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Modern Technics in Gastric Surgery
MODERN TECHNICS IN GASTRIC SURGERY WALTMAN WALTERS, M.D., F.A.C.S. * THE BILLROTH I RESECTION: ITS MODIFICATIONS AND RESULTS
Pean first perfonned an operation in which he sutured the end of the stomach to the duodenum and decreased the circumference of the stomach by sutures placed in the vicinity of the lesser curvature. As his patient failed to recover, the fact that he first employed this procedure frequently is lost sight of. Billroth later employed this type of operation in his first successful partial gastrectomy and thereafter the operation has borne his name. In view of the fact that Billroth, a few years later in 1885, abandoned this type of anastomosis for an indirect one of stomach to jejunum which had been called the "Billroth II," it might be well to call the "Billroth I" the "Pean-Billroth operation." The reason Billroth gave for his change to using an indirect type of an:}stomosis from using a direct one was that only one of three patients on whom the PeanBillroth procedure was perfonned recovered from the operation. This failure to recover apparently was due to leakage at the upper part of the anastomosis where the three suture lines of the anastomosis come together. Of the various modifications of the Pean-Billroth method of direct anastomosis that of von Haberer appears to be the most satisfactory, owing to the fact that the entire circumference of the stomach is sutured to the circumference of the duodenum. In his modification the larger circumference of the stomach is decreased by interrupted sutures placed in the mucous membrane and muscularis mucosae of the gastric wall; these sutures also serve as ligatures of the larger blood vessels of the gastric submucosa. In the first technic of the Billroth I operation the duodenum was sutured to the stomach along the lesser curvature. There seems to have been some difficulty with this procedure and there was fear of causing a diverticulum or cul-de-sac of the fundus of the stomach which appeared to be a distinct disadvantage. In later cases, "Professor Billroth, would, whenever possible, insert the duodenum into the greater curvature." Several modifications were instituted to remove portions of the lesser curvature of the stomach to prevent the fonnation of the diverticulum. Among these was that of Schoemaker of The Hague (Figs. 490 and 491) and Charles H. Mayo and William J. Mayo (Fig. 492). The modifications of the Pean-Billroth most frequently used at the Mayo Clinic have been Schoemaker's, the Mayos' and von Haberer's.l Technic of the Billroth I Operation and Its Modifications.-In all From the Division of Surgery, Mayo Clinic, Rochester, Minnesota. * Professor of Surgery, Mayo Foundation, Graduate School of Medicine, University of Minnesota. 1361
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types of partial gastrectomy, the division and ligation of the branches of the gastric artery in the gastrohepatic omentum and the ligation of the branches of the gastroduodenal artery are similar. The assistant places tension on the gastroduodenal junction by grasping the anterior wall of the stomach and pulling toward the left side of the patient. At that time the surgeon inserts the index and middle fingers of the left hand through the gastrohepatic omentum to the posterior wall of the
Fig. 490.-Schoemaker modification of Billroth I operation. Gastric vessels have been ligated high in the gastrohepatic omentum. The portion of the gastrohepatic omentum to be removed with the tumor and the pattern of stomach to be removed are shown.
stomach and duodenum with the thumb anterior to them. The upper margin of the duodenum is wiped carefully and forceps may then be introduced between the omentum and the duodenum to permit their separation, division and ligation. By extending the index and middle fingers toward the midline posterior to the duodenum and the thumb anterior, the attachment of the gastrocolic omentum to the duodenum can be well defined and forceps may be placed on the blood vessels (branches of the right gastro-~p.iploic) running through it. In cases of duodenal or gastric ulcer, the gastrocolic omentum can be disconnected
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from its attachment to the greater curvature of the stomach by repeated clamping and cutting. The line of dissection is close to the greater curvature until the left gastro-epiploic artery is encountered (Fig. 493). In cases of neoplasm of the stomach the gastrocolic omentum can be disconnected from the attachment to the transverse colon after ligation of the right'gastro-epiploic vessels below the pylorus and the gastrocolic
Fig. 491.-Schoemaker clamp placed across stomach. Payr clamp placed across duodenum. The portion of the stomach containing the tumor is being excised with the cautery.
omentum can be dissected with the scalpel from the transverse colon with little bleeding (Fig. 494). A curved hemostat of sufficient gripping power to hold the cut edges of the duodenum without slipping is placed across the duodenum well below the pylorus in cases of neoplasm of the stomach or gastric ulcer (Fig. 495). In cases of duodenal ulcer this hemostat may be placed immediately distal to the duodenal ulcer or across it so that only a small
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portion of the ulcer will be removed. In cases of duodenal ulcer in which the ulcer is rather far from the pylorus, an open closure of the duodenum without use of the hemostat will often have to be carried out. A second hemostat is placed above the first one. The duodenum is transected between the clamps. The stomach is reflected upward and toward the midline, where it is held by the assistant. The gastrohepatic omentum is wiped from the lesser curvature of the stomach at the point where the left gastric artery is to be divided and ligated (Fig. 496). Three Kocher forceps are passed through the avascular portion of the gastro-
Fig. 492.-Billroth I, Mayo method. Curved hemostats placed across the stomach and duodenum so that a large portion of the lesser curvature can be removed. Inset shows method of making anastomosis.
hepatic omentum and applied across the artery and omentum which are divided distal to the two proximal forceps. The branches of the gastric artery in the gastrohepatic omentum are ligated doubly; the first ligature is a suture ligature. The distal portion of the left gastric artery is ligated with a single suture. The region on the lesser curvature denuded of serosa as a result of the separation of the gastrohepatic omentum from it and the ligation of the left gastric artery is closed with two or three interrupted sutures which approximate the serosa of the anterior and the posterior walls of the stomach. A suction pump is introduced into the stomach and any retained gastric secretions or gas is removed (Fig. 497) In cases of duodenal or gastric ulcer from two thirds to three fourths
.,
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of the stomach is removed whereas in the presence of neoplasms of the stomach it is well to remove as much stomach above the tumor as possible and as is consistent with good postoperative gastro-intestinal function and motility. When the secretion and gas are removed from the interior of the stomach, the circumference of the stomach decreases surprisingly. This is important, since, in the Billroth-von Haberer
Fig. 493.-Billroth I operation. An opening has been made in the gastrocolic omentum as close to the colon as possible in order that the lesser peritoneal sac may be explored. Hemostat is shown in place on a branch of the gastro-epiploic vessels.
method, the entire circumference of the stomach is approximated to the circumference of the duodenum and any method of reducing the circumference of the stomach is worth while. Two rows of interrupted sutures are employed to approximate the greater and lesser curvatures of the stomach to the inferior and superior margins of the duodenum and a row of continuous or interrupted sutures are placed to approximate the serosal layers of the posterior wall of the stomach to the duodenum. These sutures include larger amounts of gastric serosa than of duodenal serosa. This procedure likewise tends to reduce the circumference of the
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stomach. Since the stomach has been emptied of its contents, it is unnecessary to place' a clamp of any sort across it. In fact, the use of such a clamp not only reduces the amount of stomach that can be removed in some cases, but in addition, so flattens the wall of the stomach that it increases considerably in circumference. After the serosal sutures are placed posteriorly, an incision which extends to the mucous membrane is made in the posterior wall of the stomach (Fig. 498). Interrupted sutures which serve as ligatures of the
Fig. 494.-Billroth I, von Haberer technic. Gastrocolic omentum containing lymph nodes is separated from the colon. Inset shows the amount of stomach and gastrocolic and gastrohepatic omentum to be removed.
