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Partial Gastrectomy for Peptic Ulcer: Operative Technique
Partial Gastrectomy for Peptic Ulcer: Operative Technique SAMUEL F. MARSHALL
technical procedures for the surgical treatment of peptic ulcer have been suggested and employed over the past few years but in our experience partial gastrectomy for the treatment of duodenal, gastric and jejunal ulcer has remained the most satisfactory operation for the complicated peptic ulcer. This operation can be performed readily with low mortality, with extremely few postoperative complications and with extremely satisfactory results for patients with longstanding ulcer distress. Operative mortality in the hands of surgeons trained in gastric surgery for severe complicated ulcer has remained less than 3 per cent and the occurrence of recurrent ulcer has remained consistently low. The most common operation other than gastric resection for peptic ulcer has been vagotomy combined with gastroenterostomy. We have done only 26 such operations in the last five years and we have employed vagotomy procedures with decreasing frequency. Mo:r.8];ecently, limited resections with vagotomy have been employed and reported in the literature. Gastric resection with restoration of gastrointestinal continuity by a Billroth I anastomosis has also been utilized more recently by many surgeons. All of these modifications of the conventional resection have the characteristics of a limited gastric resection in many cases as compared to a more radical partial resection (70 per cent of the stomach) and in many instances fail to produce a relative achlorhydria which the surgeon strives to obtain with the conventional high gastric resection. This is true of the Billroth I type of procedure as well since this type of anastomosis may be most difficult to accomplish in the presence of a badly scarred, adherent penetrating duodenal ulcer which is accompanied by shortening as well as fixation of the duodenum. Such fixation and shortening do not permit an anastomosis of a divided duodenum to the gastric remnant without some tension. The surgeon, therefore, is tempted to limit the radicalness of his resection when such severe ulcers exist (in general only these should come to surgery) and by standards based on VARIOUS
661
Samuel F. Marshall
662
surgical experience with peptic ulcer, .such an operation results in insufficiently radical resection of the stomach, and predisposes to recurrent ulcer since a relative achlorhydria cannot be obtained from such a limited resection. It is well to point out that none of these patients with limited modifications of gastric resection have been observed for a long enough period following operation to draw conclusions as to the frequency of recurrent ulcer. Such observations must cover a number of years before any conclusion as to the effectiveness of such limited resections can be reached. Radical partial gastrectomy has withstood the test of time and in our hands has proved to be the most satisfactory and effective method of Table 1 PARTIAL GASTRIC RESECTION FOR PEPTIC ULCER
January 1, 1937 to December 1, 1955 NO. OF PATIENTS
OPERATIVE NUMBER
MORTALITY Per Cent
Duodenal ulcer ............ . 1622 39 Gastric ulcer .............. . 468 13 Jejunal ulcer .............. . 256 6 Gastrojejunocolic fistula .... . 3 42 Total. ......... . 2388 61 Five year period 1951 to December 1, 1955: Vagotomy with posterior gastroenterostomy-26 cases Partial resection for duodenal ulcer-614 cases
2.4 2.8 2.3 7.1 2.55
surgical treatment. With an occasional exception, the patient is well satisfied with the results of the operation and is able to take a diet which is not only adequate for nutrition but also altered only slightly from a regular unrestricted diet. Over the past 19 years (1937 through 1955) the surgical group of the Lahey Clinic has done 2388 partial resections for peptic ulcer of all types (Table 1) with an over-all mortality of 2.55 per cent. The method of partial gastric resection is given below. TECHNIQUE
In general, the method for partial gastric resection for ulcer is similar to that for cancer, with the following exceptions. A more radical removal of the gastric wall is performed for cancer and the procedure includes removal of the duodenum almost to the ampulla of Vater, removal of the omentum and spleen, and very careful dissection of all regional nodes. Such radical resection is not necessary for the surgical treatment of nonmalignant peptic ulcer. In an individual with a heavy omentum, how-
Partial Gastrectomy for Peptic Ulcer
663
ever, resection for ulcer can be facilitated by the excision of the gastrocolic omentum. A left transrectus incision extending from the left costal margin caudalward to the level of the umbilicus permits ready mobilization of the pylorus and duodenum, since the pylorus is normally situated just to the right of the midline. At the same time a: left rectus incision allows approach to the upper half of the stomach for adequate gastric resection and also permits easy gastrojejunal anastomosis. If the patient is obese, it may be more difficult to mobilize an adherent penetrating duodenal ulcer because of the difficulty of exposing the duodenum in obese individuals. In such cases, the incision may be made through the right rectus muscle, with the upper end of the incision extended obliquely
Fig. 194. T tube inserted into exposed common bile duct with long arm of the tube passed into duodenum. An adherent low-lying duodenal ulcer can be dissected readily because the location of the duct can be easily palpated.
