Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)
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C H A P T E R 28 • Total Gastrectomy |
309 |
A
Staple closure
Suture closure
B |
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C |
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Interrupted suture |
Interrupted suture |
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over first row of |
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over stapled closure |
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running sutures |
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D E
FIGURE 28–8
3 1 0 S E C T I O N I V • TH E A B D O M E N
An opening is made in the mesocolon, taking care to not damage any vessels running in the mesocolon. The jejunum is then divided approximately 30 cm from the ligament of Treitz using the GIA device, and a Roux limb of approximately 40 to 50 cm is created
(Figure 28-9).
Figure 28-10 demonstrates creation of the jejunojejunal anastomosis using the GIA device.
Ligament of Treitz
Opening created in mesocolon
3 0
c m
Roux limb
40-
50
c
m
FIGURE 28–9
Creating a jejunojejunostomy anastomosis
Roux limb
FIGURE 28–10
C H A P T E R 28 • Total Gastrectomy |
311 |
The mesenteric rent that was created is now closed using a running (Figure 28-11, A) or interrupted suture (Figure 28-11, B).
Mesentery to be closed
A
Arrow going through mesenteric defect
Anastomosis
complete
B
Closure of mesenteric defect
B
FIGURE 28–11
3 1 2 S E C T I O N I V • TH E A B D O M E N
Stay sutures are placed on the free end of the jejunum and the jejunum is opened adjacent to the staple line. The end-to-end anastomosis (EEA) stapling device (without the anvil) is placed into the lumen of the free end of the jejunum. A point is selected approximately 4 to 5 cm from the free margin. The post on the EEA stapling device is extended and brought through the wall of the jejunum. Stay sutures are also placed on the distal esophagus, which is then opened and the anvil placed into the distal esophagus. A purse-string suture is then used to secure the anvil. The anvil is then placed into the post of the circular stapler and the tissue is approximated. Firing of the EEA stapler places a circular double ring of staples and extends a circular knife that excises the rings of the jejunum and esophagus inside the circle of staples (Figure 28-12).
Mating together circular stapler and anvil
Circular stapler
FIGURE 28–12
C H A P T E R 28 • Total Gastrectomy |
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The redundant section of jejunum is then excised using a GIA stapling device. This converts the anastomosis functionally into an end-to-end esophagojejunostomy (Figure 28-13).
Figure 28-14 demonstrates the completed esophagojejunal anastomosis with the Roux limb positioned in a retrocolic fashion.
Esophagus
Cutting away jejunal excess
Esophagus |
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Esophagojejunal |
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anastomosis |
FIGURE 28–13
Jejunojejunum anastomosis
Retrocolic
FIGURE 28–14
3 1 4 S E C T I O N I V • TH E A B D O M E N
3. CLOSING
The midline or bilateral subcostal incisions are closed in the usual fashion.
STEP 4: POSTOPERATIVE CARE
A nasogastric tube is positioned in the esophagus just proximal to the anastomosis. Once bowel function has resumed, oral feedings can be instituted when there is assurance that no anastomotic leak has occurred. Some surgeons prefer to perform a contrast study using water-soluble dye to ensure no leakage.
Postgastrectomy patients require frequent small feedings. Adequate calorie intake may be problematic in the initial postoperative period.
In addition, supplemental vitamin B12 is required at routine intervals.
STEP 5: PEARLS AND PITFALLS
The use of the EEA stapling device has greatly simplified performing the esophagojejunal anastomosis.
A Roux limb of 40 to 50 cm should be used to prevent complications of reflux into the Roux limb affecting the esophagojejunal anastomosis.
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: Total gastrectomy. In Thompson JC (ed): Atlas of Surgery of the Stomach, Duodenum and Small Bowel. St Louis, Mosby-Year Book, 1992, pp 153-165.
C H A P T E R 29
OPEN AND LAPAROSCOPIC CLOSURE OF PERFORATED PEPTIC ULCER
B. Mark Evers
STEP 1: SURGICAL ANATOMY
The usual site for a perforated peptic ulcer is anterior in the first portion of the duodenum just distal to the pylorus (Figure 29-1).
Patients with perforated peptic ulcers can be approached by either the standard open technique or laparoscopically.
Peptic ulcer
MC
FIGURE 29–1
315
3 1 6 S E C T I O N I V • TH E A B D O M E N
STEP 2: PREOPERATIVE CONSIDERATIONS
The patient should be adequately hydrated before operation, and broad-spectrum antibiotics should be initiated in the preoperative period.
Consideration should be given as to whether to perform simple closure of the perforation or to perform a more definitive operation if the patient has a history of chronic duodenal ulcer disease.
However, with current medical regimens including drugs to eradicate Helicobacter pylori, the need to perform a more definitive ulcer operation at the time of closure of the perforation has greatly diminished.
STEP 3: OPERATIVE STEPS
1.INCISION
If an open repair of a perforated ulcer is to be performed, this can be accomplished via an upper middle incision, which can be extended inferior to the umbilicus if necessary.
2.DISSECTION
Open:
Upon entering the abdomen, the surgeon should locate the perforation. As stated previously, perforated peptic ulcers are routinely located anteriorly in the first portion of the duodenum (Figure 29-2, A).
The abdomen should be copiously irrigated with warm saline, and, for a standard Graham closure, interrupted 3-0 silk sutures are placed in Lembert fashion across the ulcer
(Figure 29-2, B).
C H A P T E R 29 • Open and Laparoscopic Closure of Perforated Peptic Ulcer |
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Pylorus
Peptic ulcer
Duodenum
A
B
FIGURE 29–2
3 1 8 S E C T I O N I V • TH E A B D O M E N
Once the sutures are in place, a pedicle of omentum is placed across the base of the ulcer (Figure 29-3). The sutures are then tied over the omental pedicle, thus sealing the perforation (Figure 29-4).
Omentum to be used to plug inside of perforated ulcer
FIGURE 29–3
Omentum secured over ulcer
FIGURE 29–4