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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_630_Библиотеки_им_академика_М_И_Перельмана
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1
Duodenum
Esophageal jejunal
anastomosis
2
Jejunal
jejunostomy
3
Crus of
diaphragm
Arm of jejunum
Suture of esophagus
to diaphragm
Specimen
removed
4
Anchoring suture
Esophagus
5
25mm
Sizing
instrument
Jejunum
93
PLATE
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38
DETAILS OF PROCEDURE e security of the esopha-
geal purse string should be evaluated before the handle and cartridge are
approximated (figure 6). A er verifying that the combined thickness
of the esophagus and jejunum is within the safe range of the staples, the
circular stapler (EEA) instrument is red. Super cial interrupted sutures
about the anastomosis are added a er the instrument has been opened,
gently rotated, and withdrawn. e nasogastric tube is passed beyond the
anastomosis.
e open end of the jejunal limb is prepared for a stapled closure
(figure 7). Once again, the noncutting linear stapler (TA ) should be
applied to serosa and at an angle to ensure an adequate blood supply to
the antimesenteric border. Some prefer to place several sutures to anchor
the arm of the jejunum posteriorly. is removes tension from the suture
line and ensures against possible rotation.
e reestablishment of the gastrointestinal tract continuity beyond the
ligament of Treitz can be accomplished in many ways. e a erent limb is
connected to the Roux-en-Y jejunal loop approximately cm from the
ligament of Treitz and about cm from the esophagojejunal anastomosis.
A side-to-side anastomosis is performed, using a cutting linear stapler (GIA
) introduced into the antimesenteric sides of the jejunum (figure 8). is
anastomosis can be accomplished like the enteroenterostomy of a Roux-
T G, S
en-Y. e mucosal stab wounds are then closed with a noncutting linear
stapler (TA ) (figure 9).
e construction of a pouch below the esophagojejunal anastomosis does
not seem to have a signi cantly bene cial e ect on long-term nutrition.
e two jejunal limb mesenteries are approximated to eliminate potential internal hernia. e adequacy of the blood supply of each limb is veri ed, especially at the critical point near the anastomosis.
POSTOPERATIVE CARE e blood volume is sustained, along with uid
and electrolyte balance. Early ambulation is encouraged. Clear liquids are
given in limited amounts a er hours. Oral feedings are begun once the
integrity of the anastomosis is established with a uoroscopic water-soluble
contrast study. e patient is instructed in the value of six small feedings
per day initially and is gradually advanced to three regular meals. e
patient and family require reassurance that problems concerning eating
should be minimal. e weight should slowly increase, unless a diagnosis
of extensive malignancy has been veri ed. Vitamin B
given monthly along with a monthly dietary survey and nutritional evaluation. ese monthly visits with reassurance can be helpful to the patient
in returning the caloric intake toward normal during the rst year a er
operation (see also discussion at Plate , Total Gastrectomy). ■
injections must be
94
6
Prepared for stapling
7
Anastomosis
completed
Closure end
of jejunum
8
Ligament of Trietz
Upper jejunum
9
Jejunal jeunostomy
prepared
Closure of
stab openings
95
PLATE
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39
INDICATIONS e diversion of bile away from the gastric outlet that has
been altered by pyloroplasty or some type of gastric resection may be indicated in an occasional patient with persistent and severe symptomatic bile
gastritis.
PREOPERATIVE PREPARATION A rm diagnosis of postoperative re ux
gastritis should be established. Endoscopic studies should demonstrate
gross as well as microscopic evidence of severe gastritis of greater intensity than is routinely observed from the regurgitation of duodenal contents through an altered gastric outlet. A gastric analysis is performed
in a search for evidence of previous complete vagotomy. Barium studies
and serum gastrin determination are routinely performed. In addition
to a rm clinical diagnosis of postoperative re ux bile gastritis, there
should be evidence of persistent symptoms despite long-term intensive
medical therapy. e operative procedure is designed to completely divert
the duodenal contents away from the gastric outlet. Ulceration will occur
unless the gastric acidity is controlled by a complete vagotomy combined
with antrectomy.
Constant gastric suction by Levin tube is maintained. Systemic antibiotics may be given. e blood volume should be restored, especially in
patients with long-standing complaints and loss of considerable weight.
ANESTHESIA General anesthesia combined with endotracheal intubation
is satisfactory.