upward and to the left costal margin, dividing the ligamentum teres of the liver-a hockey stick type of incision which will facilitate exposure not only of the duodenum but also of the upper part of the stomach. Careful exploration of the abdominal contents should be carried out after the abdominal cavity has been opened. When the operation is for a duodenal ulcer the entire stomach is visualized and palpated to exclude the possibility of a gastric lesion which commonly occurs coincidental to a duodenal ulcer. If the surgical procedure is for a gastric ulcer the duodenum is likewise carefully checked before the stomach is mobilized. The common bile duct should always be exposed before proceeding with resection for an indurated adherent duodenal ulcer, as the operator must visualize the relationship of the bile duct and ampulla of Vater to the adherent ulcer in order to avoid injury to the common bile duct (Fig. 194). If the ulcer is supra-ampullary or arises in the second part of the duodenum quite close to the ampulla, and much scarring is present,
664
Samuel F. Marshall
dissection and excision of the ulcer can be made easier by incising the common bile duct and inserting a rubber T tube into the duct. The long end of the T tube is passed into the duodenum which permits the surgeon to identify the position of the duct and ampulla by palpation of the rubber tube. Such a procedure has aided immeasurably in the mobilization and excision of a low-lying ulcer associated with considerable induration and scarring around the duodenum. We prefer to remove the duodenal ulcer whenever possible and have rarely turned in the duodenum above the ulcer. A low-lying ulcer which is densely adherent,
Fig. 195. Blood supply to stomach. Ligation near the origin of major arteries such as the right and left gastric, right gastro-epiploic, and so forth, avoids hemorrhage and facilitates the mobilization of the stomach preparatory to resection.
however, can occasionlj,lly be allowed to remain provided all of the mucous membrane of the antrum is removed and the ulcer, which is allowed to remain, has not produced obstruction in the duodenum. As stated above, if the omentum is heavy and fat laden, it is removed with the resected portion of the stomach by detaching it from the colon. The omentum is elevated and an incision is made on its inferior surface at its peritoneal reflection onto the transverse colon (see Fig. 206 in "Total Gastrectomy," page 679). This detachment can usually be done readily with ligation of only a few bleeding points, as this reflection ordinarily is very thin and avascular. A gauze sponge as a traction tape is placed posterior to the stomach and brought out above the stomach through the thin avascular tissue of the gastrohepatic omentum.
Partial Gastrectomy for Peptic Ulcer
665
The stomach can then be elevated by this traction so that the distal part of the stomach and duodenum is readily mobilized. The peritoneum over the pancreas in the lesser omental sac extends to the right and is reflected upon the posterior wall of the stomach and duodenum (see Fig. 206, inset, in "Total Gastrectomy," page 679). This reflection of
Fig. 196. Mobilization of stomach. Elevation of stomach by traction tape makes dissection much easier. Omentum has not been removed in this instance but frequently is excised with stomach. Right gastro-epiploic vessels have been ligated; right gastric artery is isolated and clamped. Note incision into hepatoduodenal ligament to expose common bile duct.