branches of the gastric blood vessels, and to reef the mucous membrane and thus decrease the circumference of the stomach, are placed adjacent to each other in the mucous membrane of the posterior wall of the stomach. The mucous membrane of the stomach is incised and the curved hemostat on the duodenum is removed. The clamped crushed tissue on the duodenum is then trimmed off. Any bleeding vessels in the submucosa of the stomach are grasped and ligated. A second row of chromic catgut sutures is used to approximate the mucosa, submucosa, and
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muscularis mucosae of the stomach to the duodenum. Cutting across the anterior wall of the stomach enables removal of the segment of stomach containing the tumor or gastric ulcer. If an incision is made through the mucous membrane of the anterior wall of the stomach first, the surgeon is able to pick up the blood vessels of the submucosa with hemostats and ligate them (Fig. 499). The segment of stomach containing the lesion is removed. A point in the midportion of the mucous membrane of the anterior wall of the stomach is approximated to the midportion of the mucous membrane
Fig. 495.-Billroth I, von. Haberer method. Curved hemostats are in place across the duodenum.
and submucosa of the anterior wall of the duodenum (Fig. 500). Traction of considerable degree is placed on the two sutures at the angles of the anastomosis in Qrder to stretch the size of the duodenum to conform more nearly to the size of the stomach. The circumference of the cut end of the duodenum can be enlarged by a small incision down the anterior wall of the duodenum at right angles to the line of suture. Further interrupted sutures are placed in the mucous membrane of the stomach and the duodenum. Each suture is placed to bisect the space between two others previously placed. Another row of sutures approximates the mucosa, submucosa and muscularis mucosae of the stomach to that of the duodenum. It is frequently advisable to start th~~12 ~utures at eac4
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angle of the anastomosis, having them meet in the midline. This assists in the more accurate approximation of the structures. The serosal layers of the stomach and the duodenum are approximated with a third row of sutures. These are usually of silk and placed interruptedly. The upper angle of the anastomosis where it is sutured to the stomach
Fig. 496.-To ligate the left gastric artery, the vessel and right edge of stomach are palpated between the thumb and index finger and an opening is made as close to the stomach as possible. The duodenal stump has been buried in areolar tissue and fat and has been turned into the head of the pancreas. Inset, three clamps have been applied to the vessel and it will be ligated with double chromic catgut and a "sticktie."
and the duodenum with interrupted sutures is covered with a portion of gastrocolic omentum which is brought up posterior to the line of anastomosis. There is usually enough gastrocolic omentum lateral to the point of its removal for this purpose. A similar tag of omentum is used to protect the lower angle where it is maintained in position by sutures (Fig.
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501). The placement of omentum in this fashion safeguards against leakage at the angles as well as on the posterior wall. If possible, the gastrohepatic omentum at the points where the gastric vessels have been ligated should be brought down and sutured to the ligated duodenal portion of the omentum. This procedure helps to relieve tension on the anastomosis. One or two interrupted sutures should be placed between the anterior wall of the stomach and the falciform ligament. They will hold the anastomosis to the right of the midline and will assist in taking
Fig. 497.-Billroth I, von Haberer method. The cut end of stomach has been reflected, exposing the branches of the gastric artery and vein and the gastrohepatic omentum. Hemostats have been placed and the vessels are about to be divided. A suction pump has been introduced into the lumen of the stomach. and is emptying it of gastric se9retion and gas.
tension from the line of anastomosis (Fig. 502). If duodenal or gastric secretion has produced any soiling, from 1 pint to 1 quart (0.5 to 1 liter) of sterile water is poured slowly over the tissues and is removed with the suction pump. In this manner any gastric or duodenal secretion present is diluted and then is removed. Billroth I, Mayo Modification.-Mter the gastric vessels are divided and ligated and the duodenum is divided above the curved hemostat across it, as described previously, a curved hemostat is placed transversely across the stomach at the greater curvature at the point where it
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is to be resected. A second clamp is placed across the stomach below the first clamp so that there will be no soiling, and the gastric wall between is incised. Two additional curved hemostats then are placed across the stomach almost at right angles to the first hemostat. A segment of lesser curvature is included in these clamps (Fig. 492), and an incision is
Fig. 498.-Billroth I, von Haberer technic. The first continuous row of silk sutures has been applied to approximate the peritoneal coats of the posterior wall of the duodenum and stomach. Incision has been made in the peritoneal and muscular coats of the stomach down to the mucous membrane and interrupted sutures of silk have been used to reef the gastric mucosa, decreasing its circumference. Sutures have been placed in the superior and inferior margins of the anastomosis; these make possible the stretching of the duodenum so that its diameter nearly conforms to that of the stomach.
made between them. A continuous suture of chromic catgut is placed back of the curved hemostat on the lesser curvature which not only approximates the wall of the stomach, but also serves as a hemostatic suture. The curved hemostat on the lesser curvature then is removed. A second row of sutures continuously placed, using silk, inverts the first row by approximating the serosal layer of stomach (Fig. 503). The curved hemostat on the inferior portion of the stomach then is approximated to the curved hemostat across the duodenum. A continuous row of silk
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sutures approximates the posterior wall of the serosa of the stomach and the duodenum. When this approximation has been completed, an incision is made through the serosa and muscularis mucosae down to the mucouS membrane of both structures and the cut edges of each are approximated. Clamps then are removed, a suction pump is introduced into the lumina of the stomach and of the duodenum and the mucous
Fig. 499.-Billroth I, von Haberer method. The posterior sutures have been inserted. Incision has been made through the mucous membrane and muscularis mucosae of the anterior wall of the stomach. These make it possible to ligate the branches of the gastric vessels of the submucosa and anterior wall of the stomach and also to reef the mucous membrane, thus decreasing the size of the gastric lumen of the anastomosis.
membranes of the stomach and the duodenum are approximated with a third row of sutures of chromic catgut (Fig. 504). The anterior part of the anastomosis is completed in similar fashion with three rows of sutures. The first approximates the mucous membrane, the second mucosa, submucosa and muscular coats, and the third the serosa. Because the anterior and posterior lines of suture form an angle with the sutures used to close the lesser curvature, and because leakage is
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considered especially likely to occur at this angle, use of omentum to protect the posterior part of the anastomosis in the upper angle is particularly valuable in this method. Billroth I, Schoemaker Modification.-Schoemaker devised a heavy crushing clamp patterned in such a way that when properly placed across the stomach a larger portion of the lesser curvature than of the greater may be removed. The Furniss clamp also may be used for this purpose. The method of suturing behind Schoemaker's clamp (Figs. 490 and
Fig. 5OO.-Billroth i, von Haberer method. Posterior anastomosis has been completed and blood vessels of submucosa and anterior wall of stomach have been ligated. Interrupted sutures are being placed. The first suture is placed in the center in order to approximate as nearly as possible the mucous membrane of the stomach to that of the duodenum.
