Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)
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C H A P T E R 27 • Gastric Resection: Billroth II |
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The anastomosis is then completed anteriorly using interrupted 3-0 silk sutures placed in a Lembert fashion (Figure 27-11).
Figure 27-12 demonstrates the completed Billroth II anastomosis (Hofmeister method).
FIGURE 27–11
Gastrojejunal
anastomosis
FIGURE 27–12
3 0 0 S E C T I O N I V • TH E A B D O M E N
Figure 27-13 shows the stapled end of the stomach, and in preparation for the gastrojejunal anastomosis, the end adjacent to the greater curvature is opened using electrocautery and excess gastric tissue is trimmed (Figure 27-14).
The gastrojejunal anastomosis is performed as previously described in two layers with an outer layer of 3-0 silk (Figure 27-15), followed by opening the jejunum at the dashed line (Figure 27-16) and performing the inner layer of the anastomosis in a running fashion using a 3-0 nonabsorbable suture (Figure 27-17), which is carried anteriorly in a Connell fashion (Figure 27-18).
FIGURE 27–13
Removing excess gastric tissue
FIGURE 27–14
C H A P T E R 27 • Gastric Resection: Billroth II |
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Incision in jejunum for anastomosis
FIGURE 27–16
FIGURE 27–15
FIGURE 27–17 |
FIGURE 27–18 |
3 0 2 S E C T I O N I V • TH E A B D O M E N
The anterior suture line is then oversewn using 3-0 silk interrupted sutures, and likewise, the staple line is oversewn using running nonabsorbable sutures (Figure 27-19).
Figure 27-20 demonstrates the completed Billroth II anastomosis.
FIGURE 27–19
FIGURE 27–20
C H A P T E R 27 • Gastric Resection: Billroth II |
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3. CLOSING
The upper midline or subcostal incision is closed in the usual fashion.
STEP 4: POSTOPERATIVE CARE
A nasogastric tube is positioned proximal to the suture line, and once bowel function has resumed the nasogastric tube can be removed and a liquid diet started. If there is no gastric retention, the diet can be rapidly advanced.
STEP 5: PEARLS AND PITFALLS
In performing the Billroth II anastomosis, some surgeons prefer to use the Polya method, which uses the entire gastric opening for the gastrojejunal anastomosis. The choice between a Hofmeister or Polya method depends on the surgeon’s preference.
In operations for cancers of the stomach, most surgeons prefer the Billroth II anastomosis because local recurrence of the cancer would tend to cause earlier obstruction of a gastroduodenostomy.
In performing the Billroth II anastomosis, the choice of where the jejunal loop is brought anterior to the transverse colon or brought posterior to the transverse mesocolon is also a matter of the surgeon’s preference.
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 II anastomosis. In Thompson JC (ed): Atlas of Surgery of the Stomach, Duodenum and Small Bowel. St Louis, Mosby-Year Book, 1992, pp 61-65.
C H A P T E R 28
TOTAL GASTRECTOMY
B. Mark Evers
STEP 1: SURGICAL ANATOMY
A comprehensive understanding of the vascular anatomy of the stomach is required, and this is shown in Figure 26-1.
STEP 2: PREOPERATIVE CONSIDERATIONS
Total gastrectomies are performed predominantly for gastric cancer. Total gastrectomy is now rarely performed for bleeding or Zollinger-Ellison syndrome, given the success with current medical regimens.
STEP 3: OPERATIVE STEPS
1. INCISION
An upper midline incision carried inferior to the umbilicus, if needed, is commonly used for total gastrectomy (Figure 28-1). As an alternative incision, some surgeons prefer a bilateral subcostal incision, which affords excellent exposure to the stomach and distal esophagus.
2. DISSECTION
Wide exposure is accomplished with various self-retaining retractors. A laparotomy pad is placed under the liver, and the liver is gently retracted cephalad (Figure 28-2).
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C H A P T E R 28 • Total Gastrectomy |
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Midline
incision
FIGURE 28–1
Liver
Gastrohepatic
ligament
Stomach
FIGURE 28–2
3 0 6 S E C T I O N I V • TH E A B D O M E N
The greater curvature of the stomach is mobilized by dividing the gastroepiploic vessels in the gastrocolic ligament and ligating with silk sutures. Likewise, the lesser curvature is mobilized by division of the gastrohepatic ligament (Figure 28-3, A).
The short gastric vessels are divided between clamps and ligated with silk sutures. The spleen is gently retracted laterally to clearly identify the short gastric vessels (Figure 28-3, B).
Left gastric artery
Incision through omentum, freeing stomach
A
Dividing short gastric vessels
Spleen
FIGURE 28–3 |
B |
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C H A P T E R 28 • Total Gastrectomy |
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As shown in Figure 28-4, the tumor is visualized in the distal and mid stomach.
For an effective oncologic resection, the omentum is usually resected along with the stomach. The omentum is divided at its attachment to the transverse colon and then retracted cephalad. The stomach is likewise retracted cephalad to divide any remaining posterior attachments (Figure 28-5).
Tumor
FIGURE 28–4
Omentum swung cephalad
Incision through omentum
FIGURE 28–5
3 0 8 S E C T I O N I V • TH E A B D O M E N
Figure 28-6 demonstrates dividing the right gastric artery to allow complete mobilization of the distal stomach and proximal duodenum.
The division of the left gastric artery is accomplished for mobilization of the lesser curvature and access to the distal esophagus (Figure 28-7).
As shown in Figure 28-8, A, the duodenum is transected distal to the pylorus using a gastrointestinal anastomosis (GIA) stapling device and, likewise, the distal esophagus is transected using the GIA device proximal to the gastroesophageal junction. Figure 28-8, B demonstrates suture closure of the duodenal stump, and Figure 28-8, C shows a stapled closure of the stump. Interrupted sutures are then placed over either the running suture
(Figure 28-8, D) or the staple line (Figure 28-8, E).
Dividing right gastric artery
FIGURE 28–6
FIGURE 28–7
Dividing left gastric artery