the peritoneum is just lateral to the middle colic vessels in the mesocolon, and is quite avascular. The reflected peritoneum is divided and division of the areolar tissue laterally allows the mesocolon with the middle colic vessels to be separated easily from the duodenum and pancreas. The right gastro-epiploic vessels arise from the gastroduodenal artery (at the lower border of the pancreas) and the artery and vein can easily be clamped and divided just at the inferior border of the first part of the
666
Samuel F. Marshall
duodenum (Fig. 195). The right gastric artery at the superior border of the duodenum is then clamped, divided and ligated (Fig. 196). With the major blood supply of the duodenum and distal part of the stomach controlled by ligatures, the ulcer on the posterior wall, as most ulcers are that come to operation, can easily be detached from the pancreas without injury to the pancreas. Many ulcers in this area have penetrated the pancreas, with the base of the ulcer consisting of a callous, fibrous excavation in the pancreas; the posterior wall of the duodenum has been eroded and is absent, so that
a
----=-~~
" -~ (\)~
~'~
~~ ;. ;/
b
Fig. 197. Closure of distal end of divided duodenum can be made with clamp on duodenum (a) or with open duodenal segment (b). If duodenal cuff remaining above ampulla of Vater is short or if ulcer is densely adherent, it is better to transect duodenum without clamp and invert with Connell sutures of chromic catgut as first suture layer (b).
the ulcer is really a perforation of the posterior wall with its base a fibrotic excavation into the pancreas. It is not necessary or desirable to remove this base but the ulcerated orifice in the duodenum can be detached from the edges of the excavation. The duodenum can then be transected below the level of the ulcer and duodenal closure obtained by a Connell suture of fine chromic catgut (Fig. 197). The inverted distal duodenal stump is then reinforced with interrupted sutures of black silk and further reinforced by a few silk suturQs, inverting the closed duodenal stump against the ulcer base-sutures usually hold well in the fibrotic tissue about the upper edge of the ulcer base on the pancreas. Drainage is seldom used or required in these cases unless the duodenal
Partial Gastrectomy for Peptic Ulcer
667
closure is not considered to be secure. Drainage may occasionally be placed near a large, dirty, edematous ulcer base and brought out through a stab incision below the right costal margin. We have rarely seen the complication of _g.~Jiatula; if the duodenal stump is adequately inverted and reinforced with silk sutures, duodenal fistula should be extremely uncommon. c, _,'
" " . h ' ......"-w.,
,
Fig. 198. Application of the von Petz clamp (a). Note inverted duodenal stump. The stomach is divided with the cautery between the double row of inserted clips.
With the duodenum transected and securely inverted, the stomach is drawn cephalad and mobilization of the gastric curvatures is completed. The left gastric artery is clamped, divided and ligated high along the lesser curvature of the stomach. Dissection along the greater curvature is continued by ligation of several short gastric vessels, carefully cleaning the greater and lesser curvatures of the stomach of all fatty vascular and areolar tissue at the level of the gastric transection in order to facilitate inversion of the divided end of the stomach and to approximate the jejunal loop accurately to the gastric wall to form the new stomal orifice . About 70 per cent of the stomach is removed so that the transected end
668
Samuel F . Marshall
of the stomach lies almost transversely in the left hypochondrium. The von Petz clamp is used to place a double row of metal clips across the stomach at the point of its division, and the stomach is divided between the two rows of clips (Fig. 198) with the cautery. This method is quite satisfactory as it sterilizes the divided end of the stomach and aids con-
a.
Fig. 199. The upper portion of the transected end of the stomach has been inverted with a running suture of chromic catgut and a second layer of interrupted silk sutures. The gast.rojejunal anastomosis is placed at the greater curvature ene of the divided stomach. Note excision of clips to open into the gastric lumen. Two layer closure is used: first a mucosal layer of continuous catgut suture with an outer serosal layer of interrupted silk sutures.
siderably in the control of bleeding. The divided end of the stomach with a row of clips intact is inverted with continuous chromic catgut sutures, starting at the lesser curvature border. Sufficient room is left at the greater curvature border to form the gastrojejunal anastomosis. When the anastomosis is complete, the gastrojejunal stomal orifice will admit two fingers. This inverted two thirds of the divided end of stomach is reinforced with interrupted silk mattress sutures (Fig. 199).