491) or behind the pin of the Furniss clamp, and of approximating the stomach to the duodenum is not unlike that of the method used by C. H. Mayo and W. J. Mayo. BILLROTH II GASTRIC RESECTION AND MODIFICATIONS
The description of the Billroth II gastric resection was reported and published by von Hacker in 1885, the year in which it was devised. It differs from the Billroth I operation in that the cut ends of the stomach and duodenum are closed and the jejunum is anastomosed to the most dependent portion of the stomach in an antecolic long loop anastomosis. In 1888, von Eiselsberg first employed the modification now widely
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known as the Hofmeister or Finsterer type of Billroth II operation (Fig. 505). Polya's report in 1911 of the modification now bearing his name was more widely recognized than any of previous reports of nearly the same operation. In this modification the cut end of the duodenum is closed and a loop of jejunum is brought up through an opening in the mesocolon to form an end-to-side anastomosis with the cut end of the stomach (Fig. 505). After resection of the stomach for cancer, duodenal or gastric ulcer.
Fig. 50l.-a, Row of sutures approximating the peritoneal coat of the duodenum are nearly completed; separate sutures are started from the opposite sides and meet in the center. The omentum is brought posterior to the anastomosis and up over the upper angle to protect it; b, interrupted sutures approximating peritoneal coats of stomach and duodenum in the anterior part of the anastomosis. Note the omentum protecting the upper and lower parts of the anastomosis.
the most satisfactory method of restoration of gastro-intestinal continuity has been found to be the Polya modification of the Billroth II operation. Numerous different technical procedures have been proposed to accomplish desired ends, and in many instances surgeons personally have developed slight modifications in technic that are of undoubted value. In general, the following method has been found to be satisfactory. Technic of Posterior Polya Modification.-The two layers of peritoneum which descend from the stomach and the commencement of the duodenum enclose the left and right gastro-epiploic vessels near the
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greater curvature of the stomach. The layers of peritoneum pass downward anterior to the colon for a variable distance and then turn backward and upward to the transverse colon which they enclose between the anterior and posterior layers. The continuation of these peritoneal layers after they enclose the colQn until the structure becomes the mesentery of the transverse colon has many anatomically correct names. Usage, however, has limited them to the term "gastrocolic omentum" for that por-
Fig. 502.-Two sutures between the falciform ligament and the anterior wall of the stomach hold the anastomosis to the right of the midline and take tension from the line of anastomosis.
tion which extends between the stomach and the anterior surface of the transverse colon. In order to obtain additional evidence concerning the operability of a neoplasm of the stomach, the lesser peritoneal sac is explored. A small opening is made in the gastrocolic omentum well over to the left, away from the lesion, and as close to the colon as possible. The branches of the gastro-epiploic vessels are doubly clamped and the portions of the vessels between the clamps are cut to enlarge the opening. The mesocolon is carefully brushed away, so that the vessels contained within it
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will not be injured. If, examination within the lesser peritoneal sac reveals an operable lesion, the greater curvature can be mobilized further by continuance of dissection to the region of the pylorus as close as possible to the transverse portion of the colon. This procedure permits inclusion of the inferior gastric lymph nodes and the subpyloric lymph nodes with the portion of the stomach to be resected. The right gastro. epiploic vessels then may be clamped, cut and ligated. At this point in
Fig. 503.-Billroth I, Mayo method. Closure of the lesser curvature.
the procedure after the contained vessels have been ligated, all the remaining hemostats may be removed. A plexus of vessels will be found iH. the region of the pylorus that has not been disturbed. Since these vessels have relatively thin walls, and rather disturbing hemorrhage not infrequently is encountered, they must be ligated and cut with great care close to the duodenal wall. After these vessels are ligated, the lesser curvature of the stomach is mobilized. The superior border of the duodenum may be placed on tension and a small opening may be made through the gastrocolic omentum
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.
close to the duodenal wall. Hemostats are placed across the omentum which includes some of the branches of the gastroduodenal artery. The vessels are then divided between the hemostats and ligated. By these procedures the gastrocolic omentum is divided to just beyond the distal line of resection. A Payr clamp then is placed on the duodenum well below the pylorus (Fig. 506). A rubber-covered Doyen clamp is placed just proximal to the pylorus to prevent drainage of gastric secretion from
Fig. 504.-Billroth I, Mayo method. Approximation of the narrowed circumference of the stomach to the duodenum.
the stomach, but not in such a position as to crush the lesion. After the duodenum is divided close to the distal clamp, the stomach is retracted upward and to the left. The duodenal stump is closed with great care to prevent, if possible, the later development of a duodenal fistula. The suture material is fine chromic catgut. The first row of sutures may be placed over the clamp as shown in Figure 506 in the form of a running mattress suture. By gentle traction on the two ends, the clamp may be removed and the edges of the duodenal stump will be inverted. To invert the stump fur-
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ther, the same suture material may be utilized in the second row of a continuous mattress suture to return to the starting point. Several interrupted mattress sutures of fine silk will give added strength to the closure. The stump of the duodenum then may be buried in the areolar tissue in the region of the head of the pancreas, or available visceral peritoneum from the hepatic flexure of the colon and adjacent omentum may be placed over it in such a manner as to seal off any possible leak from the closed duodenum. At this point it is usually evident that the greater curvature of the stomach has not been mobilized sufficiently. Gentle traction may be
a HoffmeiSte'P
E>itt1"othII
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c Poly a. 1911 Fig. 505.-a, b, and c, The Billroth II operation and some of its modifications.
applied on the gastrocolic omentum to facilitate mobilization. An excellent view then is afforded of the short vessels which extend to the stomach from the left gastro-epiploic vessels themselves. Dissection may be carried as high as desired, even to the point of complete mobilization of the greater curvatures if total gastrectomy should be indicated. Aid in the placing of a clamp on the left gastric artery may be obtained by the exertion of traction straight forward on the stomach. The edge of the stomach may be palpated between the thumb and index finger as shown in Figure 496, and by breaking through the gastrohepatic omentum at a point beyond the line chosen for resection, the left gastric
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artery may be clamped and cut. It is a wise precaution to clamp this vessel doubly in case the ligature should break, and it is also advisable to apply this ligature as a double suture ligature of chromic catgut. The distal portion of the left gastric artery is ligated after the artery is divided with a single ligature and the bared musculature on the lesser curvature of the stomach resulting from the division of the gastrohepatic omentum and the left gastric artery is covered over; two or three
Fig. 506.-Inversion and closure of the duodenal stump; a, the first row of sutures utilizing a running mattress stitch; b, the second row of sutures consists of returning to the starting point with a continuous mattress suture and further inverting the stump; c, interrupted mattress sutures of fine silk form the third row of suture to reinforce the inverted stump.
