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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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52 Atlas of Gastrointestinal Surgery: The Stomach
If the perforation is so large that primary closure would
Ulcer
narrow the lumen, it is probably best converted to a
pylorplasty by extending the perforation through the
pylorus and onto the stomach (5).
Pylorus
Duodenum
5
This longitudinal incision is closed in a transverse
direction (6) to avoid narrowing the pylorus.
Duodenotomy with Oversewing of a
Bleeding Duodenal Ulcer
Operative Indications
If a duodenal ulcer is located in the anterior wall of the duodenum, deep penetration is apt to result in perforation.
However, if the duodenal ulcer is located posteriorly, which is a more common location, penetration is apt to result in
bleeding. The gastroduodenal artery comes off the common hepatic artery and passes posterior to the duodenum, just dis-
tal to the pylorus (1). If the posterior penetrating ulcer erodes into the gastroduodenal artery or one of its branches,
bleeding can be massive. Whether bleeding requires surgical control is difficult to predict and it depends on the amount
of bleeding as well as the rate. Most alimentary tract surgeons think that surgery is indicated if a patient requires 6 or
more units of blood.
Operative Technique
The patient is explored through an upper midline incision.
54 Atlas of Gastrointestinal Surgery: The Stomach
Hepatic a.
Celiac axis
Gastroduodenal a.
eroded by ulcer
Pylorus
Usually through endoscopy, the cause and site of
bleeding will have been determined preoperatively.
In this instance a posterior penetrating ulcer just
beyond the pylorus has eroded into a branch of the
gastroduodenal artery (1). A longitudinal incision is
Stomach
1
made in the anterior duodenal wall, through the pylorus,
and onto the proximal stomach, as if one is making an inci-
sion to perform a Heineke-Mikulicz pyloroplasty (2). Before
performing the enterotomy, stay sutures are placed superiorly and
Pancreas
R. gastroepiploic a.
inferiorly through the pyloric sphincter. Once the enterotomy has been
performed, the bleeding ulcer is identified (3).
Biliary
tree
Gastro-
duodenal a.
Pyloroduodenotomy
Ulcer
Duodenum
2
Pylorus
3
If bleeding is rapid, it can be controlled
initially with a fingertip (4). If the main gastro-
duodenal artery has been eroded, bleeding
Biliary
tree
Duodenotomy with Oversewing of a Bleeding Duodenal Ulcer 55
Hepatic a.
will be massive. Generally, the bleeding can be
controlled through the duodenotomy by placing
sutures directly through the ulcer base. If the
main gastroduodenal artery is thought to
be involved, sutures of 3-0 silk may be
placed deeply just above and just
below the ulcer crater itself (4), in
addition to closing the ulcer base
with 3-0 silk sutures (5). One has
to be aware of the course of the com-
mon bile duct posterior to the first
portion of the duodenum and avoid
injuring it. If there is any question to its
location, a biliary Fogarty catheter should
Manually control
hemorrhage
Gastroduodenal a.
suture ligated
proximal
and
distal
4
be inserted through the cystic duct and
passed into the duodenum.
Another alternative, used less frequently, is to ligate the
main gastroduodenal trunk just superior to the first portion of the duo-
denum and its more distal branches below the duodenum (6).
Edges of
ulcer
appromimated
Anterior superior
pancreaticoduodenal a.
Alternative
Gastroduodenal a.
Ulcer
R. gastroepiploic a.
5
6
56 Atlas of Gastrointestinal Surgery: The Stomach
Once the bleeding has been controlled, the horizontal opening through the
distal stomach, pylorus, and duodenum is then closed in a vertical direc-
tion to create a Heineke-Mikulicz pyloroplasty. This is performed, as
described in a previous section, with a single layer of 3-0 silk
sutures placed in a Gambee fashion (7). A truncal vagotomy
may be added for long-term ulcer control (8), but many would
rely on pharmacologic eradication of
Vagotomy
and
pyloroplasty
Helicobacter pylori
.