Partial Gastrectomy for Peptic Ulcer
669
Prior to resection of the stomach and immediately after abdominal exploration, the first part of the jejunum is identified and the segment of jejunum to form the gastrojejunalanastomosis is marked with a silk suture so that the correct jejunal loop can be brought anterior to the transverse colon for attachment to the stomach. The surgeon can thus avoid contamination of the abdominal cavity by identifying the jejunal loop before resection and by means of the silk suture can deliver the jejunal segment when ready for the anastomosis. The gastrojejunal anastomosis is now established by suturing the jejunum to the uninverted portion of stomach at the greater curvature
Fig. 200. Completion of gastrojejunal anastomosis. a, Continuous catgut suture inverts gastric and jejunal mucosa; outer reinforcing serosal and muscular sutures of interrupted silk. b, Distal jejunal loop is sutured to inverted end of stomach, thereby avoiding tension at angle of gastrojejunal anastomosis. Note gastrocolic omental tag is tied in at corner of anastomosis at greater curvature. Gastrohepatic omentum is used to reinforce corner at lesser curvature.
border. A serosal suture line of interrupted black silk forms the posterior external suture line. A longitudinal incision (Fig. 199) is made in the jejunum and the remaining clips in the divided end of the stomach at the greater curvature are trimmed away. An opening is made into the gastric lumen. As the mucosa of the stomach and jejunum is incised, all bleeding points are clamped and ligated. This may prevent postoperative hemorrhage, although it seldom occurs in Ol1r experience. A mucosal layer of number 0 chromic catgut is used as a continuous suture to form the second posterior layer of sutures. This continuous suture of catgut extends from the previously inverted end of stomach toward the border of the greater curvature and then continues as an anterior suture line to invert the gastric and jejunal
Samuel F. Marshall
670
mucosal layers, thus closing the gastrojejunal stoma (Fig. 200). This anterior suture line is then reinforced with interrupted black silk. Several interrupted silk sutures are used to tack the jejunum beyond the stomal orifice to the inverted portion of the stomach at the lesser curvature end. Reinforcement of the angles of the stomach at the greater and lesser curvatures is obtained by suture of the gastrocolic and gastrohepatic omentum at the respective corners of the divided end of the stomach (Fig. 200). This completes the gastrojejunal anastomosis, which has been made anterior to the transverse colon, with the efferent loop of the jeju-
Fig. 201. Completed gastric resection. Note anastomosis anterior to colon and position of jejunal segments to form the gastrojejunal anastomosis. (From Lahey and Marshall, "The surgical treatment of peptic ulcer," in New England J. Med. 246: 115 [Jan. 24]1952.)
num (Fig. 201) at the lesser curvature border of the transected stomach. The proximal jejunal loop is attached to the stomach at the greater curvature and sufficient length of jejunum beyond the ligament of Treitz is allowed so that no tension is made upon the gastrojejunal anastomosis. The abdominal wound is closed in layers, employing interrupted silk sutures for the anterior fascia layer. If the operator desires, interrupted stainless, 32 gauge, steel wire may be used in place of interrupted silk to close the anterior fascial layer, placing the wire after the Smead technique. Levin tube drainage of the stomach is employed for two or three days, _._- .._--_._, "'-."--.. ."".~,.,--"-,,
'
Partial Gastrectomy for Peptic Ulcer
671
and the patient is encouraged to be out of bed on the second postoperative day. SUMMARY
Partial gastrectomy is still the most reliable operative method for surgical treatment of peptic ulcer. The results in our experience have been uniformly excellent. During the P_~,~t ,five years,yaggt.9IDy_,.andgastJ;oellterQ.stomy has been us~Qjl). on1Y.26 cllses, while, during the same period partiatr~.§'E:lctiol!Jo!"dll()dellal.ulcer was performed in 614 cases. Prior to this five year period, utilization of vagotomy phi.s gastroenterostomy was gradually decreased at the Lahey Clinic. We believe there is lit~!e place for the use of limited reseGtiop,s of tjle stomfl,ch in cases of complica,t{jdp,eptic ulcer, because too often they re&l!l.t)l). rE;lcurrE:l?t l}!c~!. The technique of partial gastric resection employed in the Lahey Clinic is briefly described.