interrupted sutures are used to approximate the adjacent edges of serosa of the anterior and posterior walls of the stomach. The necessary mobilization of the stomach is now completed and a rubber-covered Doyen forceps may be applied just proximal to the determined line of resection while the stomach is held taut in a forward position. If the stomach is distended with gas or retained contents, it is advisable to insert a trocar through the divided end of tl,le stomach and to remove the contents of the stomach by suction aspiration before the line of resection is planned. Jf a retrocolic type of anastomosis is decided on, an appropriate por-
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tion of the transverse part of the mesocolon should be selected in which to make an opening; this portion should not contain vessels and should be situated well to the left, so that the anastomosis may lie in as nearly a normal anatomic position as possible (Fig. 507). In certain instances attachment of the posterior cut edge of the transverse part of the mesocolon to the stomach will facilitate the operation, but this procedure makes mobilization of the stomach most difficult and under most circumstances it is simpler to attach the cut edge of the opening in the transverse portion of mesocolon to the stomach after anastomosis has been
Fig. 507.-Appropriate avascular region in the transverse mesocolon; the desired line of opening, the ligament of Treitz, and the proximal loop of jejunum prior to being thrust through the transverse mesocolon for the retrocolic anastomosis are shown.
completed (Fig. 508). A loop of jejunum approximately 5 cm. from the ligament of Treitz is selected and is brought through the opening in the transverse mesocolon. A rubber-covered Doyen forceps is placed on the jejunum and the loop of jejunum is placed next to the retracted stomach, so that the two rubber-covered clamps are now adjacent and in such a position that the proximal limb of the jejunum lies next to the lesser curvature of the stomach and the distal limb of jejunum lies next to the greater curvature. It has been found convenient to approximate the proximal limb of the jejunum to the lesser curvautre of the stomach with one interrupted suture of silk and to leave a long end of suture. This suture may be used
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later for retraction and also to diminish the tendency toward distortion of the anastomosis, for it marks a point toward which the first line of suture may be directed. A continuous suture of silk is applied from the junction of the distal loop of jejunum with the greater curvature of the stomach. If possible only the serosal and muscular layers of the wall of the stomach and jejunum are included in these sutures. The suture material is tied and the ends are discarded (Fig. 509, a). The posterior wall of the stomach is incised through the extent of the stoma down to the. gastric mucosa. The jejunum is incised down to the mucosa for a distance equal to that determined as suitable for the length
Fig. 508.~The anastomosis has been brought below the colon through the opening in the transverse mesocolon and anchored there by interrupted sutures of silk, approximating the edges of the opening in the mesocolon to the stomach wall.
of the stoma and the second row of sutures of fine chromic catgut may be inserted as shown in Figure 509, b. This line of suture includes all layers of the wall of the stomach and jejunum, and is doubly locked at the lesser curvature of the stomach. The stomach clamp adjacent to the one on the jejunum then may be opened to determine whether the posterior line of suture has controlled the bleeding. The advantage in having the anterior half of the stomach intact becomes apparent at this point, for the stomach acts as a retractor when the clamp is opened and prevents retraction of the stomach upward. When any bleeding points noted have been ligated, the stomach may be cut off (Fig. 509, c). The second row of sutures posteriorly may now be continued an-
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teriorly as a locking suture on the side which is next to the stomach (Fig. 510, a and b). All coats, but only a thin edge of mucous membrane are included in the sutures. The mucous membrane then will project slightly through the anastomosis and when the clamp on the stomach is removed bleeding points may be seen. A continuous mattress suture of silk or fine chromic catgut may be applied as a second row of sutures anteriorly (Fig. 511) to invert the pro-
Fig. 509.-The posterior line of sutures in the anastomosis; a, clamps in place on the stomach and jejunum; the proximal loop of jejunum and the lesser curvature of the stomach are approximated; the first row of sutures is continuous and of silk; a guide suture has been placed between the proximal loop of jejunum and stomach for traction; b, the second row of sutures includes all layers of stomach and jejunum and is of fine chromic catgut; the anterior wall of the stomach has not been sectioned; c, the clamp on stomach has been opened and the bleeding points on the posterior suture line have been ligated; the clamp now has been closed and the stomach is being cut off.
truding edge of mucous membrane. Multiple interrupted mattress sutures of silk may be inserted to reinforce the entire line of suture throughout the Gircumference of the anastomosis. The next step in the operation is the anchoring of the anastomosis below the opening in the transverse portion of the mesocolon. In order to accomplish this the colon may be retracted upward and multiple interrupted sutures of silk may be inserted so that the stomach projects approximately 2 cm. below this opening (Fig. 508). The remaining por-
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tion of stomach should be in as nearly a normal position as possible in order to diminish the possibility of angulation of the jejunum at the site of the anastomosis or immediately distal to it. If the posterior edge of the ransverse mesocolon has been sutured to the stomach prior to the anastomosis, the anastomosis may be pushed through the opening in the transverse mesocolon from above and the anterior edge of the transverse mesocolon may be sutured to the stomach above the site of the anastomOSIS.
Fig. 51O.-The anterior line of sutures; a, the second row of sutures in the posterior line is continued anteriorly; the sutures are locked on the stomach side and all coats are included; b, this row of sutures is completed; the clamps will be removed to view bleeding points from the anterior portion of the suture line.
Technic of the Anterior Polya Operation.-The anterior Polya operation is performed in approximately the same manner as the posterior Polya. The jejunum, however, is brought up anterior to the colon and is anastomosed to the stomach approximately 12 to 16 cm. from the ligament of Treitz; the distance depends on the indications for the procedure. This type of anastomosis is indicated particularly when resection is unusually high or when the transverse mesocolon is short and contains much fat. Hofmeister Modification of the Polya Operation.-In certain instances it may be advisable to use the Hofmeister method. The anterior or posterior Polya anastomosis, however, will furnish the Same mechanicaJ
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advantages of the Hofmeister procedure if the opening in the jejunum is made somewhat smaller than the diameter of the cut end of the stomach and if the anastomosis is so made that the cut end of the stomach "funnels" down to the smaller opening in the jejunum. Added advantages of this procedure over the Hofmeister'method lie in the saving of time and
Fig, 51L-a, The second row of sutures anteriorly is of the continuous mattress type and serves to invert the protruding mucous membrane; b, starting posteriorly at the lesser curvature the entire suture line is reinforced with interrupted mattress sutures of silk.
in the abolition of the angle between the Jejunum and the partially closed end of the stomach where leakage may occur. The Hofmeister modification of the Polya operation, when it is used, is carried out in exactly the same manner as the posterior or anterior Polya operation with the exception that a greater part of the stomach at
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right angles to the lesser curvature of the stomach is removed. By this means the circumference of the opening in the stomach which is to be anastomosed to the jejunum is reduced and a valve is formed. The procedure is a valuable way of removing gastric ulcers located high on the lesser curvature of the stomach. More of the lesser curvature of the stomach is removed in the Hofmeister modification of the Polya operation in the same manner as the lesser curvature is removed in the Mayo
Posterior Polya. (Hofmeister) Fig. 512.-Hofmeister modification of the Polya operation showing the excision of a portion of the lesser curvature of the stomach.
modification of the Billroth I operation, (Fig. 492). The finished procedure is shown in Figure 512. REFERENCE 1. Walters, W. W., Gray, H. K. and Priestley, J. T.: Carcinoma and other Malignant Lesions of the Stomach. Philadelphia, W. B. Saunders Co., 1942.
