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Interrupted 3-0 silk sutures, placed in Lembert fashion, complete the anterior portion of the two-layer gastrojejunostomy (Figure 32-8).
If a retrocolic gastrojejunostomy is thought to be necessary, sites for anastomosis to the stomach and jejunum are identified as shown in the dashed lines in Figure 32-9. The transverse colon is then lifted cephalad to visualize the mesentery and identify an avascular area in which to bring the jejunal loop, as noted by the dashed lines.
Complete antecolic gastrojejunostomy
FIGURE 32–8
Sites for anastomosis
Transverse colon, and stomach mobilized cephalad
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A handsewn anastomosis is performed in the fashion already described using a two-layer anastomosis with a posterior row of 3-0 silk interrupted sutures. The jejunal and gastric stomas are then created using electrocautery (Figure 32-10).
The inner layer of the anastomosis is accomplished using a running full-thickness absorbable suture (Figure 32-11).
Creating a gastric stoma
Jejunal stoma
FIGURE 32–10
Running closure of posterior mucosal layer
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The retrocolic gastrojejunostomy is then completed using interrupted 3-0 silk seromuscular sutures placed anteriorly (Figure 32-12).
Similar techniques are used to perform a stapled anastomosis (Figure 32-13).
Completing retrocolic gastrojejunostomy
FIGURE 32–12
Site for anastomosis
Transverse colon, and stomach mobilized cephalad
MC
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The jejunal and gastric stomas are created using electrocautery. The opening should be large enough to allow entry of the stapling device (Figure 32-14).
The retrocolic gastrojejunostomy is then completed using the GIA stapler (Figure 32-15).
Site of gastric stoma
Creating a jejunal stoma
FIGURE 32–14
Completing retrocolic gastrojejunostomy with stapler
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The openings created in the stomach and jejunum are closed together using a GIA or a TA stapler (Figure 32-16).
Figure 32-17 demonstrates the completed retrocolic anastomosis.
3. CLOSING
The midline incision is closed in the usual fashion.
Removing excess gastrojejunal tissue
FIGURE 32–16
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STEP 4: POSTOPERATIVE CARE
Postoperative care is achieved as previously noted for other gastric procedures. A nasogastric tube is usually maintained postoperatively on suction, and once bowel function returns, the tube is removed and a diet initiated.
STEP 5: PEARLS AND PITFALLS
If the retrocolic approach is used, most surgeons loosely suture the edges of the mesenteric rent to the jejunum, to minimize risk of herniation of a bowel loop.
Care should be taken to clearly identify the proximal jejunum in which to make the gastrojejunostomy. A rare but tragic error is to mistakenly perform the anastomosis between the stomach and ileum.
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: Gastrojejunostomy. In Thompson JC (ed): Atlas of Surgery of the Stomach, Duodenum and Small Bowel. St Louis, Mosby-Year Book, 1992, pp 77-81.
C H A P T E R 33
PYLOROMYOTOMY
Carlos A. Angel
STEP 1: SURGICAL ANATOMY
The pylorus sits at the distal end of the stomach. It is marked by thickening of the circular smooth muscle layer, thus forming the pyloric sphincter, which acts as a valve between the stomach and the duodenum and regulates gastric emptying. The pylorus does not have independent blood supply; rather, it gets its blood supply from the vessels that perfuse the
distal stomach and proximal duodenum. Innervation of the pylorus is through the terminal branches of the right and left vagus nerves. Any injury to these nerves or denervation of the pylorus will result in pylorospasm and delayed gastric emptying.
STEP 2: PREOPERATIVE CONSIDERATIONS
The diagnosis is confirmed when, in an infant or child with a history of postprandial, nonbilious vomiting, the pyloric “olive” can be palpated. If this is not possible, hypertrophic pyloric stenosis can be confirmed by sonography when the pyloric muscle width is greater than 4 mm.
These infants often present with hypochloremic metabolic alkalosis and dehydration. Intravenous hydration, correction of metabolic disturbances, and establishment of adequate urine output are imperative before pyloromyotomy.
