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The Principles of Gastric Resection
The Principles of Gastric Resection ROBERT M. ZOLLINGER, M.D., F.A.C.S.* JAMES W. KELLER, M.D.**
Many of the pitfalls of gastric resection, regardless of extent, can be avoided by adequate exposure resulting from a liberal abdominal incision and extensive mobilization. Injury to neighboring structures can be minimized and the technical procedure facilitated if anatomical distortions, resulting from disease or previous surgery, are corrected before the definitive resection is initiated. Position
The proper positioning of the patient on the table is essential for maximum exposure as well as effectiveness of the surgeon. The patient is placed to the side of the table closest to the surgeon. The table is then rotated toward the surgeon and into a moderate reversed Trendelenburg position. This positioning insures the benefits of gravity in promoting exposure, especially in obese patients and when a high gastric resection is anticipated. Incision
The adequacy of any particular incision is influenced by the anatomical conformation of the individual patient. The flare of the costal margins, the acuteness of the xiphocostal angles, the length and prominence of the xiphoid process, the distance between the latter and the umbilicus, as well as the amount of obesity and the presence of previous incisions are all factors in planning the incision. A midline incision, which can be extended up over the xiphoid as well as below the umbilicus on the left side, is preferred. When carcinoma is strongly suspected, a limited initial incision, sufficient only to permit an evaluation as to the suitability of resection, is warranted. The xiphoid process is removed when it is unduly prominent, From the Department of SUrgery, The Ohio State University College of Medicine, Columbus, Ohio * Professor and Department Chairman ** Senior Resident in Surgery, Ohio State University Hospital
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particularly in large males, and if a high gastric resection or vagotomy is planned. Bleeding is controlled by transfixing sutures on cutting needles. Bone wax may be required to control the ooze from the open end of the sternum. A common mistake is failure to extend the incision well below the umbilicus. A more efficient operation with less blood loss tends to follow if all bleeding points in the wound have been secured before proceeding with the resection.
Initial Exploration A thorough abdominal exploration, particularly of the gastrointestinal tract, including the spleen and pancreas, is necessary in addition to confirmation of the indication for or against gastric resection. In the presence of a benign lesion such as duodenal ulcer the increased risk of gastric resection should be thoroughly weighed. This is especially true when a high-lying stomach is encountered in an obese patient. Extensive inflammation about the pylorus or marked ulcer deformity near the region of the common duct is a danger signal for the subsequent safe closure of the duodenal stump and a conservative procedure should be considered. High-lying ulcerations near the esophagus warrant frozen section proof of malignancy before deciding upon a near total gastrectomy. When exploration has suggested that a gastric malignancy is localized, it is still necessary to determine by exploration of the lesser sac that a posterior extension of the lesion has not invaded the pancreas or compromised the middle colic vessels.
Principles of Mobilization Before undue traction is applied to the stomach, any banjo-string adhesions to the margins of the spleen should be divided. If the splenic capsule is torn, splenectomy is usually necessary to avoid persistent blood loss. The omentum is commonly attached to the parietes between the inferior pole of the spleen and the splenic flexure of the colon and the greater curvature can be mobilized to a limited extent by the division of this attachment. There is less blood loss and more extensive mobilization is possible if the greater omentum is completely separated from the transverse colon, including both the hepatic and splenic flexures. Although this procedure is advisable in the presence of a benign lesion, it is essential in the presence of malignancy in order to insure removal of the lymphatic drainage area. The omentum is first detached from the midportion of the transverse colon. Since the blood vessels to the posterior aspect of the transverse colon may be angulated upward and attached to the underside of the omentum, the line of incision should be several centimeters from the bowel wall so that troublesome bleeding can be avoided. Only a few blood vessels will require ligation if the proper cleavage plane is maintained. After the lesser sac has been opened, the left hand is inserted and the fingers spread apart to facilitate the cleavage plane over to and around the splenic flexure as the
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omentum is separated. Likewise any attachments between the mesocolon and the posterior wall of the antrum of the stomach are separated by blunt hand dissection. Any adhesions between the gastric wall and capsule of the pancreas are divided. The middle colic vessels may be attached to the stomach because of a marked inflammatory reaction about the posterior penetrating ulcer or may be involved with carcinoma of the antrum. The hepatic flexure is freed of the omentum and swept downward by blunt dissection. This will visualize the middle colic vessels and the second portion of the duodenum in preparation for the Kocher maneuver. Mobilization of the Duodenum
Mobilization of the duodenum by division of its lateral avascular peritoneal reflection allows closure of the duodenal stump or gains distance if a Billroth I procedure is performed. The duodenum and head of the pancreas are separated posteriorly from the underlying vena cava by blunt dissection. Further mobilization, with straightening of the C loop, follows division of the avascular peritoneum forming the lower border of the foramen of Winslow. The middle colic vessels are retracted medially as the fine peritoneal attachments to the second and even third portions of the duodenum are divided. Any opening made through the peritoneum in the region of the ligament of Treitz should be closed to avoid an internal hernia. Mobilization of the Greater Curvature
The stomach has such a rich, placenta-like blood supply that viability can be maintained through the vascular arcade of either curvature. The greater curvature can be freed by dividing the thickened gastrosplenic ligament in the region of the left gastroepiploic vessels. If the left gastric artery is to be retained, as much of the gastric-splenic omentum can be divided as is required for mobilization. The short gastric vessels should be ligated by transfixing sutures which include a bite in the gastric wall. Such fixation prevents loosening of the ligature with hemorrhage if subsequent gastric distention occurs. Mobilization of the entire greater curvature including the fundus may be desirable in high resections or to avoid a deep anastomosis under the costal margin. The upper end of the stomach can be greatly mobilized by dividing all of the peritoneal attachments about the esophagus and division of the vagus nerves. The benefits of mobilization following vagotomy tend to more than compensate for any undesirable late side effects of the denervation even in the presence of malignancy. Division and ligation of the uppermost and thickened portion of the gastrohepatic ligament also adds to mobilization. In addition, this procedure insures a clearer view posterior to the esophagus and fewer posterior vagus nerves will be overlooked. The exposure for ligation of the left gastric vessels or removal of all lymph drainage areas up to the esophagogastric junction is improved. When the left gastric vessels have been ligated at their point of origin at the celiac axis, the blood supply to the remaining mobilized fundus is dependent on the short gastrosplenic vessels.