POSITION e patient is placed in a supine position with the feet in.
lower than the head.
OPERATIVE PREPARATION e skin of the lower thorax as well as the
abdomen is prepared in a routine manner.
INCISION AND EXPOSURE e incision is made through the old scar of the
previous gastric procedure. e incision should extend up over the xiphoid
since exploration of the esophagogastric junction may be required to determine the adequacy of a previous vagotomy. Care is taken to avoid accidental
opening of loops of intestine that may be adherent to the peritoneum.
Even when a previous vagotomy has been performed, it is advisable to
search for overlooked vagal bers, especially the posterior vagus nerves,
R--Y G
unless rm adhesions between the undersurface of the le lobe of the liver
and upper stomach make such a search too hazardous.
e site of the previous anastomosis is freed up to permit careful inspection and palpation for evidence of ulceration or stenosis, or evidence of a
previous unphysiologic procedure such as a long loop, angulation, or partial obstruction of the jejunostomy. A patulous gastroduodenotomy may be
found (figure 1).
e extent of the previous resection must be determined to be certain
that the antrum has been resected. A complete vagotomy as well as antrectomy is mandatory as a safeguard against recurrent ulceration.
DETAILS OF PROCEDURE When a Billroth I procedure is to be converted,
it is essential to carefully isolate the anastomosis both anteriorly and posteriorly before applying straight Kocher clamps to either side of the anastomosis
(figure 2). Because a Kocher mobilization and medial rotation of the duodenum were previously made to ensure absence of tension in the suture line, it is
important to sacri ce as little duodenum as possible (figure 2). Unexpected
injury to the accessory pancreatic duct or the common duct may occur if further mobilization of the rst portion of the duodenum is carried out.
e end of the duodenum is closed with a row of interrupted sutures
(figure 3), although some prefer to close the duodenum with a double row of
staples. is suture line is then reinforced with a second layer of interrupted silk
sutures that bring the anterior duodenal wall down to the pancreatic capsule.
e transverse colon is re ected upward, and the upper jejunum from the ligament of Treitz downward for at least to cm is freed from any adhesions
that may have followed previous operations. An arm of jejunum (figure 4) is
mobilized as shown in Plate , Total Gastrectomy. e end of the jejunum is
closed with a double layer of sutures. is suture line is inverted by a second
layer of interrupted silk sutures to evert the mucosal layer (figure 6); the
angles should be securely approximated. A retrocolic rather than an antecolic
anastomosis is usually made (figure 4) as the active link is brought through an
opening in the mesocolon to the le of the middle colic vessels. e open end
of the Roux-en-Y loop is closed in two layers. e rst is a running absorbable
suture (figure 5). Alternatively, this may have been stapled if the jejunum was
divided with a cutting linear stapler (GIA) instrument. A second layer of inverting interrupted silk mattress sutures is placed.
CONTINUES
96
Divided vagus nerve
1
2
Bile reux
Former
anastomosis
Middle
colic artery
Jejunum for
Roux-en-Y
anastomosis
Line of resection
3
Closed
duodenal
stump
Stomach
4
5
Divided
upper jejunum
First - layer
closure of jejunum
6
Second - layer
closure
Mattress
suture
97
PLATE
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40
DETAILS OF PROCEDURE It may be necessary to resect addi-
tional stomach to be certain that all of the antrum has been removed. A noncrushing clamp is applied across the gastric pouch to control bleeding and
prevent gross soiling, as well as to x the gastric wall for the placement of
sutures (figure 7). A two-layer anastomosis, end of stomach to side of jejunum, is made with the full width of the gastric outlet (figure 8). e end
of the jejunum should not extend more than cm beyond the anastomosis (figure 9). All openings in the mesocolon are closed with interrupted
sutures to avoid a possible internal hernia and avoid a twist or angulation of
the arm of jejunum.
A jejunojejunal anastomosis is done at least cm from the gastrojejunal anastomosis (figure 10). A two-layer anastomosis is performed,
and all openings in the mesenteries are closed to avoid any chance of
herniation or obstruction about the anastomosis (figure 11). A long
Levin tube is directed through the anastomosis and may be directed
R--Y G
around into the duodenum to ensure decompression of the duodenal
stump. Some prefer to perform a temporary gastrostomy, provided the
gastric pouch can be attached easily to the overlying peritoneum. e
gallbladder, if present, should be compressed to con rm the patency of
the ductal system following the procedure. A er a thorough search for
needles, instruments, and sponges, and a rming a correct count, the
abdomen is closed.