technical procedures for the surgical treatment of peptic ulcer have been suggested and employed over the past few years but in our experience partial gastrectomy for the treatment of duodenal, gastric and jejunal ulcer has remained the most satisfactory operation for the complicated peptic ulcer. This operation can be performed readily with low mortality, with extremely few postoperative complications and with extremely satisfactory results for patients with longstanding ulcer distress. Operative mortality in the hands of surgeons trained in gastric surgery for severe complicated ulcer has remained less than 3 per cent and the occurrence of recurrent ulcer has remained consistently low. The most common operation other than gastric resection for peptic ulcer has been vagotomy combined with gastroenterostomy. We have done only 26 such operations in the last five years and we have employed vagotomy procedures with decreasing frequency. Mo:r.8];ecently, limited resections with vagotomy have been employed and reported in the literature. Gastric resection with restoration of gastrointestinal continuity by a Billroth I anastomosis has also been utilized more recently by many surgeons. All of these modifications of the conventional resection have the characteristics of a limited gastric resection in many cases as compared to a more radical partial resection (70 per cent of the stomach) and in many instances fail to produce a relative achlorhydria which the surgeon strives to obtain with the conventional high gastric resection. This is true of the Billroth I type of procedure as well since this type of anastomosis may be most difficult to accomplish in the presence of a badly scarred, adherent penetrating duodenal ulcer which is accompanied by shortening as well as fixation of the duodenum. Such fixation and shortening do not permit an anastomosis of a divided duodenum to the gastric remnant without some tension. The surgeon, therefore, is tempted to limit the radicalness of his resection when such severe ulcers exist (in general only these should come to surgery) and by standards based on VARIOUS
661
Samuel F. Marshall
662
surgical experience with peptic ulcer, .such an operation results in insufficiently radical resection of the stomach, and predisposes to recurrent ulcer since a relative achlorhydria cannot be obtained from such a limited resection. It is well to point out that none of these patients with limited modifications of gastric resection have been observed for a long enough period following operation to draw conclusions as to the frequency of recurrent ulcer. Such observations must cover a number of years before any conclusion as to the effectiveness of such limited resections can be reached. Radical partial gastrectomy has withstood the test of time and in our hands has proved to be the most satisfactory and effective method of Table 1 PARTIAL GASTRIC RESECTION FOR PEPTIC ULCER
January 1, 1937 to December 1, 1955 NO. OF PATIENTS
OPERATIVE NUMBER
MORTALITY Per Cent
Duodenal ulcer ............ . 1622 39 Gastric ulcer .............. . 468 13 Jejunal ulcer .............. . 256 6 Gastrojejunocolic fistula .... . 3 42 Total. ......... . 2388 61 Five year period 1951 to December 1, 1955: Vagotomy with posterior gastroenterostomy-26 cases Partial resection for duodenal ulcer-614 cases
2.4 2.8 2.3 7.1 2.55
surgical treatment. With an occasional exception, the patient is well satisfied with the results of the operation and is able to take a diet which is not only adequate for nutrition but also altered only slightly from a regular unrestricted diet. Over the past 19 years (1937 through 1955) the surgical group of the Lahey Clinic has done 2388 partial resections for peptic ulcer of all types (Table 1) with an over-all mortality of 2.55 per cent. The method of partial gastric resection is given below. TECHNIQUE
In general, the method for partial gastric resection for ulcer is similar to that for cancer, with the following exceptions. A more radical removal of the gastric wall is performed for cancer and the procedure includes removal of the duodenum almost to the ampulla of Vater, removal of the omentum and spleen, and very careful dissection of all regional nodes. Such radical resection is not necessary for the surgical treatment of nonmalignant peptic ulcer. In an individual with a heavy omentum, how-
Partial Gastrectomy for Peptic Ulcer
663
ever, resection for ulcer can be facilitated by the excision of the gastrocolic omentum. A left transrectus incision extending from the left costal margin caudalward to the level of the umbilicus permits ready mobilization of the pylorus and duodenum, since the pylorus is normally situated just to the right of the midline. At the same time a: left rectus incision allows approach to the upper half of the stomach for adequate gastric resection and also permits easy gastrojejunal anastomosis. If the patient is obese, it may be more difficult to mobilize an adherent penetrating duodenal ulcer because of the difficulty of exposing the duodenum in obese individuals. In such cases, the incision may be made through the right rectus muscle, with the upper end of the incision extended obliquely
Fig. 194. T tube inserted into exposed common bile duct with long arm of the tube passed into duodenum. An adherent low-lying duodenal ulcer can be dissected readily because the location of the duct can be easily palpated.