Transverse
closure
7
8
Wedge Resection of a Benign Gastric Ulcer
Operative Indications
The ideal operation for a patient with a gastric ulcer consists of a distal hemigastrectomy including the ulcer in the speci-
men. A frozen section is then performed, and if the ulcer is benign, this is adequate treatment for the disease. If preoper-
ative acid studies have shown the patient to be a hypersecretor, a vagotomy can be added. If the gastric ulcer is not in
the distal half of the stomach, however, the management of gastric ulcer disease is more complicated. A hemigastrectomy
with or without vagotomy can still be performed, but that leaves the ulcer in place with the risk that it is malignant. Thus,
if the ulcer is in the proximal half of the stomach, some surgeons prefer to perform a wedge resection of the ulcer to deter-
mine whether it is benign or malignant, and then perform an appropriate operation.
Operative Technique
This operative procedure is best performed through an upper midline incision.
Retracting both costal margins in a cephalad direction with retractors attached
to a frame fixed to the operating table is very helpful. In this instance the gas-
tric ulcer is high along the greater curvature of the stomach.
58 Atlas of Gastrointestinal Surgery: The Stomach
Liver
Duodenum
Gastrohepatic
ligament
Stomach
1
Ulcer
Omentum cleaned off
greater curvature
Omentum in removed from this area of the stomach (1). Some vasa brevia may also have to be divided. The gastric ulcer
in this instance could be visualized, as well as palpated.
Wedge Resectioin of a Benign Gastric Ulcer 59
The limits of the ulcer are identified and, with the use of
a GIA stapler, a wedge resection is performed (2).
The ulcer is sent to the pathology department for
Wedge
resection
with
GIA
stapler
frozen section examination. The staple line is invert-
ed with a layer of 3-0 Lembert silk sutures (3). If
the ulcer proves to be benign, a variety of options
are available. If the patient is elderly or with other
systemic diseases, one may choose to perform a
truncal vagotomy and pyloroplasty (4). Even though
this carries a substantial recurrence rate, it is less than if
no other procedure is added. In some particularly high-
risk situations, such as a perforation in an elderly
patient, one might perform
2
if the ulcer is benign. A hemigastrectomy is also an
only
a wedge resection
acceptable alternative. If the ulcer is malignant, a
cancer operation should be preformed.
3
Staple
line
inverted
Optional
vagotomy
and
pyloroplasty
4
Control of Bleeding from a
Mallory–Weiss Syndrome Tear
Operative Indications
Upper gastrointestinal bleeding secondary to the Mallory–Weiss syndrome is a relatively uncommon cause of bleeding. It
is now recognized that a major prebleeding episode of forceful vomiting is not always present in the patient’s history.
Bleeding from a Mallory–Weiss tear can be difficult to identify endoscopically and may be confused with bleeding from
gastric varices or gastritis (1). Thus, in some instances the patient will be explored without the exact site of bleeding deter-
mined. If that is the case, a gastrotomy will often have to be performed first in the midstomach or antrum in an effort to
identify the bleeding site. After a proximal site is identified, the gastrotomy will need to be either extended in a cephal-
ad direction or closed and a new one placed appropriately. However, in many instances the Mallory–Weiss tear will be
identified with endoscopy, and at the time of laparotomy the surgeon will know the site of bleeding. Guidelines for oper-
ative intervention are similar to those for bleeding from a duodenal ulcer. If a patient requires 6 units or blood or more,
surgery should be performed.
Operative Technique
The patient is explored through an upper midline incision. Retraction of both
costal margins with a retractor suspended from a frame attached to the oper-
ating table is very helpful. The left lobe of the liver should be retracted in a
cephalad direction.
Control of Bleeding from a Mallory–Weiss Syndrome Tear 61
In this instance the diagnosis of a Mallory–Weiss tear
was made preoperatively. Thus the gastrotomy is initially
placed in an oblique fashion high on the fundus of the stomach
(2). With both the nasogastric tube and small retractors, the ante-
rior wall of the fundus of the stomach adjacent to the gastroesopha-
gael junction is retracted, and the bleeding tear at the gastroesophagael
junction is identified (2). The tear generally involves both the esophageal
and gastric mucosa, is linear, and runs in a vertical direction (1).
Liver
1
Nasogastric
tube
Gastroesophageal
junction
Gastrotomy
Duodenum
Mallory-Weiss
tear
Stomach
2
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