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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_670_Библиотеки_им_академика_М_И_Перельмана
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32 Atlas of Gastrointestinal Surgery: The Stomach
Liver
Gallbladder
Esophagus
Duodenum
Stomach
Greater
omentum
Gastroepiploic
1
vessels preserved
Greater curvature
cleaned
The most dependent portion of the greater curvature of the stomach is identified and is cleaned of omentum (1). The
transverse colon is retracted in a cephalad direction, and the ligament of Treitz and proximal jejunum are identified. The
preferable gastrojejunostomy in my opinion is performed in a retrocolic fashion. An opening is made in the transverse meso-
colon. The proximal loop of jejunum is brought up through this rent in the transverse mesocolon (2) and through the open-
ing in the omentum along the greater curvature of the stomach. Generally, a short afferent loop is used. The anastomosis
is performed by first placing a posterior outer layer of 3-0 silk Lembert sutures (3). The anastomosis should be approxi-
mately 2.5 cm in length. If this anastomosis is made excessively long to create an extra large opening between the stom-
ach and jejunum, the afferent or efferent limbs may kink, resulting in partial outlet obstruction.
Middle colic a.
Mesocolon
Gastrojejunostomy 33
Transverse colon
Marginal a.
Jejunum
Fourth
portion
of duodenum
2
Outer layer
of posterior row
Stomach
Omentum
3
34 Atlas of Gastrointestinal Surgery: The Stomach
Inner layer of
posterior row
Stomach
After linen-shod clamps are applied to the afferent and
efferent limbs, the adjacent greater curvature of stom-
ach and the jejunum are opened with the electro-
cautery. The inner layer of the posterior row is
Jejunum
placed using a continuous locking stitch of 3-0
absorbable synthetic material (4).
Omentum
Inner layer of
anterior row
4
It is brought anteriorly as the inner layer of the anterior row using
a Connell stitch (5).
Outer layer of
anterior row
5
The outer layer of the anterior row is placed using
3-0 silk Lembert sutures (6 and 7).
6
Esophagus
Gastrojejunostomy 35
Stomach
Duodenum
Jejunum
Transverse colon
7
36 Atlas of Gastrointestinal Surgery: The Stomach
Mesocolon
The gastrojejunostomy is sutured to the
rent in the transverse mesocolon on the
gastric side (8) to prevent the jejunal
limbs from sliding up through the rent in
the transverse mesocolon and becoming
partially obstructed.
8
When performing a retrocolic gastroje-
junostomy for unresectable carcinoma
of the pancreas, theoretically the
retrocolic gastrojejunostomy is vul-
nerable to obstruction by tumor
Alternative
Antecolic Gastrojejunostomy
9
Stomach
growth. In my experience this has
never occurred. I think an antecol-
ic gastrojejunostomy (9) should
only be performed if the transverse
mesocolon is involved with tumor,
and a retrocolic gastrojejunostomy
is thus not possible.
Vagotomy plus Antrectomy
Operative Indications
Current treatment for duodenal ulcer disease today relies primarily on the eradication of
a much smaller role than it has in the past. If pharmacological management is unsuccessful, vagotomy and drainage or pari-
etal cell vagotomy can be used. However, recurrence rates following these procedures are between 5 and 15%. The most
effective operative procedure for long-term control of ulcer disease that is refractory to non-surgical means is vagotomy plus
antrectomy. This operation not only uses vagotomy to decrease gastric acid secretion but also removes the gastrin-produc-
ing antrum, further decreasing the stimulus for acid production. If done appropriately, with a complete vagotomy, this oper-
ative procedure virtually ensures that the peptic ulcer disease will be controlled, with almost no chance of long-term recur-
rence. The operative procedure, however, carries a risk of postoperative morbidity and mortality, because it includes gas-
tric resection and duodenal anastomosis, or duodenal closure. In addition, there is long-term morbidity, which includes bile
reflux gastritis, dumping, and diarrhea. Nevertheless, antrectomy plus vagotomy remains as the most effective ulcer opera-
tion available. Today, however, it is used primarily following failure of pharmacologic management and often after failure of
truncal vagotomy and drainage, or parietal cell vagotomy. These latter two procedures can be converted to vagotomy and
antrectomy by ensuring the vagotomy is complete and performing an antrectomy.