CLOSURE e abdominal incision is closed in the routine manner.
POSTOPERATIVE CARE e calculated blood losses are replaced, and
uid and electrolyte balance maintained. Systemic antibiotics may be given.
e intubation is retained until adequate bowel activity has resumed. Clear
liquids followed by six small feedings a day are gradually permitted since
slow gastric emptying is o en a problem. Careful medical supervision is
required to ensure a good result. ■
98
7
Jejunal
incision
Stomach
8
Mobilized
jejunum
Sutures in
mesocolon
10
Blind end
of jejunum
Ligament of Treitz
Posterior
sutures
9
11
Posterior sutures
Mucosal
approximation
Noncrushing
enterostomy
clamps
40 centimeters
long
Jejunojejunostomy
Closed
mesentery
defects
Gastrojejunostomy
Colon
Jejunojejunostomy
99
PLATE
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41
INDICATIONS Fundoplication may be considered in certain patients
with symptomatic re ux gastritis associated with esophagitis. Esophagitis
with stricture and paraesophageal hernia are other possible indications.
A preliminary trial of repeated dilatations may be instituted when there is
evidence of a stricture of the lower end of the esophagus. e procedure
may be indicated in infants and children with gastroschisis or omphalocele
repair or those with gastroesophageal re ux associated with brain injury.
Substernal pain, especially in the recumbent position, di culty in
swallowing, and recurrent bouts of aspiration pneumonia are commonly
associated with roentgenologic evidence of gastroesophageal re ux. Esophagoscopy with manometric studies and intraluminal pH measurements are
indicated. e latter studies may be extended over a -hour period of
observation. Barium studies of the entire gastrointestinal tract may demonstrate a duodenal ulcer or other disorders. A gastric analysis, as well as
serum gastrin determinations, should be made. Antacid therapy, elevation
of the head of the bed, and e ective weight reduction in obese patients may
decrease the severity of symptoms.
Surgical procedures are designed to prevent acid peptic re ux and to
restore normal sphincteric function. When re ux esophagitis is associated
with duodenal ulcer, either parietal cell vagotomy or truncal vagotomy and
pyloroplasty should be considered.
PREOPERATIVE PREPARATION Pulmonary function studies are indi-
cated in patients with a history of aspiration pneumonia. Antacid therapy
is maintained. Systemic antibiotics may be given. Nasogastric intubation
should be instituted.
ANESTHESIA General anesthesia with endotracheal intubation is employed.
POSITION e patient is placed in a comfortable supine position on the
table with the feet slightly lower than the head.
OPERATIVE PREPARATION e area from the nipples downward to the
symphysis is shaved. e skin over the sternum, lower chest wall, and the
entire abdomen is cleaned with the appropriate antiseptic solutions.
INCISION AND EXPOSURE A liberal incision starting over the xiphoid
and extending down the midline to the umbilicus is made (figure 1). In
the obese patient, the incision should extend to the le and slightly below
the umbilicus. When the xiphoid is elongated, it is removed to enhance the
exposure of the esophagogastric junction. Active arterial bleeding in either
xiphocostal angle is controlled with a trans xing suture of silk.
F
DETAILS OF PROCEDURE e peritoneum is opened and the abdomen
explored with special attention given to the gallbladder, duodenal bulb, and
the size of the esophageal hiatus. A considerable portion of the stomach
may be up in the chest as a result of the enlarged hiatus opening.
It is important to develop good exposure of the margins of the esophageal hiatus. e exposure is improved by dividing the relatively avascular
triangular ligament of the le lobe of the liver and rotating it toward the
midline (figure 2). It is retracted medially by a large S retractor applied to
a moist pad placed over the mobilized le lobe (figure 3).