upward and to the left costal margin, dividing the ligamentum teres of the liver-a hockey stick type of incision which will facilitate exposure not only of the duodenum but also of the upper part of the stomach. Careful exploration of the abdominal contents should be carried out after the abdominal cavity has been opened. When the operation is for a duodenal ulcer the entire stomach is visualized and palpated to exclude the possibility of a gastric lesion which commonly occurs coincidental to a duodenal ulcer. If the surgical procedure is for a gastric ulcer the duodenum is likewise carefully checked before the stomach is mobilized. The common bile duct should always be exposed before proceeding with resection for an indurated adherent duodenal ulcer, as the operator must visualize the relationship of the bile duct and ampulla of Vater to the adherent ulcer in order to avoid injury to the common bile duct (Fig. 194). If the ulcer is supra-ampullary or arises in the second part of the duodenum quite close to the ampulla, and much scarring is present,
664
Samuel F. Marshall
dissection and excision of the ulcer can be made easier by incising the common bile duct and inserting a rubber T tube into the duct. The long end of the T tube is passed into the duodenum which permits the surgeon to identify the position of the duct and ampulla by palpation of the rubber tube. Such a procedure has aided immeasurably in the mobilization and excision of a low-lying ulcer associated with considerable induration and scarring around the duodenum. We prefer to remove the duodenal ulcer whenever possible and have rarely turned in the duodenum above the ulcer. A low-lying ulcer which is densely adherent,
Fig. 195. Blood supply to stomach. Ligation near the origin of major arteries such as the right and left gastric, right gastro-epiploic, and so forth, avoids hemorrhage and facilitates the mobilization of the stomach preparatory to resection.
however, can occasionlj,lly be allowed to remain provided all of the mucous membrane of the antrum is removed and the ulcer, which is allowed to remain, has not produced obstruction in the duodenum. As stated above, if the omentum is heavy and fat laden, it is removed with the resected portion of the stomach by detaching it from the colon. The omentum is elevated and an incision is made on its inferior surface at its peritoneal reflection onto the transverse colon (see Fig. 206 in "Total Gastrectomy," page 679). This detachment can usually be done readily with ligation of only a few bleeding points, as this reflection ordinarily is very thin and avascular. A gauze sponge as a traction tape is placed posterior to the stomach and brought out above the stomach through the thin avascular tissue of the gastrohepatic omentum.
Partial Gastrectomy for Peptic Ulcer
665
The stomach can then be elevated by this traction so that the distal part of the stomach and duodenum is readily mobilized. The peritoneum over the pancreas in the lesser omental sac extends to the right and is reflected upon the posterior wall of the stomach and duodenum (see Fig. 206, inset, in "Total Gastrectomy," page 679). This reflection of
Fig. 196. Mobilization of stomach. Elevation of stomach by traction tape makes dissection much easier. Omentum has not been removed in this instance but frequently is excised with stomach. Right gastro-epiploic vessels have been ligated; right gastric artery is isolated and clamped. Note incision into hepatoduodenal ligament to expose common bile duct.