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Mobilization of the Spleen
The mobility of the spleen should always be determined. Because of the possibility of tearing the splenic capsule with subsequent splenectomy it should be mobilized only when necessary to insure an anastomosis without tension. This may be indicated when a Billroth I procedure is planned or following a radical gastric resection with removal of the lesser curvature. The spleen is gently retracted downward by the right hand of the surgeon. Regardless of his dexterity, the surgeon uses his left hand to divide the peritoneal attachment with long curved scissors. The upper pole of the spleen is first freed and the splenorenal ligament divided down to the region of the splenic flexure of the colon. Any restraining peritoneal filaments are divided as firm medial retraction is sustained. Tension on the gastrosplenic ligament can be relieved by placing small packs posterior to the mobilized spleen. When the anastomosis has been completed, the packs are removed and the spleen returned to its original bed. By utilizing these procedures, the stomach is freely mobilized and the surgeon can remove with greater safety and ease as much as he believes to be indicated. Management of the Duodenum
The complication of leakage from the closed duodenal stump or from necrosis about one of the angles of a gastroduodenal anatomosis can be held to a minimum by insuring a good blood supply and an adequate cuff of cleared serosa. The first part of the duodenum is much more vascular and the wall more friable in the presence of duodenal ulcer than with gastric ulcer or carcinoma. In duodenal ulcer there tends to be an insufficient amount of pliable duodenal wall with good vascularity, while there is adequate duodenum with relatively poor vascularity in lesions on the gastric side. The duodenum may be unduly elongated from the weight of a large, sagging carcinoma of the stomach and the blood supply too limited for the extra long cuff of the serosa which may be unwittingly prepared. The right gastroepiploic vessels below the pylorus are first isolated from the surrounding tissues and their communications with the superior mesenteric vessels are identified. These easily torn veins can cause troublesome bleeding. As the pylorus is held upward a small curved clamp is passed between the inferior duodenal wall and the pillar of tissues containing the right gastroepiploic vessels. The clamp is gently opened to separate the vessels from the duodenal wall and to permit the placement of three hemostats to this vascular pedicle. In the presence of malignancy the vessels should be ligated as far below any presenting infra pyloric lymph nodes as possible. The application of ligatures behind the two proximal hemostats insures a definite pedicle which may be used as a point of subsequent fixation for the inferior margin of a Billroth I anastomosis. The division of the right gastric vessels adds little to the mobility of the duodenum. These vessels, which often appear insignificant in size, are divided several centimeters from the superior margin of the duodenum in the region of the pylorus. This should be done under clear vision, in order to
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insure a good pedicle an adequate distance from the duodenum and avoid injury to the common duct or other important structures. It is helpful to depress the other structures in the hepatoduodenalligament with the middle finger of the left hand as the tissues containing the right gastric vessels are held firmly between the thumb and index finger. Straight clamps are used to develop a cleavage plane as they are spread open at right angles to the superior duodenal wall. Once again a pedicle is developed by the application of three hemostats with double ligature on the proximal side. At least 2.5 cm. of duodenum should be resected in the presence of carcinoma of the antrum. At least 1 cm. of both margins should be cleared of fatty tissue to insure a free serosal surface for the proper placement of the angle or closure sutures. The posterior wall of the duodenum may be attached to the adjacent capsule of the pancreas. Division of these attachB
c
Figure 1. Closure of Duodenal Stump. A, Preferred closure with double row of inverting sutures of nonabsorbable material. B, With posterior perforating ulcer and short duodenal cuff the anterior wall may be sutured to capsule of pancreas. C, When closure is insecure the stump may be drained externally by a catheter. D, A long Levin tube can be inserted through the gastroenteric stoma into the afferent loop for decompression.
