Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

3 3 0 S E C T I O N I V • TH E A B D O M E N

Once the peritoneum is incised, the index finger is placed around the esophagus to encircle it at the hiatus. Care should be taken to pass the finger around the esophagus above the diaphragm to ensure that the posterior vagus is included in this maneuver. A Penrose drain is then normally placed around the distal esophagus, and the anterior vagus nerve is identified lying in the substance of the anterior esophagus (Figure 31-4).

The anterior vagus nerve is then dissected and freed from the underlying esophagus (Figure 31-5). In performing the truncal vagotomy, we place small metal clips on the vagus nerve and excise a 2-cm segment between the clips. Excised vagal segments are sent for pathologic examination of permanent sections (Figure 31-6).

Traction is placed on the Penrose drain and the posterior vagus nerve identified (Figure 31-7).

The procedure is repeated for the larger posterior nerve. Clips are placed and at least a 2-cm segment of the nerve is excised.

Anterior vagus nerve

FIGURE 31–4

As noted, a careful assessment and identification of accessory vagal fibers should be undertaken to prevent ulcer recurrence.

Truncal vagotomy must always be accompanied by a drainage procedure to prevent gastric stasis.

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: Truncal vagotomy. In Thompson JC (ed): Atlas of Surgery of the Stomach, Duodenum and Small Bowel. St Louis, Mosby-Year Book, 1992, pp 71-75.

C H A P T E R 32

GASTROJEJUNOSTOMY

B. Mark Evers

STEP 1: SURGICAL ANATOMY

Understanding the anatomy of the stomach and small bowel and determining whether an antecolic or retrocolic approach is more appropriate are key points in this procedure.

STEP 2: PREOPERATIVE CONSIDERATIONS

Gastrojejunostomy can be performed in an antecolic fashion, which provides a quick and effective method of connecting the distal stomach to the jejunum. In some instances, the more direct path is a retrocolic anastomosis involving placement of the jejunal loop through the transverse colon mesentery.

Gastrojejunostomy is usually performed to bypass an obstructed distal stomach or duodenum and provide relief. This is particularly useful in cancers that obstruct the duodenal lumen or the distal stomach and are not resectable. Gastrojejunostomy should also be considered in the patient who requires a drainage procedure in whom a pyloroplasty may not be safe because of chronic scarring of the duodenal bulb.

STEP 3: OPERATIVE STEPS

1.INCISION

Using an open technique, an upper midline incision is usually performed. We are illustrating the open technique in this chapter; however, gastrojejunostomy may be also accomplished via laparoscopy.

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2. DISSECTION

To create an antecolic gastrojejunostomy, the surgeon identifies a convenient section of distal stomach and a loop of jejunum that is easily maneuverable to the stomach distal to the ligament of Treitz. A convenient location in the proximal jejunum is usually 15 to 20 cm distal to the ligament of Treitz.

A posterior row of seromuscular 3-0 silk sutures are placed in Lembert fashion to connect the stomach and the jejunum. If a stapled anastomosis is to be performed, an enterotomy is created using electrocautery; likewise, a gastrotomy is also performed to facilitate placement of the stapler (Figure 32-1).

Creating an opening in jejunum for stapler

MC

FIGURE 32–1