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Ростовский Государственный Медицинский Университет

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Книга_1050_Библиотеки_им_академика_М_И_Перельмана

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TECHNIQUES

OPENPYLOROPLASTY

SkinIncisionandRetractorPositioning

■ Anuppermidlineincisionisusedforallopendrainageprocedures.Thisshould beginattheleveloftheumbilicusandextendtojustbelowthexiphoid process.Bodywallretractorbladesareplacedoneithersideoftheupperhalf oftheincisiontofacilitateexposure.Ifnecessary,amalleableorHarrington retractorbladecanbeplacedontheleftlobeofthelivertoexposethepylorus (FIG1).

KocherManeuver

■ AKochermaneuverisperformedtofacilitateexposureoftheduodenumand pylorusandtoeliminatetensiononthesutureline.Aforcepsisusedtograsp

theperitoneumlateraltotheduodenum,whichisthenincisedwithscissorsor theelectrosurgicaldevice.Thesurgeonthencaninsertanindexfingerbehind theduodenumandheadofthepancreasandsweepthefingertotheright, elevatingthelateralduodenalligamentandavascularretroperitonealtissues, whichcanthenbedividedwiththeelectrosurgicaldevice(FIG2).Theplane ofdissectionshouldremainclosetotheduodenalwalltoavoidinjurytothe gonadalveinontheanteriorsurfaceoftheinferiorvenacava.Theduodenum andheadofthepancreasshouldbemobilizedfromthejunctionofthe duodenalbulbandsecondportionoftheduodenumtojustbeforethelateral aspectofthesuperiormesentericvein.Iftheprocedureisbeingperformedfor ableedingduodenalulcer,theKochermaneuverstepcanbedeferreduntil aftercontrolofthebleedingvesselhasbeenachieved.

PyloricIncision

■ Thepylorusisidentifiedeithervisuallyorbypalpationofthemuscularringwith afingerinsertedfromthegastricside.Beginningroughly2cmproximalto thepylorusonthegastricantrum,incisethegastricwall,enterthelumen,and extendtheincisiondistallyparalleltothelongaxisofthebowelacrossthe pylorusontotheduodenumtodistanceofroughly5cmusingthe electrosurgicaldevice(FIG3).Thisincisionwillprovidereasonableexposure oftheduodenalbulb.Iftheoperationisbeingperformedforulcerbleeding, theincisioncanbeextendedfurtheralongtheduodenumtoexposethe

bleedingsite.Thepyloroplastyincisioncanbefacilitatedbyplacinga seromuscularstaystitchonthesuperiorandinferioredgeofthepylorus.

BleedingControl

■ Iftheoperationisbeingperformedforableedingduodenalulcer,theulceris identifiedontheposterioraspectoftheduodenalbulb.Temporaryhemostasis isachievedbydigitalpressure,andthendefinitivehemostasisisachievedby placingthree2-0silksutureligatures.Thefirstsutureisplacedatthecranial marginoftheulcer,encirclingtheproximalgastroduodenalartery(GDA). Thesecondsutureisplacedatthecaudaledgeoftheduodenalulcer encirclingthedistalGDA.ThefinalsutureisaUsutureplacedunderneath theulcercratertocontroltheposteriorentryofthetransversepancreatic arteryintothebackwalloftheGDA(FIG4).

ClosureofPyloroplasty—Heineke-Mikulicz

■ ThemostcommonclosureofthepyloroplastyistheHeineke-Mikulicz approach,closingthelongitudinalpyloroplastywithasinglelayerofsutures inatransversefashion.Thisclosureisappropriatewhentheduodenumisnot distortedorscarredandthepyloroplastyincisionisshorterthan6to7cm. Theclosureisperformedbyapplyingsuperiorandinferiortractiononthe staysutures,convertingthelongitudinalgastroduodenalincisionintoa transverseincision.Theincisionisthenclosedwithinterrupted3-0silk suturesor3-0polyglycolicacidsutureswitheitherafull-thicknesssimple stitchoraGambeestitch.Theclosureisbestperformedbystartingatthetop corneroftheincisionandalternatingfromthetoptothebottomproceeding towardthemiddle.Thesuturesmaybetiedastheyareplaceduntilthelast threesutures,whichshouldbeleftuntieduntilallofthesuturesareplacedto

ensurethatthemucosallayerisincludedinallofthebites(FIG5).A vascularizedpedicleofomentumisthenplacedovertheclosureandthestay suturestiedovertheomentalpedicletoholditinplaceinthefashionofa Grahampatch.

ClosureofPyloroplasty—Finney

■ Iftheduodenumissignificantlyinflamedorscarredfromchronicpeptic ulcerationorifalongerduodenotomyisrequiredtoobtainhemostasisona bleedingsourcebeyondtheduodenalbulb,aFinneyclosureofthepylorusis appropriatetopreventtensionontheclosureandgastricoutletobstruction. TheFinneyclosureisinessenceaside-to-sidegastroduodenostomywiththe pylorusatthecranialapexoftheanastomosis.Theduodenumwillneedtobe completelymobilizedtoallowthisclosuretobetensionfree.Removethe inferiorstaysutureandapplycranialtensiononthesuperiorstaysutureto convertthelongitudinalincisionintoaninvertedUshape.TheFinneyclosure isastandardtwo-layeredanastomosis.Abackrowofinterrupted3-0silk seromuscular(Lembert)suturesisplacedbetweentheinferioredgeofthe