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ments without injury to the nearby pancreaticoduodenal artery will provide additional surface for suturing. The posterior wall of the duodenum is surprisingly free of vascular attachment except for a small segment near the inferior margin. Noncrushing clamps of the Potts type insure a viable divided margin. The greatest challenge is encountered in the presence of deeply penetrating duodenal ulcers particularly near the common duct. The dangers of pancreatitis from ductal damage due to deeply placed sutures makes it mandatory to control all bleeding by meticulously placed superficial sutures. The finger may be inserted into the duodenum to provide countertraction as a small rim of posterior duodenal wall is developed. In rare instances the common duct may be opened above the duodenum and a longarm T-tube directed downward through the papilla of Vater to avoid obstruction of the common duct during closure of the duodenal stump. A twolayered closure of the duodenum using nonabsorbable sutures is preferred. Rather than risk a blowout of the duodenal stump because of limited amount of available duodenal wall for closure, other methods should be considered. The anterior wall of the duodenum can be anchored down to the posterior wall or to the fibrotic capsule of the pancreas. A catheter can be inserted into the lumen of the duodenum to provide drainage and the duodenal wall closed around it. Whenever the closure of the duodenum leaves any doubts as to its safety, it is advisable to provide adequate drainage to the area and to decompress the stump by directing a Levin tube through the gastrojejunal anastomosis around into the duodenum (Fig. 1). Soilage from the stomach must be held to a minimum in order to prevent sepsis. This is particularly true in the presence of achlorhydria. Resection of Stomach There is a tendency to overestimate the extent of the gastric resection. Certain landmarks can serve as guidelines for a hemigastrectomy as well as a radical gastric resection. Hemigastrectomy has been commonly performed to control the gastric phase of secretion in the treatment of duodenal ulcer and is usually combined with vagotomy to control the cephalic phase. The vascular landmarks can be used as approximate guides in the selection of the half-way point for resection. On the greater curvature, the area is selected where the gastroepiploic vessels are nearest to the gastric wall. A point is selected on the lesser curvature at the level of the third vein from the esophagogastric junction (Fig. 2). A more extensive resection of 60 to 75 per cent can be estimated if the left gastroepiploic is ligated and the blood supply on the lesser curvature divided as high as possible without ligation of the left gastric artery near its point of origin from the celiac axis. The division of the latter enhances the removal of the lymphatic drainage area to the lesser curvature in the presence of malignancy and insures a high radical gastric resection of more than 75 per cent. Ligation of the left gastric vessels should not be done if the spleen has been removed or the short
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gastric vessels ligated. If the left gastric vessels are to be divided, a finger should be passed around the column which incorporates the coronary vein and left gastric artery to facilitate the application of three hemostats. The contents of the hemostats are carefully tied to avoid vascular retraction and bleeding which can be difficult to control. The blood supply along the lesser curvature can be bluntly dissected away from the adjacent gastric wall. A small curved hemostat is directed under the fatty tissues at a point away from the veins extending down over the gastric wall. The left hand rotates the mobilized stomach as the clamp is passed on through under the tissues along the posterior wall. The jaws of the clamp are opened several times to bluntly separate the tissues from the underlying nonperitonealized surface between the anterior and posterior serosal surfaces of the stomach. A sizable portion of tissue may be doubly clamped and ligated. These ligatures should be transfixed to the serosa to prevent tearing of the blood supply away from the gastric wall. Additional sutures should be taken next to the ligated blood supply to approximate the serosal surfaces and obliterate the nonperitonealized zone of the lesser curvature (Fig. 3). An additional traction suture 1 fingerbreadth distally is placed to insure a prepared peritoneal surface around the lesser curvature for the placement of subsequent reconstruction sutures. Likewise, the greater curvature should be prepared with traction sutures 1 fingerbreadth apart next to the blood supply to insure accurate closure of the greater curvature. In the presence of malignancy all the lymphatic drainage area of the lesser curvature is commonly removed along with the width of the hand of adjacent gastric wall proximal to the lesion. While the surgeon tends to develop a favorite type of resection based on his experience and training, he should remain flexible in his choice because of the many variables which should alter his decision. Females and underweight or highly emotional patients tend to do better if a conservative procedure or conservative type of resection is performed. The decision for or against a Billroth I or gastroduodenal anastomosis should not be firmly made until the lesion, if malignant, has been adequately resected, or if benign ulcer, the acid factor controlled. Figure 2. Line of Resection. For hemigastrectomy the stomach is divided between the point on the lesser curvature at the third great vein from the esophagus and on the greater curvature where the gastroepiploic arcade most closely approximates the gastric wall. Seventy per cent resection includes nearly all the lesser curvature. with ligation of the left gastric artery and the left gastroepiploic artery at its origin.
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Figure 3. Bare area of lesser curvature. The nonperitonealized area on the lesser curvature is closed by approximating the peritoneal surfaces. Dotted line represents line of resection for hemigastrectomy.