e peritoneum over the esophagus is incised and the esophagus mobilized with the index nger of the right hand (Plate , figure 7). e vagus
nerves are not divided unless the operative, laboratory, roentgenographic,
and clinical studies veri ed gastric hypersecretion with evidence of duodenal deformity and a concurrent drainage procedure such as a pyloroplasty is also planned. It is important to divide and ligate the uppermost
portion of the gastrohepatic ligament in order to provide exposure for the
“wraparound” of the fundus. e uppermost portion of the gastrohepatic
ligament is grasped by a long pair of right-angle clamps (figure 3). e
contents between the clamps are divided, and each side is tied with silk
to ensure adequate control of the le phrenic artery (figure 3). is may
include the hepatic branch of the vagus nerve. e cu of peritoneum at
the esophagogastric junction may include considerable extra tissue due to
trauma from the hiatus hernia. Additional sutures may be required to control bleeding in this area. Such sutures must not include the vagus nerves
unless vagotomy is indicated by an associated duodenal ulcer and measured high acid values. e peritoneum to the le of the esophagogastric
junction should be divided meticulously with great care to avoid tearing
of the splenic capsule.
Downward traction with a rubber tissue (Penrose) drain about the
esophagus is maintained to completely reduce the funds of the stomach
into the peritoneal cavity. A small S retractor is introduced posterior to the
esophagus to provide exposure to the hiatus (figure 4). e margins of the
hiatus are grasped with long Babcock forceps to facilitate the placement of
two or three interrupted sutures of silk for closure of the hiatus posterior
to the esophagus (figure 4). e hiatus is narrowed to the point where the
index nger can be inserted easily alongside the esophagus. Alternatively,
many surgeons prefer to size the opening with passage of a large esophageal dilator usually ranging between and French. e decision for or
against vagotomy depends upon the nding of the duodenal ulcer or preoperative ndings of gastric hypersecretion.
CONTINUES
100
2
1
Suspensory
ligament
Incision
Left lobe
liver
Diaphragm
3
Retractor
Gastrohepatic
ligament
Vagus
nerves
Enlarged
hiatus
Retractor
4
Esophagus
Suture
approximating
hiatus
101
PLATE
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42
DETAILS OF PROCEDURE e e ectiveness of the fundopli-
cation depends upon the adequacy of the “wraparound” procedure. It is
important to mobilize the fundus of the stomach by ligating four or ve gastrosplenic (short gastric) vessels (figure 5). is must be done very carefully to avoid splenic injury. Some prefer to ligate the vessel on the gastric
side by a trans xing suture that includes a portion of the gastric wall. When
the exposure is quite di cult, the vessels on the splenic side may be ligated
by the application of silver clips. A rubber tissue (Penrose) drain is placed
around the esophagus to provide downward traction on it (figure 6). A
large gastric tube (Ewald) or the (Maloney) - French rubber esophageal dilator is inserted into the esophagus before the procedure to prevent
undue compression of the esophageal lumen. e right hand is introduced
behind the fundus of the stomach to test the adequacy of the gastric mobilization (figure 6). It is absolutely essential that su cient fundus be freed up
to permit an easy wrap around the lower esophagus. As downward traction
is maintained on the esophagus with the rubber drain around the esophagus, the right hand holds the gastric wall around the esophagus. One or
more long Babcock forceps are applied to the gastric wall on either side of
the esophagus (figure 7). Traction on both sets of forceps makes it unnecessary for the hand of the surgeon to be in the wound. e anterior and
posterior gastric walls are approximated with interrupted sutures of silk
(figure 7). Several interrupted sutures are usually adequate along a - to
F
-cm zone. Some prefer to have the highest suture include a super cial
bite in the esophageal wall and the gastric wall as insurance against the
sliding upward of the “wraparound” (figure 8). Additionally, many place
an anchoring suture between the gastric wrap and the crus. is prevents
upward migration of the gastric tunnel around the esophagus. e large
dilator in the esophagus prevents undue constriction of the esophagus.
A er the traction rubber drain and esophageal dilator are removed, the
surgeon introduces the index nger or thumb upward under the plicated
gastric wall. No undue constriction must exist nor further mobilization of
the greater curvature of the fundus be provided. e area of the esophagus
is nally inspected to be certain the vagus nerves have not been injured. A
pyloroplasty should be added if the vagotomy is performed, and a temporary gastrostomy may be carried out with xation of the anterior gastric
wall to the overlying peritoneum. e dilator is removed and the nasogastric tube is replaced.
CLOSURE Routine closure of the abdominal wall is performed.
POSTOPERATIVE CARE e nasogastric Levin tube is removed within
several days. Clear liquids are given in limited amounts, followed by a gradual return to a full diet. Postoperative dilatation may be required for a few
days to relieve abdominal discomfort in an occasional patient following the
return to solid food. ■
102
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