Pean first perfonned an operation in which he sutured the end of the stomach to the duodenum and decreased the circumference of the stomach by sutures placed in the vicinity of the lesser curvature. As his patient failed to recover, the fact that he first employed this procedure frequently is lost sight of. Billroth later employed this type of operation in his first successful partial gastrectomy and thereafter the operation has borne his name. In view of the fact that Billroth, a few years later in 1885, abandoned this type of anastomosis for an indirect one of stomach to jejunum which had been called the "Billroth II," it might be well to call the "Billroth I" the "Pean-Billroth operation." The reason Billroth gave for his change to using an indirect type of an:}stomosis from using a direct one was that only one of three patients on whom the PeanBillroth procedure was perfonned recovered from the operation. This failure to recover apparently was due to leakage at the upper part of the anastomosis where the three suture lines of the anastomosis come together. Of the various modifications of the Pean-Billroth method of direct anastomosis that of von Haberer appears to be the most satisfactory, owing to the fact that the entire circumference of the stomach is sutured to the circumference of the duodenum. In his modification the larger circumference of the stomach is decreased by interrupted sutures placed in the mucous membrane and muscularis mucosae of the gastric wall; these sutures also serve as ligatures of the larger blood vessels of the gastric submucosa. In the first technic of the Billroth I operation the duodenum was sutured to the stomach along the lesser curvature. There seems to have been some difficulty with this procedure and there was fear of causing a diverticulum or cul-de-sac of the fundus of the stomach which appeared to be a distinct disadvantage. In later cases, "Professor Billroth, would, whenever possible, insert the duodenum into the greater curvature." Several modifications were instituted to remove portions of the lesser curvature of the stomach to prevent the fonnation of the diverticulum. Among these was that of Schoemaker of The Hague (Figs. 490 and 491) and Charles H. Mayo and William J. Mayo (Fig. 492). The modifications of the Pean-Billroth most frequently used at the Mayo Clinic have been Schoemaker's, the Mayos' and von Haberer's.l Technic of the Billroth I Operation and Its Modifications.-In all From the Division of Surgery, Mayo Clinic, Rochester, Minnesota. * Professor of Surgery, Mayo Foundation, Graduate School of Medicine, University of Minnesota. 1361
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'YALTl\fAN WALTERS
types of partial gastrectomy, the division and ligation of the branches of the gastric artery in the gastrohepatic omentum and the ligation of the branches of the gastroduodenal artery are similar. The assistant places tension on the gastroduodenal junction by grasping the anterior wall of the stomach and pulling toward the left side of the patient. At that time the surgeon inserts the index and middle fingers of the left hand through the gastrohepatic omentum to the posterior wall of the
Fig. 490.-Schoemaker modification of Billroth I operation. Gastric vessels have been ligated high in the gastrohepatic omentum. The portion of the gastrohepatic omentum to be removed with the tumor and the pattern of stomach to be removed are shown.
stomach and duodenum with the thumb anterior to them. The upper margin of the duodenum is wiped carefully and forceps may then be introduced between the omentum and the duodenum to permit their separation, division and ligation. By extending the index and middle fingers toward the midline posterior to the duodenum and the thumb anterior, the attachment of the gastrocolic omentum to the duodenum can be well defined and forceps may be placed on the blood vessels (branches of the right gastro-~p.iploic) running through it. In cases of duodenal or gastric ulcer, the gastrocolic omentum can be disconnected
MODERN TECHNICS IN GASTRIC SURGERY
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from its attachment to the greater curvature of the stomach by repeated clamping and cutting. The line of dissection is close to the greater curvature until the left gastro-epiploic artery is encountered (Fig. 493). In cases of neoplasm of the stomach the gastrocolic omentum can be disconnected from the attachment to the transverse colon after ligation of the right'gastro-epiploic vessels below the pylorus and the gastrocolic
Fig. 491.-Schoemaker clamp placed across stomach. Payr clamp placed across duodenum. The portion of the stomach containing the tumor is being excised with the cautery.
omentum can be dissected with the scalpel from the transverse colon with little bleeding (Fig. 494). A curved hemostat of sufficient gripping power to hold the cut edges of the duodenum without slipping is placed across the duodenum well below the pylorus in cases of neoplasm of the stomach or gastric ulcer (Fig. 495). In cases of duodenal ulcer this hemostat may be placed immediately distal to the duodenal ulcer or across it so that only a small
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WALTMAN WALTERS
portion of the ulcer will be removed. In cases of duodenal ulcer in which the ulcer is rather far from the pylorus, an open closure of the duodenum without use of the hemostat will often have to be carried out. A second hemostat is placed above the first one. The duodenum is transected between the clamps. The stomach is reflected upward and toward the midline, where it is held by the assistant. The gastrohepatic omentum is wiped from the lesser curvature of the stomach at the point where the left gastric artery is to be divided and ligated (Fig. 496). Three Kocher forceps are passed through the avascular portion of the gastro-
Fig. 492.-Billroth I, Mayo method. Curved hemostats placed across the stomach and duodenum so that a large portion of the lesser curvature can be removed. Inset shows method of making anastomosis.
hepatic omentum and applied across the artery and omentum which are divided distal to the two proximal forceps. The branches of the gastric artery in the gastrohepatic omentum are ligated doubly; the first ligature is a suture ligature. The distal portion of the left gastric artery is ligated with a single suture. The region on the lesser curvature denuded of serosa as a result of the separation of the gastrohepatic omentum from it and the ligation of the left gastric artery is closed with two or three interrupted sutures which approximate the serosa of the anterior and the posterior walls of the stomach. A suction pump is introduced into the stomach and any retained gastric secretions or gas is removed (Fig. 497) In cases of duodenal or gastric ulcer from two thirds to three fourths
.,
MODERN TECHNICS IN GASTRIC SURGERY
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of the stomach is removed whereas in the presence of neoplasms of the stomach it is well to remove as much stomach above the tumor as possible and as is consistent with good postoperative gastro-intestinal function and motility. When the secretion and gas are removed from the interior of the stomach, the circumference of the stomach decreases surprisingly. This is important, since, in the Billroth-von Haberer
Fig. 493.-Billroth I operation. An opening has been made in the gastrocolic omentum as close to the colon as possible in order that the lesser peritoneal sac may be explored. Hemostat is shown in place on a branch of the gastro-epiploic vessels.
method, the entire circumference of the stomach is approximated to the circumference of the duodenum and any method of reducing the circumference of the stomach is worth while. Two rows of interrupted sutures are employed to approximate the greater and lesser curvatures of the stomach to the inferior and superior margins of the duodenum and a row of continuous or interrupted sutures are placed to approximate the serosal layers of the posterior wall of the stomach to the duodenum. These sutures include larger amounts of gastric serosa than of duodenal serosa. This procedure likewise tends to reduce the circumference of the
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WALTMAN WALTERS
stomach. Since the stomach has been emptied of its contents, it is unnecessary to place' a clamp of any sort across it. In fact, the use of such a clamp not only reduces the amount of stomach that can be removed in some cases, but in addition, so flattens the wall of the stomach that it increases considerably in circumference. After the serosal sutures are placed posteriorly, an incision which extends to the mucous membrane is made in the posterior wall of the stomach (Fig. 498). Interrupted sutures which serve as ligatures of the
Fig. 494.-Billroth I, von Haberer technic. Gastrocolic omentum containing lymph nodes is separated from the colon. Inset shows the amount of stomach and gastrocolic and gastrohepatic omentum to be removed.
