Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)
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C H A P T E R 29 • Open and Laparoscopic Closure of Perforated Peptic Ulcer |
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Figure 29-5 illustrates a cross-section of the final repair showing the omental pedicle sealing the perforated ulcer.
Omental pedicle
Duodenum
Omentum plug inside perforated ulcer
Stomach
FIGURE 29–5
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Laparoscopic:
Depending on the preference of the surgeon and the patient’s characteristics, a laparoscopic closure of the perforated ulcer can be accomplished.
Figure 29-6 illustrates port placement for performing the laparoscopic procedure. Trocars are placed subcostally and one below the xiphoid process. The camera port is placed superior to the umbilicus. Upon entering the abdomen, the surgeon achieves visualization of the perforated peptic ulcer (Figure 29-7).
Port Placement
MC
FIGURE 29–6
Peptic ulcer
FIGURE 29–7
C H A P T E R 29 • Open and Laparoscopic Closure of Perforated Peptic Ulcer |
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The closure of the perforation is achieved in a similar fashion as noted for the open procedure (Figure 29-8, A). The stomach is grasped at the pylorus, and the duodenum is grasped distal to the perforation. Interrupted sutures are placed across the ulcer bed laparoscopically (Figure 29-8, B).
A pedicle of omentum is identified and grasped with the trocar and positioned over the ulcer bed (Figure 29-9).
A B
FIGURE 29–8
Omentum to be used to plug inside of perforated ulcer
FIGURE 29–9
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The interrupted sutures are tied over the omental pedicle (Figure 29-10).
3. CLOSING
If an open repair has been performed, the midline excision is closed in the usual fashion. If the operation is performed laparoscopically, the trocar sites are approximated using a subcuticular absorbable suture.
STEP 4: POSTOPERATIVE CARE
Intravenous fluids and antibiotics should be continued over the postoperative period.
Medical treatment for the ulcer disease should also be continued, as well as assessment of H. pylori, which should be treated if identified.
With return of bowel function and absence of any signs of intra-abdominal sepsis, clear liquids can be instituted and the diet rapidly advanced as tolerated.
Omentum secured over ulcer
FIGURE 29–10
C H A P T E R 29 • Open and Laparoscopic Closure of Perforated Peptic Ulcer |
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STEP 5: PEARLS AND PITFALLS
The Graham closure of a perforated peptic ulcer is usually a highly effective and efficient way of controlling the perforation site.
A well-vascularized pedicle of omentum must be selected and approximated under no tension.
If the patient has a history of chronic ulcer disease that has been unsuccessfully treated with medical management, a more definitive ulcer operation, such as a truncal vagotomy and pyloroplasty, should be performed depending on the amount of contamination in the abdominal cavity and the duration of the perforation. However, as noted previously, the current medical regimens for ulcer treatment have greatly diminished the need for a definitive operation at the time of ulcer closure.
The abdomen should be copiously irrigated with saline to decrease the chances of intraabdominal abscess forming after the procedure.
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: Perforation of duodenal ulcer: Treatment by simple closure or by closure plus acidreducing operation. In Thompson JC (ed): Atlas of Surgery of the Stomach, Duodenum and Small Bowel. St Louis, Mosby-Year Book, 1992, pp 113-119.
C H A P T E R 30
BLEEDING DUODENAL ULCER
B. Mark Evers
STEP 1: SURGICAL ANATOMY
Bleeding duodenal ulcers are normally located posteriorly in the first portion of the duodenum, with the bleeding due to penetration into the gastroduodenal artery (Figure 30-1).
STEP 2: PREOPERATIVE CONSIDERATIONS
Most patients with bleeding duodenal ulcers will stop bleeding and can be managed with nonoperative medical management or endoscopic treatment, which includes injection of the ulcer bed or actual ligation of the visible vessel. These techniques are usually highly effective; however, surgery is required if these measures are unsuccessful and the patient continues to bleed.
STEP 3: OPERATIVE STEPS
1.INCISION
The abdomen is usually approached via an upper midline incision, which allows good exposure and can be performed quickly.
2.DISSECTION
The first step is to perform a Kocher maneuver to mobilize the first and second portions of the duodenum, followed by a horizontal pyloroplasty, as noted by the dashed line in
Figure 30-2.
Traction sutures are placed in the mid-portion of the superior and inferior limbs of the pyloroplasty incision to afford exposure of the bleeding ulcer. Once the ulcer is identified, the ongoing bleeding can be controlled using a finger and placement of a 2-0 silk suture (U-stitch) to control the bleeding and occlude any collateral bleeding from the transverse pancreatic artery (Figure 30-3).
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C H A P T E R 30 • Bleeding Duodenal Ulcer |
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Transverse pancreatic artery
Gastroduodenal
artery
FIGURE 30–1
MC
FIGURE 30–2
FIGURE 30–3
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After the U-stitch is tied, sutures are placed above and below the ulcer crater to ligate the gastroduodenal artery (Figure 30-4).
The horizontal pyloroplasty is then closed in a vertical fashion (Heineke-Mikulicz pyloroplasty), and a truncal vagotomy is performed (Figure 30-5).
FIGURE 30–4
FIGURE 30–5
C H A P T E R 30 • Bleeding Duodenal Ulcer |
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3. CLOSING
The midline incision is closed in the usual fashion.
STEP 4: POSTOPERATIVE CARE
Intravenous fluids are continued postoperatively.
The patient is usually monitored in the intensive care unit for possible signs of rebleeding and to ensure adequate hemodynamics.
Once bowel function resumes, the nasogastric tube can be discontinued and clear liquids initiated with rapid advancement of the diet as tolerated.
STEP 5: PEARLS AND PITFALLS
In addition to the sutures placed above and below the ulcer crater, it is important to place the U-stitch to prevent rebleeding from a collateral anastomosis from the transverse pancreatic artery. The application of this technique has diminished the incidence of post–suture ligation rebleeding.
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: Pyloroplasty for bleeding duodenal ulcer using the U-stitch. In Thompson JC (ed): Atlas of Surgery of the Stomach, Duodenum and Small Bowel. St Louis, Mosby-Year Book, 1992, pp 109-111.
C H A P T E R 31
TRUNCAL VAGOTOMY
B. Mark Evers
STEP 1: SURGICAL ANATOMY
The vagus nerves are not always easily identified. Sometimes their location can be more quickly discovered by palpation. The left vagus nerve is usually located on the anterior surface of the esophagus, a little to the left of the midline, whereas the right vagus nerve
is usually located a little to the right of the midline, posteriorly. The left vagus nerve is intimately associated with the anterior surface of the esophagus, whereas the right vagus nerve is located in the tissue adjacent to the posterior esophagus (Figure 31-1).
STEP 2: PREOPERATIVE CONSIDERATIONS
Truncal vagotomy provides a safe and simple means for reducing acid secretion by the stomach. Because the vagus provides motor fibers to the circular muscle of the antrum, a truncal vagotomy must be accompanied by a procedure to facilitate gastric drainage, such as a pyloroplasty or gastroenterostomy. The advantages of truncal vagotomy are that it is safe and many of the serious late postgastrectomy sequelae can be avoided.
STEP 3: OPERATIVE STEPS
1.INCISION
For an open truncal vagotomy procedure, a standard upper midline incision is performed.
Retraction is obtained with self-retaining retractors, which allow excellent exposure of the distal esophagus and upper stomach.
2.DISSECTION
The left lobe of the liver is retracted upward and toward the midline, so as to clearly expose the gastroesophageal junction. The peritoneal reflection at the diaphragm is incised to expose the esophagus as shown by the dashed line (Figures 31-2 and 31-3).
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