Gastric ulcer disease is less responsive to pharmacologic management and can also
Helicobacter pylori
. Surgery plays
be treated effectively with this operative procedure. The standard treatment for gastric
ulcer is hemigastrectomy, including the ulcer in the resection specimen if possible.
However, many surgeons add vagotomy, particularly if preoperative studies have
demonstrated acid production.
Operative Technique
The operative procedure is best performed through an upper midline incision.
Retraction of both costal margins in a cephalad direction by retractors fixed to a frame
38 Atlas of Gastrointestinal Surgery: The Stomach
attached to the operating table is most helpful. The liver is retracted in a cephalad direction. Occasionally it is preferable
to take down the triangular ligament and retract the left lobe of the liver to the right. A truncal vagotomy is performed as
described previously (Page xx). There are no exact landmarks for performing an antrectomy. Approximately 40% of the
stomach is removed, by estimating the total amount of stomach along the lesser and greater curvatures. The point along the
greater curvature that represents the point of division is picked. The omentum is cleaned off the greater curvature of the
antrum by doubly clamping branches of the gastroepiploic arcade and dividing and ligating with 2-0 silks. The thin lesser
omentum is divided along the lesser curvature (1). Branches of the left gastric artery require division along the lesser cur-
vature at the point of resection.
Gallbladder
Duodenum
Esophagus
Liver
Truncal
vagotomy
Fundus
Lesser
omentum
Antrum of stomach
Pylorus
Colon
1
Greater
omentum
Greater
curvature
Pylorus
Liver
Antrum
Vagotomy plus Antrectomy 39
Esophagus
Fundus
The stomach is divided
with a GIA stapler, starting at
the greater curvature and
working toward the lesser cur-
vature. Two or three firings are
generally required (2).
Duodenum
2
GIA
stapler
Once the stomach had been divided,
the antrum is grasped with a Babcock clamp
and retracted laterally. Attachments between the
distal antrum and proximal duodenum and between the
Attachments
between
duodenum and
neck of pancreas
Posterior wall
of antrum
of stomach
neck and head of the pancreas are divided (3).
3
Pancreas
40 Atlas of Gastrointestinal Surgery: The Stomach
The pyloric channel is identified by palpating the pyloric muscle, and adequate duodenum beyond the pylorus is mobi-
lized so that a secure duodenal closure or anastomosis can be carried out. During the mobilization of the proximal duode-
num, the right gastric vessels are encountered superiorly, and the right
gastroepiploic vessels are encountered inferiorly. These should be doubly
clamped, divided, and ligated. Once adequate duodenum has been mobi-
lized, it is divided just beyond the pylorus with a GIA stapler (4). The
specimen is removed from the operative field.
Posterior
antrum
Duodenum
Staple line
inverted
4
GIA
stapler
Pancreas
Esophagus
It is generally accepted that a
Billroth I gastroduodenostomy is
preferable to a Billroth II gastroje-
Kocherized
duodenum
Pancreas
junostomy, where the gastric resec-
Stomach
tion has been performed for benign
disease. The lesser curvature, which
has been closed with the stapler, is fur-
ther inverted with a series of interrupt-
ed 3-0 silk Lembert sutures (5).
5
A gastroduodenostomy is then
peformed in two layers. The outer
layer of the posterior row is
Vagotomy plus Antrectomy 41
placed using interrupted 3-0
silk Lembert sutures. The staple
lines on the gastric and duode-
nal side are removed using the
electrocautery (6). The inner
layer of the posterior row is placed
using a continuous locking suture of
3-0 synthetic absorbable material (7).
This inner layer is brought around anterior-
ly using a running Connell suture (8).
Staple line resected
Outer layer
of posterior row
6
Inner layer
of posterior row
7 8
Inner layer
of anterior row
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