branches of the gastric blood vessels, and to reef the mucous membrane and thus decrease the circumference of the stomach, are placed adjacent to each other in the mucous membrane of the posterior wall of the stomach. The mucous membrane of the stomach is incised and the curved hemostat on the duodenum is removed. The clamped crushed tissue on the duodenum is then trimmed off. Any bleeding vessels in the submucosa of the stomach are grasped and ligated. A second row of chromic catgut sutures is used to approximate the mucosa, submucosa, and
MODERN 'rECHNICS IN GASTRIC SURGERY
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muscularis mucosae of the stomach to the duodenum. Cutting across the anterior wall of the stomach enables removal of the segment of stomach containing the tumor or gastric ulcer. If an incision is made through the mucous membrane of the anterior wall of the stomach first, the surgeon is able to pick up the blood vessels of the submucosa with hemostats and ligate them (Fig. 499). The segment of stomach containing the lesion is removed. A point in the midportion of the mucous membrane of the anterior wall of the stomach is approximated to the midportion of the mucous membrane
Fig. 495.-Billroth I, von. Haberer method. Curved hemostats are in place across the duodenum.
and submucosa of the anterior wall of the duodenum (Fig. 500). Traction of considerable degree is placed on the two sutures at the angles of the anastomosis in Qrder to stretch the size of the duodenum to conform more nearly to the size of the stomach. The circumference of the cut end of the duodenum can be enlarged by a small incision down the anterior wall of the duodenum at right angles to the line of suture. Further interrupted sutures are placed in the mucous membrane of the stomach and the duodenum. Each suture is placed to bisect the space between two others previously placed. Another row of sutures approximates the mucosa, submucosa and muscularis mucosae of the stomach to that of the duodenum. It is frequently advisable to start th~~12 ~utures at eac4
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WAL'l'ERS
angle of the anastomosis, having them meet in the midline. This assists in the more accurate approximation of the structures. The serosal layers of the stomach and the duodenum are approximated with a third row of sutures. These are usually of silk and placed interruptedly. The upper angle of the anastomosis where it is sutured to the stomach
Fig. 496.-To ligate the left gastric artery, the vessel and right edge of stomach are palpated between the thumb and index finger and an opening is made as close to the stomach as possible. The duodenal stump has been buried in areolar tissue and fat and has been turned into the head of the pancreas. Inset, three clamps have been applied to the vessel and it will be ligated with double chromic catgut and a "sticktie."
and the duodenum with interrupted sutures is covered with a portion of gastrocolic omentum which is brought up posterior to the line of anastomosis. There is usually enough gastrocolic omentum lateral to the point of its removal for this purpose. A similar tag of omentum is used to protect the lower angle where it is maintained in position by sutures (Fig.
r!
MODERN TECHNICS IN GASTRIC SURGERY
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501). The placement of omentum in this fashion safeguards against leakage at the angles as well as on the posterior wall. If possible, the gastrohepatic omentum at the points where the gastric vessels have been ligated should be brought down and sutured to the ligated duodenal portion of the omentum. This procedure helps to relieve tension on the anastomosis. One or two interrupted sutures should be placed between the anterior wall of the stomach and the falciform ligament. They will hold the anastomosis to the right of the midline and will assist in taking
Fig. 497.-Billroth I, von Haberer method. The cut end of stomach has been reflected, exposing the branches of the gastric artery and vein and the gastrohepatic omentum. Hemostats have been placed and the vessels are about to be divided. A suction pump has been introduced into the lumen of the stomach. and is emptying it of gastric se9retion and gas.
tension from the line of anastomosis (Fig. 502). If duodenal or gastric secretion has produced any soiling, from 1 pint to 1 quart (0.5 to 1 liter) of sterile water is poured slowly over the tissues and is removed with the suction pump. In this manner any gastric or duodenal secretion present is diluted and then is removed. Billroth I, Mayo Modification.-Mter the gastric vessels are divided and ligated and the duodenum is divided above the curved hemostat across it, as described previously, a curved hemostat is placed transversely across the stomach at the greater curvature at the point where it
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WALTMAN WALTERS
is to be resected. A second clamp is placed across the stomach below the first clamp so that there will be no soiling, and the gastric wall between is incised. Two additional curved hemostats then are placed across the stomach almost at right angles to the first hemostat. A segment of lesser curvature is included in these clamps (Fig. 492), and an incision is
Fig. 498.-Billroth I, von Haberer technic. The first continuous row of silk sutures has been applied to approximate the peritoneal coats of the posterior wall of the duodenum and stomach. Incision has been made in the peritoneal and muscular coats of the stomach down to the mucous membrane and interrupted sutures of silk have been used to reef the gastric mucosa, decreasing its circumference. Sutures have been placed in the superior and inferior margins of the anastomosis; these make possible the stretching of the duodenum so that its diameter nearly conforms to that of the stomach.
made between them. A continuous suture of chromic catgut is placed back of the curved hemostat on the lesser curvature which not only approximates the wall of the stomach, but also serves as a hemostatic suture. The curved hemostat on the lesser curvature then is removed. A second row of sutures continuously placed, using silk, inverts the first row by approximating the serosal layer of stomach (Fig. 503). The curved hemostat on the inferior portion of the stomach then is approximated to the curved hemostat across the duodenum. A continuous row of silk
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sutures approximates the posterior wall of the serosa of the stomach and the duodenum. When this approximation has been completed, an incision is made through the serosa and muscularis mucosae down to the mucouS membrane of both structures and the cut edges of each are approximated. Clamps then are removed, a suction pump is introduced into the lumina of the stomach and of the duodenum and the mucous
Fig. 499.-Billroth I, von Haberer method. The posterior sutures have been inserted. Incision has been made through the mucous membrane and muscularis mucosae of the anterior wall of the stomach. These make it possible to ligate the branches of the gastric vessels of the submucosa and anterior wall of the stomach and also to reef the mucous membrane, thus decreasing the size of the gastric lumen of the anastomosis.
membranes of the stomach and the duodenum are approximated with a third row of sutures of chromic catgut (Fig. 504). The anterior part of the anastomosis is completed in similar fashion with three rows of sutures. The first approximates the mucous membrane, the second mucosa, submucosa and muscular coats, and the third the serosa. Because the anterior and posterior lines of suture form an angle with the sutures used to close the lesser curvature, and because leakage is
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WALTMAN WALTERS
considered especially likely to occur at this angle, use of omentum to protect the posterior part of the anastomosis in the upper angle is particularly valuable in this method. Billroth I, Schoemaker Modification.-Schoemaker devised a heavy crushing clamp patterned in such a way that when properly placed across the stomach a larger portion of the lesser curvature than of the greater may be removed. The Furniss clamp also may be used for this purpose. The method of suturing behind Schoemaker's clamp (Figs. 490 and
Fig. 5OO.-Billroth i, von Haberer method. Posterior anastomosis has been completed and blood vessels of submucosa and anterior wall of stomach have been ligated. Interrupted sutures are being placed. The first suture is placed in the center in order to approximate as nearly as possible the mucous membrane of the stomach to that of the duodenum.
