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42 Atlas of Gastrointestinal Surgery: The Stomach
The outer layer of the anterior row consists of a series of inter-
rupted 3-0 silk Lembert sutures (9).
A reinforcing three-corner stitch is placed at the
point where the gastric suture line, along
the lesser curvature, joins the
duodenal suture line.
Vagotomy
Esophagus
Stomach
Outer layer
of anterior row
Duodenum
9
Care is taken when placing this 3-0 silk suture. It passes into
the stomach on one side of the gastric suture line and out the
other side, parallel to the gastroduodenostomy. On the duo-
denum, the suture passes in the opposite direction, also par-
allel to the gastroduodenostomy, and is tied (10). A Billroth
I gastroduodenostomy is performed only when there is enough
gastric remnant so that the stomach can be approximated to
3-corner
suture
the duodenum with absolutely no tension. In addition, if duo-
denal ulcer disease is present, the duodenal tissue must be
healthy enough to be anastomosed to stomach. At times it is
easier and safer to close the duodenum and perform a Billroth
II gastrojejunostomy.
10
Vagotomy plus Antrectomy 43
If for technical reasons a Billroth I gastroduo-
denostomy cannot be performed or if the
Posterior antrum
of stomach
Duodenum
11
GIA
stapler
Pancreas
gastric resection was performed for
stomach cancer, a Billroth II gastro-
jejunostomy is an acceptable alter-
native. The first part of the oper-
ation procedure is identical to
that of a Billroth I resection.
The antrum is mobilized, and
the duodenum is divided with a
GIA stapler (11).
The duodenal stump, which has been closed with the
stapler, is further inverted with a layer of 3-0 silk
Lembert sutures (12). Some surgeons prefer to
place a third layer by inverting the duodenal stump
into the head of the pancreas. If the duodenal clo-
sure has been adequate, this is not necessary.
Inverted
staple
line
Pancreas
12
Duodenum
44 Atlas of Gastrointestinal Surgery: The Stomach
The lesser curvature of the stomach, which has previously been closed with a GIA stapler, is further inverted with a series
of interrupted 3-0 silk Lembert sutures (13). This is similar to the lesser curvature closure that is carried out in prepara-
tion for a Billroth I gastroduodenostomy. The proximal jejunum just distal to the ligament of Treitz is identified. It is brought
up in an antecolic fashion with a short afferent loop,
which fits comfortably over the omentum and
transverse colon.
Esophagus
Staple
line
inverted
Stomach
Pancreas
Omentum
Colon
13
Jejunal loop
Mesentery
Proximal
jejunum
Esophagus
Vagotomy plus Antrectomy 45
The gastrojejunostomy is carried
14
Outer layer
of posterior row
Duodenum
Stomach
out along the greater curvature and is
performed in two layers. The poste-
rior outer layer consists of interrupt-
ed 3-0 silk Lembert sutures (14).
Fourth portion
of duodenum
Jejunal loop
After this layer is placed, the staple line on the stomach is removed
with the electrocautery, and a jejunotomy is performed (15).
Stomach
Staple
line
resected
Jejunum
15
46 Atlas of Gastrointestinal Surgery: The Stomach
Inner
Inner layer
of posterior row
16 17 18
layer of
anterior row
Outer layer
of anterior row
3-corner suture
Stomach
Jejunum
The inner posterior row is placed using a continuous locking stitch of 3-0 synthetic absorbable suture material (16). This
is brought around anteriorly as the inner layer of the anterior row using the Connell stitch (17). The outer anterior row
consists of interrupted 3-0 silk Lembert sutures. As with the Billroth I gastroduodenostomy, care is taken to place a 3-0
silk reinforcing suture at the junction of the lesser curvature gastric suture line and the gastrojejunostomy. This suture pass-
es into the stomach on one side of the gastric suture line and out the other side, parallel to the gastrojejunostomy. On
the jejunum, the suture passes in the opposite direction, also parallel to the gastrojejunostomy, and is tied (18).
Truncal vagotomy
Vagotomy plus Antrectomy 47
Liver
Duodenum
Pancreas
Esophagus
Stomach
Omentum
Jejunal loop
Colon
19
When performing a gastrojejunostomy without a gastric resection, a retrocolic anastomosis is impor-
tant to ensure adequate gastric emptying. However, after antrectomy the stomach is allowed to ride
anteriorly because it is no longer attached to the retroperitoneal duodenum, and an antecolic gastroje-
junostomy (19) will empty as readily as a retrocolic gastrojejunostomy.
48 Atlas of Gastrointestinal Surgery: The Stomach
Therefore, whether the anastomosis is performed antercolic (20) or retrocolic (21) depends in large part on personal pref-
erence. If a patient requires reoperation following a Billroth II gastrojejunostomy, it is much easier to take down and redo
if the anastomosis is in an antecolic position (20). However, if a patient is obese and has a large transverse colon with a
huge greater omentum, perhaps there are advantages in placing the anastomosis in a retrocolic position.
20
Antecolic
Billroth II
Colon Colon
Gastrojejunostomy
covered with
mesocolon
21
Retrocolic
Billroth II
Closure of a Perforated Duodenal Ulcer
Operative Indications
A variety of options are available when exploring a patient with a perforated duodenal ulcer. Experience has demonstrat-
ed that a primary ulcer operation can be performed safely if the perforation is recent, and/or if peritonitis is not wide-
spread. For many years, pyloroplasty plus vagotomy was the operative procedure of choice if the perforation could be
incorporated in the horizontal incision through the stomach, pylorus, and duodenum. Most recently, some have advocat-
ed closure of the ulcer and parietal cell vagotomy. Today the most common management of perforated ulcer consists of
merely closing the perforation, with the expectation of controlling the ulcer disease postoperatively pharmacologically with
the eradication of
Helicobacter pylori
.
Operative Technique
The procedure is best performed through an upper midline incision. When the
peritoneal cavity is entered, the abdomen is explored, and the area of the per-
foration is identified. Often omentum will have already sealed the perforation,
so blunt dissection is necessary to expose the site of perforation. The peritoneal
cavity is then copiously irrigated with an antibiotic-containing saline solution.
50 Atlas of Gastrointestinal Surgery: The Stomach
Duodenum
Perforated
ulcer
Pylorus
Stomach
Close
defect
1
The perforation often is in the anterior superior aspect of the
first portion of the duodenum (1). If one elects to close
the perforation, it generally can be carried out by first
placing a series of through-and-through full-thickness
sutures, so that the perforation is closed in a transverse
fashion (2). The tissues surrounding the ulcer may vary
from virtually normal duodenum that is edematous to
chronically scarred tissue. Generally, however, the tissue
will hold sutures well, and the perforation is small enough
Omental pedicle
2
so that it can be easily closed without narrowing the first
portion of the duodenum.
Reinforce
with
omental
patch
Closure of a Perforated Duodenal Ulcer 51
Most alimentary tract surgeons think it is wise
to reinforce the closure with an omental patch. A
pedicle of omentum can easily be constructed
from the greater curvature of the distal stomach
(2). The patch is brought up and sutured cir-
cumferentially around the site of the closed ulcer
(3, 4). The abdomen is further irrigated and
generally closed without drainage, unless the
duodenal closure is thought to be tenuous.
3
4
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