Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)
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C H A P T E R 26 • Gastric Resection: Billroth I |
279 |
Left gastric artery
Splenic artery
Right gastric artery
Gastroduodenal artery
Gastroepiploic artery
MC
FIGURE 26–1
Incision line
Incision line 
Pylorus
FIGURE 26–2
2 8 0 S E C T I O N I V • TH E A B D O M E N
2. DISSECTION
The greater curvature of the stomach is mobilized by serial division of the gastric branches of the gastroepiploic vessels. The lesser curvature is then mobilized by serially dividing the gastrohepatic ligament to the point of planned transection of the stomach. The left gastric vessels are then identified, clamped, and ligated (Figure 26-3).
After the lesser curvature has been mobilized, proximal to the left gastric artery and distal to the gastric duodenal artery, Kocher or Payr clamps are applied to the stomach and the stomach is divided with a scalpel (Figure 26-4).
C H A P T E R 26 • Gastric Resection: Billroth I |
281 |
Ligate and divide gastric artery
FIGURE 26–3
Divide stomach
FIGURE 26–4
2 8 2 S E C T I O N I V • TH E A B D O M E N
Excess gastric tissue is removed, which includes the crushed tissue from the placement of the clamp (Figure 26-5).
The lesser curvature side of the gastric division is then closed using a running nonabsorbable suture (Figure 26-6), this is carried down to the point of the Kocher clamp, which is on the greater curvature side where the gastroduodenal anastomosis will be performed
(Figure 26-7).
Removing excess gastric tissue
FIGURE 26–5
FIGURE 26–6 |
FIGURE 26–7 |
C H A P T E R 26 • Gastric Resection: Billroth I |
283 |
After the distal stomach is fully mobilized, the proximal duodenum is divided between Kocher clamps just distal to the pylorus (Figure 26-8).
The gastroduodenal anastomosis is then performed by placing interrupted seromuscular sutures with 3-0 nonabsorbable sutures placed in Lembert fashion (Figure 26-9).
Excess duodenal tissue is removed using electrocautery (Figure 26-10).
Pylorus
Incising distal to pylorus
Portion of stomach removed
FIGURE 26–8
Removing excess duodenal tissue
FIGURE 26–9 |
FIGURE 26–10 |
2 8 4 S E C T I O N I V • TH E A B D O M E N
The anastomosis is completed using a running full-thickness 3-0 absorbable suture such as chromic or Vicryl (Figure 26-11).
At the end of the posterior row, the sutures are brought out and the corner is turned by converting to a running Connell suture. The continuous Connell suture is carried around anteriorly and tied together (see Figure 26-11).
The anterior suture line is then reinforced with interrupted seromuscular 3-0 silk sutures
(Figure 26-12).
The completed gastroduodenal anastomosis is shown in Figure 26-13.
C H A P T E R 26 • Gastric Resection: Billroth I |
285 |
FIGURE 26–11
FIGURE 26–12
FIGURE 26–13
2 8 6 S E C T I O N I V • TH E A B D O M E N
Figure 26-14 demonstrates transection of the duodenum using the stapler, usually a gastrointestinal anastomosis (GIA) stapler. The lesser and greater curvatures have been dissected as noted previously, and the left gastric artery is divided between clamps.
The proximal stomach is then stapled using the transanastomotic (TA) stapler device and transected staying right on the staple line using the scalpel (Figure 26-15).
Ligate and divide gastric artery
FIGURE 26–14
FIGURE 26–15
Divide stomach
C H A P T E R 26 • Gastric Resection: Billroth I |
287 |
Figure 26-16 shows the stapled end of the stomach and the duodenal stump.
As shown in Figure 26-17, preparation for the gastroduodenal anastomosis is performed by trimming excess gastric tissue and opening the staple line on the greater curvature side of the stomach. This is accomplished with electrocautery. The staple line is also removed from the duodenal stump using electrocautery (see Figure 26-17).
Preserved stomach
Duodenal stump
FIGURE 26–16
Removing excess gastric tissue
FIGURE 26–17
2 8 8 S E C T I O N I V • TH E A B D O M E N
The posterior gastroduodenal anastomosis is then performed by first placing interrupted 3-0 silk sutures in Lembert fashion (Figure 26-18).
The inner layer is performed using a running 3-0 nonabsorbable suture (Figure 26-19) and then carried anteriorly in a Connell fashion (Figure 26-20).
The anastomosis is completed with anterior interrupted 3-0 silk sutures placed in Lembert fashion (Figure 26-21).