491) or behind the pin of the Furniss clamp, and of approximating the stomach to the duodenum is not unlike that of the method used by C. H. Mayo and W. J. Mayo. BILLROTH II GASTRIC RESECTION AND MODIFICATIONS
The description of the Billroth II gastric resection was reported and published by von Hacker in 1885, the year in which it was devised. It differs from the Billroth I operation in that the cut ends of the stomach and duodenum are closed and the jejunum is anastomosed to the most dependent portion of the stomach in an antecolic long loop anastomosis. In 1888, von Eiselsberg first employed the modification now widely
MODERN TECHNICS IN GASTRIC SURGERY
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known as the Hofmeister or Finsterer type of Billroth II operation (Fig. 505). Polya's report in 1911 of the modification now bearing his name was more widely recognized than any of previous reports of nearly the same operation. In this modification the cut end of the duodenum is closed and a loop of jejunum is brought up through an opening in the mesocolon to form an end-to-side anastomosis with the cut end of the stomach (Fig. 505). After resection of the stomach for cancer, duodenal or gastric ulcer.
Fig. 50l.-a, Row of sutures approximating the peritoneal coat of the duodenum are nearly completed; separate sutures are started from the opposite sides and meet in the center. The omentum is brought posterior to the anastomosis and up over the upper angle to protect it; b, interrupted sutures approximating peritoneal coats of stomach and duodenum in the anterior part of the anastomosis. Note the omentum protecting the upper and lower parts of the anastomosis.
the most satisfactory method of restoration of gastro-intestinal continuity has been found to be the Polya modification of the Billroth II operation. Numerous different technical procedures have been proposed to accomplish desired ends, and in many instances surgeons personally have developed slight modifications in technic that are of undoubted value. In general, the following method has been found to be satisfactory. Technic of Posterior Polya Modification.-The two layers of peritoneum which descend from the stomach and the commencement of the duodenum enclose the left and right gastro-epiploic vessels near the
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WALTMAN WALTERS
greater curvature of the stomach. The layers of peritoneum pass downward anterior to the colon for a variable distance and then turn backward and upward to the transverse colon which they enclose between the anterior and posterior layers. The continuation of these peritoneal layers after they enclose the colQn until the structure becomes the mesentery of the transverse colon has many anatomically correct names. Usage, however, has limited them to the term "gastrocolic omentum" for that por-
Fig. 502.-Two sutures between the falciform ligament and the anterior wall of the stomach hold the anastomosis to the right of the midline and take tension from the line of anastomosis.
tion which extends between the stomach and the anterior surface of the transverse colon. In order to obtain additional evidence concerning the operability of a neoplasm of the stomach, the lesser peritoneal sac is explored. A small opening is made in the gastrocolic omentum well over to the left, away from the lesion, and as close to the colon as possible. The branches of the gastro-epiploic vessels are doubly clamped and the portions of the vessels between the clamps are cut to enlarge the opening. The mesocolon is carefully brushed away, so that the vessels contained within it
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will not be injured. If, examination within the lesser peritoneal sac reveals an operable lesion, the greater curvature can be mobilized further by continuance of dissection to the region of the pylorus as close as possible to the transverse portion of the colon. This procedure permits inclusion of the inferior gastric lymph nodes and the subpyloric lymph nodes with the portion of the stomach to be resected. The right gastro. epiploic vessels then may be clamped, cut and ligated. At this point in
Fig. 503.-Billroth I, Mayo method. Closure of the lesser curvature.
the procedure after the contained vessels have been ligated, all the remaining hemostats may be removed. A plexus of vessels will be found iH. the region of the pylorus that has not been disturbed. Since these vessels have relatively thin walls, and rather disturbing hemorrhage not infrequently is encountered, they must be ligated and cut with great care close to the duodenal wall. After these vessels are ligated, the lesser curvature of the stomach is mobilized. The superior border of the duodenum may be placed on tension and a small opening may be made through the gastrocolic omentum
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WALTMAN WALTERS
.
close to the duodenal wall. Hemostats are placed across the omentum which includes some of the branches of the gastroduodenal artery. The vessels are then divided between the hemostats and ligated. By these procedures the gastrocolic omentum is divided to just beyond the distal line of resection. A Payr clamp then is placed on the duodenum well below the pylorus (Fig. 506). A rubber-covered Doyen clamp is placed just proximal to the pylorus to prevent drainage of gastric secretion from
Fig. 504.-Billroth I, Mayo method. Approximation of the narrowed circumference of the stomach to the duodenum.
the stomach, but not in such a position as to crush the lesion. After the duodenum is divided close to the distal clamp, the stomach is retracted upward and to the left. The duodenal stump is closed with great care to prevent, if possible, the later development of a duodenal fistula. The suture material is fine chromic catgut. The first row of sutures may be placed over the clamp as shown in Figure 506 in the form of a running mattress suture. By gentle traction on the two ends, the clamp may be removed and the edges of the duodenal stump will be inverted. To invert the stump fur-
MODERN TECHNICS IN GASTRIC SURGERY
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ther, the same suture material may be utilized in the second row of a continuous mattress suture to return to the starting point. Several interrupted mattress sutures of fine silk will give added strength to the closure. The stump of the duodenum then may be buried in the areolar tissue in the region of the head of the pancreas, or available visceral peritoneum from the hepatic flexure of the colon and adjacent omentum may be placed over it in such a manner as to seal off any possible leak from the closed duodenum. At this point it is usually evident that the greater curvature of the stomach has not been mobilized sufficiently. Gentle traction may be
a HoffmeiSte'P
E>itt1"othII
1588
1885
c Poly a. 1911 Fig. 505.-a, b, and c, The Billroth II operation and some of its modifications.
applied on the gastrocolic omentum to facilitate mobilization. An excellent view then is afforded of the short vessels which extend to the stomach from the left gastro-epiploic vessels themselves. Dissection may be carried as high as desired, even to the point of complete mobilization of the greater curvatures if total gastrectomy should be indicated. Aid in the placing of a clamp on the left gastric artery may be obtained by the exertion of traction straight forward on the stomach. The edge of the stomach may be palpated between the thumb and index finger as shown in Figure 496, and by breaking through the gastrohepatic omentum at a point beyond the line chosen for resection, the left gastric
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artery may be clamped and cut. It is a wise precaution to clamp this vessel doubly in case the ligature should break, and it is also advisable to apply this ligature as a double suture ligature of chromic catgut. The distal portion of the left gastric artery is ligated after the artery is divided with a single ligature and the bared musculature on the lesser curvature of the stomach resulting from the division of the gastrohepatic omentum and the left gastric artery is covered over; two or three
Fig. 506.-Inversion and closure of the duodenal stump; a, the first row of sutures utilizing a running mattress stitch; b, the second row of sutures consists of returning to the starting point with a continuous mattress suture and further inverting the stump; c, interrupted mattress sutures of fine silk form the third row of suture to reinforce the inverted stump.