Reconstruction Favor for the Billroth I or II procedure fluctuates depending upon the experience of the surgeon and the indications for the gastric resection. Gastroduodenostomy has been challenged because of the tendency to perform a limited resection which may not control the acid factor in duodenal ulcer or provide a sufficient margin beyond a gastric lesion. The utilization of the previously mentioned principles of mobilization, including the spleen and combined with vagotomy has obviated many of the previous objections. Indeed, it is not too unusual for the esophagus to be anastomosed to the duodenum in a thin individual with lax structures. Fear of leakage from one of the angles of the gastroduodenostomy due to technical difficulties in anastomosing the larger gastric opening to the smaller duodenal opening has tended to limit the acceptance of this procedure. The discrepancy in lumen size can be corrected in one of several ways. The serosal suture layer of interrupted mattress sutures can be placed to include a larger bite on the gastric side than on the duodenal side. It is technically easier and safer if the first suture includes the superior margins of both stomach and duodenum to avoid difficulties in sealing the superior angle. When these are tied, the gastric opening is puckered to the size of the duodenum. If the duodenal opening is too small as the sutures are tied, the Horsley principle is followed. This consists of incising the midportion of the anterior duodenal wall, allowing it to flare out to the required size. The incision is made parallel to the long axis of the duodenum (Fig. 4). The gastric outlet can be narrowed and hemostasis provided by the insertion of interrupted 4-0 silk sutures placed near the cut margin according to the von Haberer principle. The gastric wall is gradually puckered as these sutures are tied around the entire circumference of the gastric outlet.
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Additional sutures are placed and tied until the gastric outlet is similar in size to the duodenal opening. Since the normal pyloric canal is hardly larger than the index finger, no effort is made to provide an outlet larger than 2 fingerbreadths. The possible early postoperative delay in gastric emptying from a modest sized stoma must be weighed against fewer postgastrectomy complaints in the future. Added sealing of the angles and anchoring of the gastric wall help to avoid tension on the suture line. This is accomplished by tying the serosal guide sutures on either curvature about the vascular pedicles of the right gastric and gastroepiploic vessels. The limits of the stoma may be marked by applying several Cushing's silver clips along the serosal suture line. When the mobility of the duodenum is limited and a radical gastric resection is indicated, a Billroth II type of resection is performed. Many variations of this procedure have been proposed. The antecolic Hofmeister modification is probably the most commonly performed procedure of this type. If a retrocolic anastomosis is to be done, the opening in the mesocolon should be made to the left of the middle colic vessels. The gastric pouch should be firmly secured to the margins of this opening to prevent a subsequent internal hernia. The antecolic anastomosis is easier provided a retained thickened omentum is not compressed against the transverse colon. The upper one-half or more of the gastric outlet is closed by two layers of interrupted silk, leaving a stoma on the greater curvature side of approximately 2 fingerbreadths. This closure makes it unnecessary to carry out a high anastomosis under difficult technical conditions. The more flexible greater curvature facilitates an easier and more secure anastomosis. The jejunum can be secured to the closed end of the stomach to avoid
Figure 4. Gastroduodenostomy (Billroth I Anastomosis). The larger gastric lumen has been reduced by the puckering von Haberer sutures. The duodenal circumference can be increased by the Horsley maneuver (dotted line). Posterior suture layer has been placed. The long sutures over the vascular pedicles on the duodenal and gastric side are later tied together to reinforce the angles (A-A' and B-B').
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angulation and provide added security to the upper gastrojejunal anastomotic angle. Decompression of the gastric pouch is effectively and comfortably carried out by a temporary gastrostomy provided sufficient stomach remains. An inexpensive Pezzer catheter (16-18 French) is inserted through a stab wound at a previously tested site on the anterior gastric wall which can be easily approximated to the parietal peritoneum. Gastric bleeding is avoided by silk sutures placed at either side of the tube. The gastric wall is inverted about the tube to assure prompt closure of the gastric stoma when the catheter is removed. At the previously tested site a straight hemostat is passed through the abdominal wall. The peritoneal opening should be as far from the margins of the incision as possible to avoid contamination of the suture line in the wound closure. Likewise, the gastric wall is anchored to the peritoneum by several 00 silk sutures to the left of the point of the introduced hemostat. These are tied before the catheter is pulled through the stab wound to insure accurate approximation of the gastric wall. A sufficient number of sutures are placed about the catheter to insure a water-tight seal should it be accidentally pulled out in the early postoperative period. A long tube may be inserted in a similar fashion and directed around into the duodenum to insure decompression of the afferent loop down into the upper jejunum to facilitate early alimentation.
Wound Closure In the presence of emaciation, recent massive hemorrhage, chronic cough, obesity or malignancy, the addition of retention sutures to the wound closure should be considered. The blood volume should be sustained, pulmonary complications anticipated, and effective decompression of the gastric pouch maintained. Intravenous fluids should be given judiciously and the serum electrolytes monitored frequently in order to avoid electrolyte imbalance and errors of hydration. Gastric surgery requires an understanding of physiology seldom demanded in surgery of the remainder of the alimentary tract.
