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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_794_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter • Operation for Achalasia
Step 4
Step 5
Construction of the Dor fundoplication
e anterior wall of the fundus wall is sutured with three interrupted stitches (Prolene for extracorporeal knots, Ethibond for intracorporeal knots) to the adjacent le muscle edge of the myotomy.
e most cranial stitch incorporates the diaphragmatic crus (
. Fig.19.2
Security of the fundic wall
A more lateral portion of the anterior wall of the fundus wall is secured with three interrupted
stitches to the right muscle edge of the myotomy and to the le diaphragmatic crus.
. Fig. 19.2).
Standard Postoperative Investigations
Gastrogran swallow on postoperative day1 to check for esophagogastric transit and absence of
leaks
Postoperative Complications
Persistent dysphagia
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Delayed esophageal emptying
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Recurrent dysphagia due to an incomplete distal myotomy or to an incorrect geometry of
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the Dor fundoplication
Esophagectomy may be required in patients with decompensated sigmoid megaesophagus
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Gastroesophageal reux
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Evidence of stricture may require mechanical dilatation followed by vagotomy and total
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duodenal diversion
Leak aer undetected perforation
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Consider revisional laparoscopy or endoscopic endoluminal stenting and percutaneous CT-
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guided drainage
Section II • Esophagus, Stomach, and Duodenum
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Tricks of the Senior Surgeon
Once the submucosal plane has been identied, use a pledget swab or peanut to create a
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tunnel before cutting the muscle upward.
Bleeding from the muscle edges of the myotomy is self-limiting; it is wise to avoid excessive
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electrocoagulation and to compress with a warm gauze for a few minutes.
Be careful when the nasogastric tube or the endoscope is advanced into the stomach after
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the myotomy is performed to prevent iatrogenic perforation.
Pay attention to include the sling bers of the proximal stomach in the myotomy and to
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avoid tension in the construction of the Dor wrap to prevent twisting of the distal esophagus.
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Subtotal Gastrectomy, Antrectomy, BillrothII,
and Roux-en-Y Reconstruction and Local Excision
in Complicated Gastric Ulcers
Dean Bogoevski, Enrique Moreno Gonzalez, Carmelo Loinaz, Dr. Reeh Matthias
Subtotal Gastrectomy
In subtotal gastrectomy, at least 75 % of the stomach is resected. Gastrointestinal continuity is
reconstructed using the proximal jejunum either as an omega loop or as a Roux-en-Y reconstruction.
Indications
Gastric carcinoma of the intestinal type in the distal part of the stomach
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Complicated ulcers of the distal part of the stomach and the duodenum
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Preoperative Investigations/Preparation for the Procedure
Step 1
In gastric carcinoma patients, the carcinoma should be clearly identified histologically as an
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intestinal type.
e location of the carcinoma/ulcerative lesion should be clearly identified by means of
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endoscopy.
Procedure
Abdominal incision and mobilization of the stomach
For laparotomy, a transverse epigastric incision should be chosen. In case of inadequate exposure,
this incision should be extended with an upper midline extension (reverse T laparotomy). is
approach provides adequate exposure up to the gastroesophageal junction. A valuable alternative
is the midline laparotomy. Following the exploration of the whole abdominal cavity for metastatic
disease in case of gastric cancer, the gastric lesion should be located.
e greater omentum of the stomach is dissected from the transverse colon, exposing the
posterior wall of the stomach and opening the lesser sac (. Fig. 20.1).
P.-A. Clavien, M. G. Sarr, Y. Fong, M. Miyazaki (Eds.), Atlas of Upper Gastrointestinal and Hepato-Pancreato-Biliary Surger y,
DOI 10.1007/978-3-662-46546-2_20, © Springer-Verlag Berlin Heidelberg 2016
Section II • Esophagus, Stomach, and Duodenum
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Step1 (continued)
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. Fig.20.1
e pylorus is freed from adjacent connective tissue (. Fig. 20.2), and the lesser omentum is
opened along the minor curvature. Care has to be taken not to overlook an accessory le hepatic
artery. e le gastric artery is exposed at its origin as well as the coronary vein. Both structures
are ligated and transected (.
curvature is included in the specimen. e right gastric artery and vein are ligated and transected
as well as the right gastroepiploic artery and vein at the greater curve, preserving the arcade vessels
of the proximal part of the stomach.
Fig. 20.3
). us, the lymphatic tissue along the lesser and greater
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. Fig.20.2
Chapter • Subtotal Gastrectomy, Antrectomy, BillrothII, and Roux-en-Y Reconstruction
Step1 (continued)
Step 2
. Fig.20.3
Resection
e resection margins are set about 1 cm distal to the pylorus and the proximal third of the stomach (
. Fig. 20.4). e duodenum is divided with the stapler device. It is recommended to make a
single-layer closure of the gastric incision with a running suture or interrupted stitches. In case a
stapler device is used, the serosa should be approximated with seromuscular stitches (.
e duodenal stump should be treated with special care, avoiding any tension on the suture line.