the peritoneum is just lateral to the middle colic vessels in the mesocolon, and is quite avascular. The reflected peritoneum is divided and division of the areolar tissue laterally allows the mesocolon with the middle colic vessels to be separated easily from the duodenum and pancreas. The right gastro-epiploic vessels arise from the gastroduodenal artery (at the lower border of the pancreas) and the artery and vein can easily be clamped and divided just at the inferior border of the first part of the
666
Samuel F. Marshall
duodenum (Fig. 195). The right gastric artery at the superior border of the duodenum is then clamped, divided and ligated (Fig. 196). With the major blood supply of the duodenum and distal part of the stomach controlled by ligatures, the ulcer on the posterior wall, as most ulcers are that come to operation, can easily be detached from the pancreas without injury to the pancreas. Many ulcers in this area have penetrated the pancreas, with the base of the ulcer consisting of a callous, fibrous excavation in the pancreas; the posterior wall of the duodenum has been eroded and is absent, so that
a
----=-~~
" -~ (\)~
~'~
~~ ;. ;/
b
Fig. 197. Closure of distal end of divided duodenum can be made with clamp on duodenum (a) or with open duodenal segment (b). If duodenal cuff remaining above ampulla of Vater is short or if ulcer is densely adherent, it is better to transect duodenum without clamp and invert with Connell sutures of chromic catgut as first suture layer (b).
the ulcer is really a perforation of the posterior wall with its base a fibrotic excavation into the pancreas. It is not necessary or desirable to remove this base but the ulcerated orifice in the duodenum can be detached from the edges of the excavation. The duodenum can then be transected below the level of the ulcer and duodenal closure obtained by a Connell suture of fine chromic catgut (Fig. 197). The inverted distal duodenal stump is then reinforced with interrupted sutures of black silk and further reinforced by a few silk suturQs, inverting the closed duodenal stump against the ulcer base-sutures usually hold well in the fibrotic tissue about the upper edge of the ulcer base on the pancreas. Drainage is seldom used or required in these cases unless the duodenal
Partial Gastrectomy for Peptic Ulcer
667
closure is not considered to be secure. Drainage may occasionally be placed near a large, dirty, edematous ulcer base and brought out through a stab incision below the right costal margin. We have rarely seen the complication of _g.~Jiatula; if the duodenal stump is adequately inverted and reinforced with silk sutures, duodenal fistula should be extremely uncommon. c, _,'
" " . h ' ......"-w.,
,
Fig. 198. Application of the von Petz clamp (a). Note inverted duodenal stump. The stomach is divided with the cautery between the double row of inserted clips.
With the duodenum transected and securely inverted, the stomach is drawn cephalad and mobilization of the gastric curvatures is completed. The left gastric artery is clamped, divided and ligated high along the lesser curvature of the stomach. Dissection along the greater curvature is continued by ligation of several short gastric vessels, carefully cleaning the greater and lesser curvatures of the stomach of all fatty vascular and areolar tissue at the level of the gastric transection in order to facilitate inversion of the divided end of the stomach and to approximate the jejunal loop accurately to the gastric wall to form the new stomal orifice . About 70 per cent of the stomach is removed so that the transected end
668
Samuel F . Marshall
of the stomach lies almost transversely in the left hypochondrium. The von Petz clamp is used to place a double row of metal clips across the stomach at the point of its division, and the stomach is divided between the two rows of clips (Fig. 198) with the cautery. This method is quite satisfactory as it sterilizes the divided end of the stomach and aids con-
a.
Fig. 199. The upper portion of the transected end of the stomach has been inverted with a running suture of chromic catgut and a second layer of interrupted silk sutures. The gast.rojejunal anastomosis is placed at the greater curvature ene of the divided stomach. Note excision of clips to open into the gastric lumen. Two layer closure is used: first a mucosal layer of continuous catgut suture with an outer serosal layer of interrupted silk sutures.
siderably in the control of bleeding. The divided end of the stomach with a row of clips intact is inverted with continuous chromic catgut sutures, starting at the lesser curvature border. Sufficient room is left at the greater curvature border to form the gastrojejunal anastomosis. When the anastomosis is complete, the gastrojejunal stomal orifice will admit two fingers. This inverted two thirds of the divided end of stomach is reinforced with interrupted silk mattress sutures (Fig. 199).