REFERENCES 1. Grant, G. N., Elliott, D. W. and Frederick, P. L.: Postoperative decompression by
temporary gastrostomy or nasogastric tube. A.M.A. Arch. Surg. 85: 844, 1962. 2. Klug, T. J., Zollinger, R. M. and Ellensohn, J.: A long-term evaluation of two conservative surgical procedures for duodenal ulcer. Am. J. Surg. 105: 370, 1963. 3. Zollinger, R. M.: Late postoperative problems following radical surgery of the . stomach and pancreas. Postgrad. Med. 23: 297, 1958. 4. Zollinger, R. M.: Technic of vagotomy, hemigastrectomy, and Billroth I anastomosis. Am. J. Surg. 105: 413, 1963. 5. Zollinger, R. M. and Stewart, W. R. C.: Surgical management of gastric ulcer. J.A.M.A. 171: 2056, 1959. 410 West 10th Avenue Columbus, Ohio 43210
Many of the pitfalls of gastric resection, regardless of extent, can be avoided by adequate exposure resulting from a liberal abdominal incision and extensive mobilization. Injury to neighboring structures can be minimized and the technical procedure facilitated if anatomical distortions, resulting from disease or previous surgery, are corrected before the definitive resection is initiated. Position
The proper positioning of the patient on the table is essential for maximum exposure as well as effectiveness of the surgeon. The patient is placed to the side of the table closest to the surgeon. The table is then rotated toward the surgeon and into a moderate reversed Trendelenburg position. This positioning insures the benefits of gravity in promoting exposure, especially in obese patients and when a high gastric resection is anticipated. Incision
The adequacy of any particular incision is influenced by the anatomical conformation of the individual patient. The flare of the costal margins, the acuteness of the xiphocostal angles, the length and prominence of the xiphoid process, the distance between the latter and the umbilicus, as well as the amount of obesity and the presence of previous incisions are all factors in planning the incision. A midline incision, which can be extended up over the xiphoid as well as below the umbilicus on the left side, is preferred. When carcinoma is strongly suspected, a limited initial incision, sufficient only to permit an evaluation as to the suitability of resection, is warranted. The xiphoid process is removed when it is unduly prominent, From the Department of SUrgery, The Ohio State University College of Medicine, Columbus, Ohio * Professor and Department Chairman ** Senior Resident in Surgery, Ohio State University Hospital
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ZOLLINGER, JAMES
W.
KELLER
particularly in large males, and if a high gastric resection or vagotomy is planned. Bleeding is controlled by transfixing sutures on cutting needles. Bone wax may be required to control the ooze from the open end of the sternum. A common mistake is failure to extend the incision well below the umbilicus. A more efficient operation with less blood loss tends to follow if all bleeding points in the wound have been secured before proceeding with the resection.
Initial Exploration A thorough abdominal exploration, particularly of the gastrointestinal tract, including the spleen and pancreas, is necessary in addition to confirmation of the indication for or against gastric resection. In the presence of a benign lesion such as duodenal ulcer the increased risk of gastric resection should be thoroughly weighed. This is especially true when a high-lying stomach is encountered in an obese patient. Extensive inflammation about the pylorus or marked ulcer deformity near the region of the common duct is a danger signal for the subsequent safe closure of the duodenal stump and a conservative procedure should be considered. High-lying ulcerations near the esophagus warrant frozen section proof of malignancy before deciding upon a near total gastrectomy. When exploration has suggested that a gastric malignancy is localized, it is still necessary to determine by exploration of the lesser sac that a posterior extension of the lesion has not invaded the pancreas or compromised the middle colic vessels.
Principles of Mobilization Before undue traction is applied to the stomach, any banjo-string adhesions to the margins of the spleen should be divided. If the splenic capsule is torn, splenectomy is usually necessary to avoid persistent blood loss. The omentum is commonly attached to the parietes between the inferior pole of the spleen and the splenic flexure of the colon and the greater curvature can be mobilized to a limited extent by the division of this attachment. There is less blood loss and more extensive mobilization is possible if the greater omentum is completely separated from the transverse colon, including both the hepatic and splenic flexures. Although this procedure is advisable in the presence of a benign lesion, it is essential in the presence of malignancy in order to insure removal of the lymphatic drainage area. The omentum is first detached from the midportion of the transverse colon. Since the blood vessels to the posterior aspect of the transverse colon may be angulated upward and attached to the underside of the omentum, the line of incision should be several centimeters from the bowel wall so that troublesome bleeding can be avoided. Only a few blood vessels will require ligation if the proper cleavage plane is maintained. After the lesser sac has been opened, the left hand is inserted and the fingers spread apart to facilitate the cleavage plane over to and around the splenic flexure as the
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omentum is separated. Likewise any attachments between the mesocolon and the posterior wall of the antrum of the stomach are separated by blunt hand dissection. Any adhesions between the gastric wall and capsule of the pancreas are divided. The middle colic vessels may be attached to the stomach because of a marked inflammatory reaction about the posterior penetrating ulcer or may be involved with carcinoma of the antrum. The hepatic flexure is freed of the omentum and swept downward by blunt dissection. This will visualize the middle colic vessels and the second portion of the duodenum in preparation for the Kocher maneuver. Mobilization of the Duodenum
Mobilization of the duodenum by division of its lateral avascular peritoneal reflection allows closure of the duodenal stump or gains distance if a Billroth I procedure is performed. The duodenum and head of the pancreas are separated posteriorly from the underlying vena cava by blunt dissection. Further mobilization, with straightening of the C loop, follows division of the avascular peritoneum forming the lower border of the foramen of Winslow. The middle colic vessels are retracted medially as the fine peritoneal attachments to the second and even third portions of the duodenum are divided. Any opening made through the peritoneum in the region of the ligament of Treitz should be closed to avoid an internal hernia. Mobilization of the Greater Curvature
The stomach has such a rich, placenta-like blood supply that viability can be maintained through the vascular arcade of either curvature. The greater curvature can be freed by dividing the thickened gastrosplenic ligament in the region of the left gastroepiploic vessels. If the left gastric artery is to be retained, as much of the gastric-splenic omentum can be divided as is required for mobilization. The short gastric vessels should be ligated by transfixing sutures which include a bite in the gastric wall. Such fixation prevents loosening of the ligature with hemorrhage if subsequent gastric distention occurs. Mobilization of the entire greater curvature including the fundus may be desirable in high resections or to avoid a deep anastomosis under the costal margin. The upper end of the stomach can be greatly mobilized by dividing all of the peritoneal attachments about the esophagus and division of the vagus nerves. The benefits of mobilization following vagotomy tend to more than compensate for any undesirable late side effects of the denervation even in the presence of malignancy. Division and ligation of the uppermost and thickened portion of the gastrohepatic ligament also adds to mobilization. In addition, this procedure insures a clearer view posterior to the esophagus and fewer posterior vagus nerves will be overlooked. The exposure for ligation of the left gastric vessels or removal of all lymph drainage areas up to the esophagogastric junction is improved. When the left gastric vessels have been ligated at their point of origin at the celiac axis, the blood supply to the remaining mobilized fundus is dependent on the short gastrosplenic vessels.