For its closure, the staple line is oversewn with interrupted seromuscular stitches (
For the gastrojejunostomy, an omega loop (i. e., the BillrothII reconstruction (Steps1–3) or a
Roux-en-Y reconstruction (Step1) is used.
Fig. 20.5
).
. Fig. 20.6).
. Fig.20.4
Section II • Esophagus, Stomach, and Duodenum
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Step2 (continued)
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Indications
. Fig.20.5
. Fig.20.6
Antrectomy
In antrectomy, the distal 25 to 40% of the stomach is resected.
Complicated duodenal ulcers and ulcers of the prepyloric region. Antrectomy is performed
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in combination with bilateral selective vagotomy. is procedure reduces acid secretion
by reduction of acetylcholine stimulus of the vagus nerve and gastrin production of the
antrum.
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Preoperative Investigations
Endoscopic verification of the lesion
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Exclusion of gastrinoma and hypercalcemia as risk factors
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Exclusion of carcinoma (multiple biopsies)
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Chapter • Subtotal Gastrectomy, Antrectomy, BillrothII, and Roux-en-Y Reconstruction
Procedure
Step 1
Mobilization of the stomach and vagotomy
As in subtotal gastrectomy, the stomach is mobilized and freed from the omentum, and the pylorus
is isolated. e vagal trunks are identified on the distal part of the esophagus, with the anterior
nerve lying to the le of the esophagus, and the posterior nerve lying on the back or to the right
of the esophagus (
the nerves are ligated about 5 cm proximal to the esophago-gastric junction; care should be taken
to look for and transect any accessory vagal branches that have originated proximal to the site of
vagal nerve transection. ese nerves tend to innervate the proximal great curvature of the stomach. Also the esophagus should be isolated and any other branches going to the stomach arising
from cranial to the point of ligation and excision of the segment should be sought for and also
transected , especially the so called criminal nerve of Grassi. Alternatively, a selective vagotomy
can be performed by transecting all the branches of the anterior and posterior vagus traveling to
the esophagus and stomach starting about 7 cm proximal to the esophagogastric junction through
the esophageal hiatus and then transecting the trunks of both the anterior and posterior vagus
nerves distal to the takeo of the intestinal branches that travel toward the celiac axis and the
hepatic branch that travels with the le hepatic artery in the lesser omentum (
selective vagotomy the intestinal vagal bers can be preserved (
. Fig. 20.7). For truncal vagotomy about 2 cm of each nerve is resected, and
. Fig. 20.8). By a
. Fig. 20.8).
. Fig.20.7
Section II • Esophagus, Stomach, and Duodenum
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Step1 (continued)
. Fig.20.8
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Step 2
Step 3
Step 4
Exposure of the antrum
e pylorus (see “Subtotal Gastrectomy” Step1) and the distal part of the stomach are transected,
ligating the vasculature on the greater and lesser curvature. Using a stapling device is the most
convenient way to perform the resection.
Resection margins
e gastric resection line is positioned just proximal to the incisura on the lesser curvature and
along the greater curvature at the junction of the right and le gastroepiploic vessels.
Reconstruction of the passage
For reconstruction of gastrointestinal continuity, the BillrothII (Steps1–3) or the Roux-en-Y
procedure is used (Step1).
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Chapter • Subtotal Gastrectomy, Antrectomy, BillrothII, and Roux-en-Y Reconstruction
BillrothII Reconstruction
Procedure
e gastrojejunostomy is done with an omega loop.
Step 1
Placement of the omega loop
Choose a loop of the proximal jejunum that can easily be mobilized to the distal part of the posterior
wall of the remnant stomach. e distance of the loop is kept short when a retrocolic route is chosen.
Prepare a small passage in the mesentery of the transverse colon and pull the omega loop
through the defect in the transverse colonic mesentery. Keep in mind that no tension is applied
on the mesentery when the loop is in place (
. Fig.20.9
. Fig. 20.9).
Step 2
Gastrojejunostomy
Open the closure of the distal gastric remnant and the antimesenteric side of the omega loop. For
the backward layer, use interrupted stitches or a running suture (
. Fig. 20.10).
. Fig.20.10
Section II • Esophagus, Stomach, and Duodenum
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Step2 (continued)
For the anterior layer, a running inverting suture is adequate. However, a monolayer with interrupted stitches is also possible as well as the use of a stapling device (
tomotic stricture, the gastrojejunostomy should be performed over a distance of at least5–6 cm
for a retrocolic gastrojejunostomy, aer completion of the anastomosis, the stomach just proximal
to the anastomosis should be sewn to the edges of the mesenteric defect to keep the anastomosis
below the transverse mesocolon to prevent retraction of the anastomosis into the lesser sac and
potentially leading to an obstruction at the defect in the transverse mesocolon.
. Fig. 20.11). To avoid anas-
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. Fig.20.11
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