Partial Gastrectomy for Peptic Ulcer
669
Prior to resection of the stomach and immediately after abdominal exploration, the first part of the jejunum is identified and the segment of jejunum to form the gastrojejunalanastomosis is marked with a silk suture so that the correct jejunal loop can be brought anterior to the transverse colon for attachment to the stomach. The surgeon can thus avoid contamination of the abdominal cavity by identifying the jejunal loop before resection and by means of the silk suture can deliver the jejunal segment when ready for the anastomosis. The gastrojejunal anastomosis is now established by suturing the jejunum to the uninverted portion of stomach at the greater curvature
Fig. 200. Completion of gastrojejunal anastomosis. a, Continuous catgut suture inverts gastric and jejunal mucosa; outer reinforcing serosal and muscular sutures of interrupted silk. b, Distal jejunal loop is sutured to inverted end of stomach, thereby avoiding tension at angle of gastrojejunal anastomosis. Note gastrocolic omental tag is tied in at corner of anastomosis at greater curvature. Gastrohepatic omentum is used to reinforce corner at lesser curvature.
border. A serosal suture line of interrupted black silk forms the posterior external suture line. A longitudinal incision (Fig. 199) is made in the jejunum and the remaining clips in the divided end of the stomach at the greater curvature are trimmed away. An opening is made into the gastric lumen. As the mucosa of the stomach and jejunum is incised, all bleeding points are clamped and ligated. This may prevent postoperative hemorrhage, although it seldom occurs in Ol1r experience. A mucosal layer of number 0 chromic catgut is used as a continuous suture to form the second posterior layer of sutures. This continuous suture of catgut extends from the previously inverted end of stomach toward the border of the greater curvature and then continues as an anterior suture line to invert the gastric and jejunal
Samuel F. Marshall
670
mucosal layers, thus closing the gastrojejunal stoma (Fig. 200). This anterior suture line is then reinforced with interrupted black silk. Several interrupted silk sutures are used to tack the jejunum beyond the stomal orifice to the inverted portion of the stomach at the lesser curvature end. Reinforcement of the angles of the stomach at the greater and lesser curvatures is obtained by suture of the gastrocolic and gastrohepatic omentum at the respective corners of the divided end of the stomach (Fig. 200). This completes the gastrojejunal anastomosis, which has been made anterior to the transverse colon, with the efferent loop of the jeju-
Fig. 201. Completed gastric resection. Note anastomosis anterior to colon and position of jejunal segments to form the gastrojejunal anastomosis. (From Lahey and Marshall, "The surgical treatment of peptic ulcer," in New England J. Med. 246: 115 [Jan. 24]1952.)
num (Fig. 201) at the lesser curvature border of the transected stomach. The proximal jejunal loop is attached to the stomach at the greater curvature and sufficient length of jejunum beyond the ligament of Treitz is allowed so that no tension is made upon the gastrojejunal anastomosis. The abdominal wound is closed in layers, employing interrupted silk sutures for the anterior fascia layer. If the operator desires, interrupted stainless, 32 gauge, steel wire may be used in place of interrupted silk to close the anterior fascial layer, placing the wire after the Smead technique. Levin tube drainage of the stomach is employed for two or three days, _._- .._--_._, "'-."--.. ."".~,.,--"-,,
'
Partial Gastrectomy for Peptic Ulcer
671
and the patient is encouraged to be out of bed on the second postoperative day. SUMMARY
Partial gastrectomy is still the most reliable operative method for surgical treatment of peptic ulcer. The results in our experience have been uniformly excellent. During the P_~,~t ,five years,yaggt.9IDy_,.andgastJ;oellterQ.stomy has been us~Qjl). on1Y.26 cllses, while, during the same period partiatr~.§'E:lctiol!Jo!"dll()dellal.ulcer was performed in 614 cases. Prior to this five year period, utilization of vagotomy phi.s gastroenterostomy was gradually decreased at the Lahey Clinic. We believe there is lit~!e place for the use of limited reseGtiop,s of tjle stomfl,ch in cases of complica,t{jdp,eptic ulcer, because too often they re&l!l.t)l). rE;lcurrE:l?t l}!c~!. The technique of partial gastric resection employed in the Lahey Clinic is briefly described.