The operation is performed with the patient under general endotracheal anesthesia. Gastric contents are suctioned thoroughly. Rapid sequence induction is used to prevent aspiration of gastric contents.
The patient is placed supine on the operating table. A folded towel under the thoracic vertebrae facilitates exposure to the pylorus. The abdomen is painted with iodine solution.
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STEP 3: OPERATIVE STEPS
1. INCISION
A transverse incision 2 to 3 cm long is made in the right upper quadrant. This incision can be made midway between the xiphoid and umbilicus, just off the midline to the right side. The anterior rectus fascia is opened in the direction of the incision, the rectus muscle is divided transversely using electrocautery, and the posterior rectus fascia and peritoneum are opened in the direction of the incision. If necessary, on the lateral side, the incision may be extended by division (for a short distance) of the internal oblique and transversus abdominis muscles to facilitate the delivery of the pyloric olive from the abdominal cavity (Figure 33-1). Alternatively, a transumbilical approach may be performed by making a semicircular incision superior to the umbilicus with a small cephalad extension (like a Mercedes Benz star). The skin is undermined, and the rectus fascia is opened in the midline for a distance of approximately 2.5 cm. The peritoneum is opened, and the pyloric tumor is delivered into the operating field by gentle traction on the antrum. After the pyloromyotomy, closure is performed with running 5-0 polyglactin sutures for the fascia, the most cephalad portion of the skin is reapproximated to the umbilicus, excess skin is trimmed on both the right and left sides, and skin closure is completed with 6-0 polyglactin sutures leaving a very well-hidden small semi-circular supraumbilical scar. Since there is more extensive dissection and undermining of the skin with this incision, I routinely administer a pre-operative dose and two post-operative doses of intravenous cefazolin to these patients.
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2. DISSECTION
Upon entering the abdomen, the surgeon uses a small, malleable retractor over a moist gauze to retract the liver and the falciform ligament cephalad and to the right side of the patient. This maneuver usually exposes the greater curvature of the stomach. If the stomach is not exposed, gentle caudal traction on the transverse colon will expose the greater curvature of the stomach. Any attempts to grasp the pyloric tumor directly must be avoided because the tumor is friable and will easily tear and bleed. With the stomach firmly grasped (a sponge will help, because the stomach is slippery), the surgeon applies gentle to-and-fro rocking traction to deliver the pylorus out of the incision (Figure 33-2). Palpation of the tumor will allow precise identification of the pyloroduodenal junction, because the tumor feels firm and the duodenum is very soft. There is a relative avascular plane on the anterior surface of the pylorus. A superficial serosal incision is made over this avascular plane, extending it distally just proximal to the pyloroduodenal junction and proximally to the junction of the antrum and pylorus; the length of this incision is 2 to 3 cm (Figure 33-3). There is a critical zone of folded duodena mucosa in a very superficial position at the pyloroduodenal junction. This is the area where perforations more commonly occur. Using a knife handle or another blunt instrument, the surgeon splits the brittle pyloric muscle in the middle of the pyloromyotomy down to the submucosa by gently pushing over the incision while supporting the pylorus with the other hand. No attempts are made to split the muscle toward the duodenal side. Using a pyloric spreader or a hemostat (ensuring that the tips are well above the mucosa), the surgeon spreads the muscle beginning in the middle of the incision and then proceeding distally and proximally (Figure 33-4). Hemostasis is performed with a fine-tipped cautery at low setting; touching the mucosa with the cautery must be avoided. Completeness of the pyloromyotomy is confirmed when the two halves of the muscle move independently from each other (Figure 33-5). Now the pylorus is placed back in the abdomen and a clean gauze is placed on top of the pyloromyotomy for 2 minutes and subsequently inspected for the presence of bile, gastric juice, or excessive bleeding. Closure is performed in layers with running 5-0 or 6-0 polyglactin sutures. The skin is closed with a running 6-0 polyglactin subcuticular sutures after infiltration with 0.25% bupivacaine and is dressed with Steri-Strips.