duodenumandthegastricwall(FIG6A).Thesesuturesshouldbeplaced5to 10mmfromthecutedgeofthemucosa.Itisoftennecessarytoextendthe incisiononthegastricsideofthepylorustoensurethatthelengthsofthetwo armsoftheincisionareequal.Whenextendingthepyloroplastyinthis fashion,itisadvisabletocheattowardthegreatercurvatureofthestomach. Next,begintheinnerlayeroftheclosureusinga3-0polyglycolicacid runningsuturebeginningatthedividedpylorusmuscle,suturingtheinferior edgeoftheduodenumtotheinferioredgeofthestomach(FIG6B).Runthis suturearoundtheinferioredgeoftheclosureontotheanterioredgeofthe gastroduodenalanastomosis.Next,beginasecondrunning3-0polyglycolic acidatthesuperioredgeofthecutpylorus,suturingthesuperioredgeofthe duodenumtothestomachandrunningtowardtheothersuture(FIG7A). ManysurgeonsprefertouseaConnellsutureontheanteriorwalltoachieve bettermucosalinversion.Tiethetwosuturesandthencompletethe pyloroplastyclosurewithananteriorlayerofinterrupted3-0silk seromuscularsutures(FIG7B).

OPENPYLOROMYOTOMY

IncisionandIdentificationofthePylorus

■ Anuppermidlineincisionandfixedretractorisusedasdescribedpreviouslyfor

pyloroplasty(FIG1).Thepylorusisidentifiedeithervisuallyorbypalpation ofthemuscularringwithafingerinsertedfromthegastricside.

SerosalIncisionandDivisionofMuscularFibers

■ A3-cmlonglongitudinalserosalincisionismadeacrossthepylorus,beginning 1to2cmproximaltothepylorusonthegastricsideandextending1cm distaltothepylorus.Thisserosalincisioncanbeperformedeitherwitha knifeoranelectrosurgicaldevice(FIG8A).Iftheelectrosurgicaldeviceis used,careshouldbeexercisedtoavoiddeeppenetrationintothemuscularis andthermalinjurytothemucosa.Beginningonthegastricsideofthe incision,useafinetippedhemostattodissectthemuscularfibersoffofthe submucosaanddividethecircularmuscularfiberswithaknife(FIG8B). Muscularbleederscanusuallybecontrolledwithpressure,andthereisavery limitedroleforcauteryatthispointoftheoperation.Greatcareshouldbe takentoavoidmucosalinjuryespeciallyontheduodenalside,asthe submucosaisthinnerandmorefragile.Whenproperlyperformed,themucosa andsubmucosawillbulgeoutoftheincision(FIG8C).

OmentalPatch

■ Avascularizedpedicleofomentumisplacedoverthepyloromyotomyand suturedwiththree3-0silksutures.Thefirstisplacedthroughthesuperior

edgeofthedividedpyloricringandthesuperioredgeoftheomentalpedicle topreventthetwocutedgesofthepylorusfromcomingintocontact.The nexttwoareplacedbetweeneachlateraledgeoftheserosalincisionandthe lateraledgesoftheomentalpatchtoensurethatthepatchcoverstheentire pyloromyotomy(FIG8D).

OPENGASTROJEJUNOSTOMY

SkinIncisionandRetractorPositioning

■ Anuppermidlineincisionisusedforallopendrainageprocedures.Thisshould beginattheleveloftheumbilicusandextendtojustbelowthexiphoid process.Bodywallretractorbladesareplacedoneithersideoftheupperhalf oftheincisiontofacilitateexposure(FIG1).Ifnecessary,amalleableor Harringtonretractorbladecanbeplacedontheleftlobeofthelivertoexpose thestomachandpyloricregion.

PreparationoftheStomachandIdentificationofProximalJejunum

■ Thereisinsufficientevidencetorecommendaposteriorgastrojejunostomyover ananteriorgastrojejunostomy,andanantecolic,anteriorgastricwall gastrojejunostomyistheeasiesttocreate.Identifythepylorus,andthen identifyapoint,5cmproximaltothepylorus,asthegastricsiteofthe anastomosis.Next,identifytheligamentofTreitz,andselectasectionofthe jejunum15to30cmdistaltotheligamentofTreitz,whichwilleasilyreach thedistalstomachwithouttension.

ConstructionoftheAnastomosis

■ Astandarddouble-layeredside-to-sideanastomosisisconstructedbyaligning thesmallbowelwiththestomachinanisoperistalticfashion,withthedistal portionofthesmallbowellocatedclosesttothepylorus.Thebackrowofthe anastomosisisfirstcreatedbysuturingthejejunumtothegreatercurvatureof

thestomachusingseromuscular3-0silkinterruptedsutures.Thetailsofthe suturesateithercornerareleftlongtoallowthemtobeusedasstaysutures (FIG9A).Usingtheelectrosurgicaldevice,afull-thicknessjejunotomyis madeinthesmallbowel,andagastrotomyismadeinthestomachroughly5 mmfromtheouterlayeroftheanastomosis(FIG9B).Beginninginthe middleoftheposteriorportionoftheanastomosis,theinnerlayerofthe anastomosisisconstructedbyrunningtwo3-0polyglycolicacidsuturesfrom themiddleofthebackrowinoppositedirections(FIG10A).Manysurgeons prefertouseConnellsuturesontheanteriorrowtoachievebettereversion, butthisstepisnotnecessary(FIG10B).Theanastomosisiscompletedwith anouteranteriorlayerofseromuscular3-0silkinterruptedsutures.

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