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KELLER
Mobilization of the Spleen
The mobility of the spleen should always be determined. Because of the possibility of tearing the splenic capsule with subsequent splenectomy it should be mobilized only when necessary to insure an anastomosis without tension. This may be indicated when a Billroth I procedure is planned or following a radical gastric resection with removal of the lesser curvature. The spleen is gently retracted downward by the right hand of the surgeon. Regardless of his dexterity, the surgeon uses his left hand to divide the peritoneal attachment with long curved scissors. The upper pole of the spleen is first freed and the splenorenal ligament divided down to the region of the splenic flexure of the colon. Any restraining peritoneal filaments are divided as firm medial retraction is sustained. Tension on the gastrosplenic ligament can be relieved by placing small packs posterior to the mobilized spleen. When the anastomosis has been completed, the packs are removed and the spleen returned to its original bed. By utilizing these procedures, the stomach is freely mobilized and the surgeon can remove with greater safety and ease as much as he believes to be indicated. Management of the Duodenum
The complication of leakage from the closed duodenal stump or from necrosis about one of the angles of a gastroduodenal anatomosis can be held to a minimum by insuring a good blood supply and an adequate cuff of cleared serosa. The first part of the duodenum is much more vascular and the wall more friable in the presence of duodenal ulcer than with gastric ulcer or carcinoma. In duodenal ulcer there tends to be an insufficient amount of pliable duodenal wall with good vascularity, while there is adequate duodenum with relatively poor vascularity in lesions on the gastric side. The duodenum may be unduly elongated from the weight of a large, sagging carcinoma of the stomach and the blood supply too limited for the extra long cuff of the serosa which may be unwittingly prepared. The right gastroepiploic vessels below the pylorus are first isolated from the surrounding tissues and their communications with the superior mesenteric vessels are identified. These easily torn veins can cause troublesome bleeding. As the pylorus is held upward a small curved clamp is passed between the inferior duodenal wall and the pillar of tissues containing the right gastroepiploic vessels. The clamp is gently opened to separate the vessels from the duodenal wall and to permit the placement of three hemostats to this vascular pedicle. In the presence of malignancy the vessels should be ligated as far below any presenting infra pyloric lymph nodes as possible. The application of ligatures behind the two proximal hemostats insures a definite pedicle which may be used as a point of subsequent fixation for the inferior margin of a Billroth I anastomosis. The division of the right gastric vessels adds little to the mobility of the duodenum. These vessels, which often appear insignificant in size, are divided several centimeters from the superior margin of the duodenum in the region of the pylorus. This should be done under clear vision, in order to
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insure a good pedicle an adequate distance from the duodenum and avoid injury to the common duct or other important structures. It is helpful to depress the other structures in the hepatoduodenalligament with the middle finger of the left hand as the tissues containing the right gastric vessels are held firmly between the thumb and index finger. Straight clamps are used to develop a cleavage plane as they are spread open at right angles to the superior duodenal wall. Once again a pedicle is developed by the application of three hemostats with double ligature on the proximal side. At least 2.5 cm. of duodenum should be resected in the presence of carcinoma of the antrum. At least 1 cm. of both margins should be cleared of fatty tissue to insure a free serosal surface for the proper placement of the angle or closure sutures. The posterior wall of the duodenum may be attached to the adjacent capsule of the pancreas. Division of these attachB
c
Figure 1. Closure of Duodenal Stump. A, Preferred closure with double row of inverting sutures of nonabsorbable material. B, With posterior perforating ulcer and short duodenal cuff the anterior wall may be sutured to capsule of pancreas. C, When closure is insecure the stump may be drained externally by a catheter. D, A long Levin tube can be inserted through the gastroenteric stoma into the afferent loop for decompression.
