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 |
289 |
Removing excess duodenal tissue
FIGURE 26–18 |
FIGURE 26–19 |
FIGURE 26–20 |
FIGURE 26–21 |
2 9 0 S E C T I O N I V • TH E A B D O M E N
The staple line is secured by running 3-0 silk sutures (Figure 26-22).
Figure 26-23 shows the completed gastroduodenal anastomosis.
FIGURE 26–22
FIGURE 26–23
C H A P T E R 26 • Gastric Resection: Billroth I |
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3. CLOSING
The upper midline or subcostal incision is closed in usual fashion.
STEP 4: POSTOPERATIVE CARE
Before closure, a nasogastric tube is positioned proximal to the suture line. When bowel activity has resumed, the nasogastric tube can be removed and clear liquids initiated. If there is no evidence of gastric retention, the feeding regimen can be progressed.
STEP 5: PEARLS AND PITFALLS
The stomach and duodenum must be thoroughly mobilized for performance of the anastomosis.
Duodenal edema, shortening, or deformity may prevent performance of a Billroth I anastomosis and require a Billroth II anastomosis for safe closure.
SELECTED REFERENCES
1. Mercer DW, Robinson EK: Stomach. In Townsend CM Jr (ed): Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice, 18th ed. Philadelphia, Saunders, 2008, pp 1223-1277.
2. Thompson JC: Subtotal gastrectomy with stapled Billroth I anastomosis (also resection for benign distal gastric ulcer). In Thompson JC (ed): Atlas of Surgery of the Stomach, Duodenum and Small Bowel.
St Louis, Mosby-Year Book, 1992, pp 45-53.
3. Thompson JC: Subtotal gastrectomy with stapled Billroth I anastomosis. In Thompson JC (ed): Atlas of Surgery of the Stomach, Duodenum and Small Bowel. St Louis, Mosby-Year Book, 1992, pp 55-59.
C H A P T E R 27
GASTRIC RESECTION: BILLROTH II
B. Mark Evers
STEP 1: SURGICAL ANATOMY
The vascular supply to the stomach has been previously described (see Figure 26-1).
STEP 2: PREOPERATIVE CONSIDERATIONS
The Billroth II gastric resection is one of the most commonly performed procedures for cancer of the stomach and is also used for operative treatment of duodenal ulcer disease if gastric resection is required.
STEP 3: OPERATIVE STEPS
1.INCISION
The patient is placed supine on the table, and an upper midline incision or subcostal incision is used as described for the Billroth I anastomosis.
2.DISSECTION
Figure 27-1 demonstrates transection of the stomach, indicating a 50% distal gastric resection, starting at the incisura on the lesser curvature as noted by the dashed line. The duodenum is transected distal to the pylorus. The greater curvature is mobilized by dividing the gastroepiploic vessels and is ligated with 2-0 silk sutures.
The lesser curvature is then likewise mobilized to the incisura (see Figure 27-1).
The left gastric artery and vein are ligated in continuity with 2-0 silk sutures and divided
(Figure 27-2).
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C H A P T E R 27 • Gastric Resection: Billroth II |
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Incision line
Incision line
Pylorus
FIGURE 27–1
Ligate and divide gastric artery
FIGURE 27–2
2 9 4 S E C T I O N I V • TH E A B D O M E N
The stomach is transected between Kocher or Payr clamps using the scalpel, and likewise, the first portion of the duodenum is transected between Kocher clamps (Figure 27-3).
Figure 27-4 demonstrates a stapled division of the stomach and duodenum with the duodenum stapled using a gastrointestinal anastomosis (GIA) stapler device and the stomach stapled using a transanastomotic (TA)-30 or TA-55 stapler. The stomach is then transected using the scalpel staying right on the staple line.
Incising just beyond pylorus
Dividing stomach
FIGURE 27–3
Dividing stomach
FIGURE 27–4
C H A P T E R 27 • Gastric Resection: Billroth II |
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Figure 27-5, A shows the duodenal stump closure performed using running nonabsorbable sutures. Figure 27-5, B shows a stapled closure of the duodenal stump. Interrupted seromuscular sutures are then placed over the first row of running sutures (Figure 27-5, C) or over the staple line (Figure 27-5, D). Some surgeons prefer to secure the duodenal stump to the pancreas as shown in Figure 27-5, E.
Staple closure
Suture closure
A B
Interrupted suture |
Interrupted suture |
over first row of |
over stapled closure |
running sutures |
|
C D
Securing duodenum to pancreas
E
FIGURE 27–5
2 9 6 S E C T I O N I V • TH E A B D O M E N
Excess gastric tissue that had been crushed with the clamp is trimmed using the scalpel or electrocautery (Figure 27-6, A). Starting on the lesser curvature side, the stomach is closed with running nonabsorbable sutures (Figure 27-6, B). This is accomplished to the level of the Kocher clamp (Figure 27-6, C).
Removing excess gastric tissue
A
B C
FIGURE 27–6
C H A P T E R 27 • Gastric Resection: Billroth II |
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A loop of proximal jejunum is brought up in an antecolic fashion, and the anastomosis is performed in two layers. The outer layer is performed with interrupted 3-0 silk sutures placed in a Lembert fashion (Figure 27-7).
The electrocautery is then used to open the jejunum at the dashed line as shown in
Figure 27-8.
FIGURE 27–7
Incision in jejunum for anastomosis
FIGURE 27–8
2 9 8 S E C T I O N I V • TH E A B D O M E N
The inner row of the anastomosis is performed in a running fashion using a 3-0 nonabsorbable suture such as chromic or Vicryl. The suture is carried anteriorly in a Connell fashion
(Figures 27-9 and 27-10).
FIGURE 27–9
FIGURE 27–10