interrupted sutures are used to approximate the adjacent edges of serosa of the anterior and posterior walls of the stomach. The necessary mobilization of the stomach is now completed and a rubber-covered Doyen forceps may be applied just proximal to the determined line of resection while the stomach is held taut in a forward position. If the stomach is distended with gas or retained contents, it is advisable to insert a trocar through the divided end of tl,le stomach and to remove the contents of the stomach by suction aspiration before the line of resection is planned. Jf a retrocolic type of anastomosis is decided on, an appropriate por-
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tion of the transverse part of the mesocolon should be selected in which to make an opening; this portion should not contain vessels and should be situated well to the left, so that the anastomosis may lie in as nearly a normal anatomic position as possible (Fig. 507). In certain instances attachment of the posterior cut edge of the transverse part of the mesocolon to the stomach will facilitate the operation, but this procedure makes mobilization of the stomach most difficult and under most circumstances it is simpler to attach the cut edge of the opening in the transverse portion of mesocolon to the stomach after anastomosis has been
Fig. 507.-Appropriate avascular region in the transverse mesocolon; the desired line of opening, the ligament of Treitz, and the proximal loop of jejunum prior to being thrust through the transverse mesocolon for the retrocolic anastomosis are shown.
completed (Fig. 508). A loop of jejunum approximately 5 cm. from the ligament of Treitz is selected and is brought through the opening in the transverse mesocolon. A rubber-covered Doyen forceps is placed on the jejunum and the loop of jejunum is placed next to the retracted stomach, so that the two rubber-covered clamps are now adjacent and in such a position that the proximal limb of the jejunum lies next to the lesser curvature of the stomach and the distal limb of jejunum lies next to the greater curvature. It has been found convenient to approximate the proximal limb of the jejunum to the lesser curvautre of the stomach with one interrupted suture of silk and to leave a long end of suture. This suture may be used
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WALTMAN WALTERS
later for retraction and also to diminish the tendency toward distortion of the anastomosis, for it marks a point toward which the first line of suture may be directed. A continuous suture of silk is applied from the junction of the distal loop of jejunum with the greater curvature of the stomach. If possible only the serosal and muscular layers of the wall of the stomach and jejunum are included in these sutures. The suture material is tied and the ends are discarded (Fig. 509, a). The posterior wall of the stomach is incised through the extent of the stoma down to the. gastric mucosa. The jejunum is incised down to the mucosa for a distance equal to that determined as suitable for the length
Fig. 508.~The anastomosis has been brought below the colon through the opening in the transverse mesocolon and anchored there by interrupted sutures of silk, approximating the edges of the opening in the mesocolon to the stomach wall.
of the stoma and the second row of sutures of fine chromic catgut may be inserted as shown in Figure 509, b. This line of suture includes all layers of the wall of the stomach and jejunum, and is doubly locked at the lesser curvature of the stomach. The stomach clamp adjacent to the one on the jejunum then may be opened to determine whether the posterior line of suture has controlled the bleeding. The advantage in having the anterior half of the stomach intact becomes apparent at this point, for the stomach acts as a retractor when the clamp is opened and prevents retraction of the stomach upward. When any bleeding points noted have been ligated, the stomach may be cut off (Fig. 509, c). The second row of sutures posteriorly may now be continued an-
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teriorly as a locking suture on the side which is next to the stomach (Fig. 510, a and b). All coats, but only a thin edge of mucous membrane are included in the sutures. The mucous membrane then will project slightly through the anastomosis and when the clamp on the stomach is removed bleeding points may be seen. A continuous mattress suture of silk or fine chromic catgut may be applied as a second row of sutures anteriorly (Fig. 511) to invert the pro-
Fig. 509.-The posterior line of sutures in the anastomosis; a, clamps in place on the stomach and jejunum; the proximal loop of jejunum and the lesser curvature of the stomach are approximated; the first row of sutures is continuous and of silk; a guide suture has been placed between the proximal loop of jejunum and stomach for traction; b, the second row of sutures includes all layers of stomach and jejunum and is of fine chromic catgut; the anterior wall of the stomach has not been sectioned; c, the clamp on stomach has been opened and the bleeding points on the posterior suture line have been ligated; the clamp now has been closed and the stomach is being cut off.
truding edge of mucous membrane. Multiple interrupted mattress sutures of silk may be inserted to reinforce the entire line of suture throughout the Gircumference of the anastomosis. The next step in the operation is the anchoring of the anastomosis below the opening in the transverse portion of the mesocolon. In order to accomplish this the colon may be retracted upward and multiple interrupted sutures of silk may be inserted so that the stomach projects approximately 2 cm. below this opening (Fig. 508). The remaining por-
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tion of stomach should be in as nearly a normal position as possible in order to diminish the possibility of angulation of the jejunum at the site of the anastomosis or immediately distal to it. If the posterior edge of the ransverse mesocolon has been sutured to the stomach prior to the anastomosis, the anastomosis may be pushed through the opening in the transverse mesocolon from above and the anterior edge of the transverse mesocolon may be sutured to the stomach above the site of the anastomOSIS.
Fig. 51O.-The anterior line of sutures; a, the second row of sutures in the posterior line is continued anteriorly; the sutures are locked on the stomach side and all coats are included; b, this row of sutures is completed; the clamps will be removed to view bleeding points from the anterior portion of the suture line.
Technic of the Anterior Polya Operation.-The anterior Polya operation is performed in approximately the same manner as the posterior Polya. The jejunum, however, is brought up anterior to the colon and is anastomosed to the stomach approximately 12 to 16 cm. from the ligament of Treitz; the distance depends on the indications for the procedure. This type of anastomosis is indicated particularly when resection is unusually high or when the transverse mesocolon is short and contains much fat. Hofmeister Modification of the Polya Operation.-In certain instances it may be advisable to use the Hofmeister method. The anterior or posterior Polya anastomosis, however, will furnish the Same mechanicaJ
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advantages of the Hofmeister procedure if the opening in the jejunum is made somewhat smaller than the diameter of the cut end of the stomach and if the anastomosis is so made that the cut end of the stomach "funnels" down to the smaller opening in the jejunum. Added advantages of this procedure over the Hofmeister'method lie in the saving of time and
Fig, 51L-a, The second row of sutures anteriorly is of the continuous mattress type and serves to invert the protruding mucous membrane; b, starting posteriorly at the lesser curvature the entire suture line is reinforced with interrupted mattress sutures of silk.
in the abolition of the angle between the Jejunum and the partially closed end of the stomach where leakage may occur. The Hofmeister modification of the Polya operation, when it is used, is carried out in exactly the same manner as the posterior or anterior Polya operation with the exception that a greater part of the stomach at
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right angles to the lesser curvature of the stomach is removed. By this means the circumference of the opening in the stomach which is to be anastomosed to the jejunum is reduced and a valve is formed. The procedure is a valuable way of removing gastric ulcers located high on the lesser curvature of the stomach. More of the lesser curvature of the stomach is removed in the Hofmeister modification of the Polya operation in the same manner as the lesser curvature is removed in the Mayo
Posterior Polya. (Hofmeister) Fig. 512.-Hofmeister modification of the Polya operation showing the excision of a portion of the lesser curvature of the stomach.
modification of the Billroth I operation, (Fig. 492). The finished procedure is shown in Figure 512. REFERENCE 1. Walters, W. W., Gray, H. K. and Priestley, J. T.: Carcinoma and other Malignant Lesions of the Stomach. Philadelphia, W. B. Saunders Co., 1942.