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ments without injury to the nearby pancreaticoduodenal artery will provide additional surface for suturing. The posterior wall of the duodenum is surprisingly free of vascular attachment except for a small segment near the inferior margin. Noncrushing clamps of the Potts type insure a viable divided margin. The greatest challenge is encountered in the presence of deeply penetrating duodenal ulcers particularly near the common duct. The dangers of pancreatitis from ductal damage due to deeply placed sutures makes it mandatory to control all bleeding by meticulously placed superficial sutures. The finger may be inserted into the duodenum to provide countertraction as a small rim of posterior duodenal wall is developed. In rare instances the common duct may be opened above the duodenum and a longarm T-tube directed downward through the papilla of Vater to avoid obstruction of the common duct during closure of the duodenal stump. A twolayered closure of the duodenum using nonabsorbable sutures is preferred. Rather than risk a blowout of the duodenal stump because of limited amount of available duodenal wall for closure, other methods should be considered. The anterior wall of the duodenum can be anchored down to the posterior wall or to the fibrotic capsule of the pancreas. A catheter can be inserted into the lumen of the duodenum to provide drainage and the duodenal wall closed around it. Whenever the closure of the duodenum leaves any doubts as to its safety, it is advisable to provide adequate drainage to the area and to decompress the stump by directing a Levin tube through the gastrojejunal anastomosis around into the duodenum (Fig. 1). Soilage from the stomach must be held to a minimum in order to prevent sepsis. This is particularly true in the presence of achlorhydria. Resection of Stomach There is a tendency to overestimate the extent of the gastric resection. Certain landmarks can serve as guidelines for a hemigastrectomy as well as a radical gastric resection. Hemigastrectomy has been commonly performed to control the gastric phase of secretion in the treatment of duodenal ulcer and is usually combined with vagotomy to control the cephalic phase. The vascular landmarks can be used as approximate guides in the selection of the half-way point for resection. On the greater curvature, the area is selected where the gastroepiploic vessels are nearest to the gastric wall. A point is selected on the lesser curvature at the level of the third vein from the esophagogastric junction (Fig. 2). A more extensive resection of 60 to 75 per cent can be estimated if the left gastroepiploic is ligated and the blood supply on the lesser curvature divided as high as possible without ligation of the left gastric artery near its point of origin from the celiac axis. The division of the latter enhances the removal of the lymphatic drainage area to the lesser curvature in the presence of malignancy and insures a high radical gastric resection of more than 75 per cent. Ligation of the left gastric vessels should not be done if the spleen has been removed or the short
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gastric vessels ligated. If the left gastric vessels are to be divided, a finger should be passed around the column which incorporates the coronary vein and left gastric artery to facilitate the application of three hemostats. The contents of the hemostats are carefully tied to avoid vascular retraction and bleeding which can be difficult to control. The blood supply along the lesser curvature can be bluntly dissected away from the adjacent gastric wall. A small curved hemostat is directed under the fatty tissues at a point away from the veins extending down over the gastric wall. The left hand rotates the mobilized stomach as the clamp is passed on through under the tissues along the posterior wall. The jaws of the clamp are opened several times to bluntly separate the tissues from the underlying nonperitonealized surface between the anterior and posterior serosal surfaces of the stomach. A sizable portion of tissue may be doubly clamped and ligated. These ligatures should be transfixed to the serosa to prevent tearing of the blood supply away from the gastric wall. Additional sutures should be taken next to the ligated blood supply to approximate the serosal surfaces and obliterate the nonperitonealized zone of the lesser curvature (Fig. 3). An additional traction suture 1 fingerbreadth distally is placed to insure a prepared peritoneal surface around the lesser curvature for the placement of subsequent reconstruction sutures. Likewise, the greater curvature should be prepared with traction sutures 1 fingerbreadth apart next to the blood supply to insure accurate closure of the greater curvature. In the presence of malignancy all the lymphatic drainage area of the lesser curvature is commonly removed along with the width of the hand of adjacent gastric wall proximal to the lesion. While the surgeon tends to develop a favorite type of resection based on his experience and training, he should remain flexible in his choice because of the many variables which should alter his decision. Females and underweight or highly emotional patients tend to do better if a conservative procedure or conservative type of resection is performed. The decision for or against a Billroth I or gastroduodenal anastomosis should not be firmly made until the lesion, if malignant, has been adequately resected, or if benign ulcer, the acid factor controlled. Figure 2. Line of Resection. For hemigastrectomy the stomach is divided between the point on the lesser curvature at the third great vein from the esophagus and on the greater curvature where the gastroepiploic arcade most closely approximates the gastric wall. Seventy per cent resection includes nearly all the lesser curvature. with ligation of the left gastric artery and the left gastroepiploic artery at its origin.
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Figure 3. Bare area of lesser curvature. The nonperitonealized area on the lesser curvature is closed by approximating the peritoneal surfaces. Dotted line represents line of resection for hemigastrectomy.
Reconstruction Favor for the Billroth I or II procedure fluctuates depending upon the experience of the surgeon and the indications for the gastric resection. Gastroduodenostomy has been challenged because of the tendency to perform a limited resection which may not control the acid factor in duodenal ulcer or provide a sufficient margin beyond a gastric lesion. The utilization of the previously mentioned principles of mobilization, including the spleen and combined with vagotomy has obviated many of the previous objections. Indeed, it is not too unusual for the esophagus to be anastomosed to the duodenum in a thin individual with lax structures. Fear of leakage from one of the angles of the gastroduodenostomy due to technical difficulties in anastomosing the larger gastric opening to the smaller duodenal opening has tended to limit the acceptance of this procedure. The discrepancy in lumen size can be corrected in one of several ways. The serosal suture layer of interrupted mattress sutures can be placed to include a larger bite on the gastric side than on the duodenal side. It is technically easier and safer if the first suture includes the superior margins of both stomach and duodenum to avoid difficulties in sealing the superior angle. When these are tied, the gastric opening is puckered to the size of the duodenum. If the duodenal opening is too small as the sutures are tied, the Horsley principle is followed. This consists of incising the midportion of the anterior duodenal wall, allowing it to flare out to the required size. The incision is made parallel to the long axis of the duodenum (Fig. 4). The gastric outlet can be narrowed and hemostasis provided by the insertion of interrupted 4-0 silk sutures placed near the cut margin according to the von Haberer principle. The gastric wall is gradually puckered as these sutures are tied around the entire circumference of the gastric outlet.
