. In Townsend CM, Beauchamp RD, Evers MB, Mattox KL (eds): Sabiston Textbook of Surgery, 17th ed. Philadelphia, Saunders, 2004, pp 2097-2132.

C H A P T E R 26

GASTRIC RESECTION: BILLROTH I

B. Mark Evers

STEP 1: SURGICAL ANATOMY

The blood supply to the stomach is abundant. The right gastric artery, a branch from the hepatic artery, courses along the lesser curvature of the stomach to meet the left gastric artery, which is a branch of the celiac axis. The right gastroepiploic artery, a branch of the gastroduodenal artery, courses along the greater curvature of the stomach to meet the left gastroepiploic artery, which is a branch of the splenic artery. In addition, the stomach receives short gastric branches from the splenic artery. The venous drainage of the stomach is into the portal venous system (Figure 26-1).

STEP 2: PREOPERATIVE CONSIDERATIONS

The Billroth I procedure for gastroduodenostomy is the most physiologic type of gastric resection, because it restores normal gastroduodenal continuity. It has been the preferred treatment of gastric ulcer or antral cancer by a number of surgeons; however, its use for duodenal ulcer has been less popular. The principal contraindications to a Billroth I operation include edema from acute or recurrent inflammation and scarring and deformation secondary to chronic disease.

STEP 3: OPERATIVE STEPS

1.INCISION

An upper midline incision or subcostal incision is an acceptable option for performing this procedure. The line of division varies according to the extent of resection required. The dashed line indicates an approximate 50% gastric transection with a line from the lesser curvature slightly proximal to the incisura angularis (Figure 26-2).

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