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Additional sutures are placed and tied until the gastric outlet is similar in size to the duodenal opening. Since the normal pyloric canal is hardly larger than the index finger, no effort is made to provide an outlet larger than 2 fingerbreadths. The possible early postoperative delay in gastric emptying from a modest sized stoma must be weighed against fewer postgastrectomy complaints in the future. Added sealing of the angles and anchoring of the gastric wall help to avoid tension on the suture line. This is accomplished by tying the serosal guide sutures on either curvature about the vascular pedicles of the right gastric and gastroepiploic vessels. The limits of the stoma may be marked by applying several Cushing's silver clips along the serosal suture line. When the mobility of the duodenum is limited and a radical gastric resection is indicated, a Billroth II type of resection is performed. Many variations of this procedure have been proposed. The antecolic Hofmeister modification is probably the most commonly performed procedure of this type. If a retrocolic anastomosis is to be done, the opening in the mesocolon should be made to the left of the middle colic vessels. The gastric pouch should be firmly secured to the margins of this opening to prevent a subsequent internal hernia. The antecolic anastomosis is easier provided a retained thickened omentum is not compressed against the transverse colon. The upper one-half or more of the gastric outlet is closed by two layers of interrupted silk, leaving a stoma on the greater curvature side of approximately 2 fingerbreadths. This closure makes it unnecessary to carry out a high anastomosis under difficult technical conditions. The more flexible greater curvature facilitates an easier and more secure anastomosis. The jejunum can be secured to the closed end of the stomach to avoid
Figure 4. Gastroduodenostomy (Billroth I Anastomosis). The larger gastric lumen has been reduced by the puckering von Haberer sutures. The duodenal circumference can be increased by the Horsley maneuver (dotted line). Posterior suture layer has been placed. The long sutures over the vascular pedicles on the duodenal and gastric side are later tied together to reinforce the angles (A-A' and B-B').
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angulation and provide added security to the upper gastrojejunal anastomotic angle. Decompression of the gastric pouch is effectively and comfortably carried out by a temporary gastrostomy provided sufficient stomach remains. An inexpensive Pezzer catheter (16-18 French) is inserted through a stab wound at a previously tested site on the anterior gastric wall which can be easily approximated to the parietal peritoneum. Gastric bleeding is avoided by silk sutures placed at either side of the tube. The gastric wall is inverted about the tube to assure prompt closure of the gastric stoma when the catheter is removed. At the previously tested site a straight hemostat is passed through the abdominal wall. The peritoneal opening should be as far from the margins of the incision as possible to avoid contamination of the suture line in the wound closure. Likewise, the gastric wall is anchored to the peritoneum by several 00 silk sutures to the left of the point of the introduced hemostat. These are tied before the catheter is pulled through the stab wound to insure accurate approximation of the gastric wall. A sufficient number of sutures are placed about the catheter to insure a water-tight seal should it be accidentally pulled out in the early postoperative period. A long tube may be inserted in a similar fashion and directed around into the duodenum to insure decompression of the afferent loop down into the upper jejunum to facilitate early alimentation.
Wound Closure In the presence of emaciation, recent massive hemorrhage, chronic cough, obesity or malignancy, the addition of retention sutures to the wound closure should be considered. The blood volume should be sustained, pulmonary complications anticipated, and effective decompression of the gastric pouch maintained. Intravenous fluids should be given judiciously and the serum electrolytes monitored frequently in order to avoid electrolyte imbalance and errors of hydration. Gastric surgery requires an understanding of physiology seldom demanded in surgery of the remainder of the alimentary tract.
REFERENCES 1. Grant, G. N., Elliott, D. W. and Frederick, P. L.: Postoperative decompression by
temporary gastrostomy or nasogastric tube. A.M.A. Arch. Surg. 85: 844, 1962. 2. Klug, T. J., Zollinger, R. M. and Ellensohn, J.: A long-term evaluation of two conservative surgical procedures for duodenal ulcer. Am. J. Surg. 105: 370, 1963. 3. Zollinger, R. M.: Late postoperative problems following radical surgery of the . stomach and pancreas. Postgrad. Med. 23: 297, 1958. 4. Zollinger, R. M.: Technic of vagotomy, hemigastrectomy, and Billroth I anastomosis. Am. J. Surg. 105: 413, 1963. 5. Zollinger, R. M. and Stewart, W. R. C.: Surgical management of gastric ulcer. J.A.M.A. 171: 2056, 1959. 410 West 10th Avenue Columbus, Ohio 43210