Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

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CHAPTER 24 • Finney Pyloroplasty 269

Duodenum

Continuous

incision

(all layers)

Antrum

FIGURE 24 –2

Antrum

Pylorus

Duodenum

Running closure

of posterior

mucosal layer

FIGURE 24 –3

270 Section IV • The Abdomen

Duodenum

Running closure

of anterior

mucosal layer

Antrum

FIGURE 24 –4

Antrum

Duodenum

Interrupted

seromuscular stitches

FIGURE 24 –5

CHAPTER 24 • Finney Pyloroplasty 271

3. CLOSING

◆ The incision is closed in layers using 2-0 polyglactin in a running fashion. The subcutane-

ous tissue is reapproximated with a running 3-0 polyglactin suture. The skin can be stapled

together or closed with a running subcuticular suture of 4-0 undyed absorbable monoﬁ la-

ment and adhesive strips.

STEP 4: POSTOPERATIVE CARE

◆ The patient should have already received a preoperative dose of a prophylactic antibiotic

such as cefazolin. Two additional doses should be given after the operation. Hydration will

be maintained with an intravenous infusion of a balanced dextrose and electrolyte solution.

Intravenous analgesics are used until the patient resumes enteral feeds. The decision to

decompress the stomach with a nasogastric tube is up to the individual surgeon, and the

current tendency is to use these tubes sparingly. Certainly, if the repair was deemed to be

tenuous, a nasogastric tube could prove to be very helpful. After 2 to 3 days (on average),

enteral feeds can be slowly and gradually resumed. The presence of bile in the gastric aspi-

rate does not necessarily represent a persistent postoperative paralytic ileus, because it could

be the result of the pyloroplasty itself, and it should not be a reason for undue delays in

resumption of enteral feeds. Pain, abdominal distention, tachycardia, and guarding should

prompt the surgeon to order a contrast study to investigate for leaks in the suture line.

STEP 5: PEARLS AND PITFALLS

◆ As mentioned previously, avoidance of tension on the suture line is essential. This is accom-

plished by a generous Kocher maneuver. Avoid approximating the antrum and duodenum

in such a manner that both structures have to be excessively rolled inward to approximate

the anterior layers. This can be achieved by placing the posterior seromuscular stitches as

posterior as possible (taking care not to involve the ampulla of Vater in the suture line),

giving ample room to perform the incisions in both the duodenum and antrum and

complete the anastomosis with minimal tension.

◆ As with any pyloroplasty, alkaline reﬂ ux, alkaline gastritis, and dumping syndrome can be

problematic. Suture line leaks can result from undue tension or the approximation of

acutely inﬂ amed or poorly perfused tissues.

SELECTED REFERENCES

1. Mercer DW: Stomach. In Townsend CM, Beauchamp RD, Evers MB, Mattox KL (eds): Sabiston Textbook

of Surgery, 17th ed. Philadelphia, Saunders, 2004, pp 1265-1317.

2. Warner BW: Pediatric surgery. In Townsend CM, Beauchamp RD, Evers MB, Mattox KL (eds): Sabiston

Textbook of Surgery, 17th ed. Philadelphia, Saunders, 2004, pp 2097-2132.

272

INTRODUCTION

This bypass operation is indicated in the presence of marked inﬂ ammation or scarring of the

pylorus that precludes a Heineke-Mikulicz pyloroplasty. The procedure can be performed using

a standard handsewn technique or a stapler. The handsewn technique described in this chapter

is a two-layer anastomosis with a running inner layer of 3-0 absorbable sutures and a seromus-

cular outer layer of interrupted 3-0 silk sutures.

STEP 1: SURGICAL ANATOMY

◆ The pylorus sits at the distal end of the stomach and is marked by thickening of the circular

smooth muscle layer, thus forming the pyloric sphincter, which acts as a valve between the

stomach and the duodenum and regulates gastric emptying. The pylorus does not have

independent blood supply; rather, it gets its blood supply from the vessels that perfuse the

distal stomach and proximal duodenum. Innervation of the pylorus is through the terminal

branches of the right and left vagus nerves. Any injury to these nerves or denervation of the

pylorus will result in pylorospasm and delayed gastric emptying.

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Conﬁ rmation of the diagnosis of peptic ulcer disease or delay in gastric emptying should

be documented before the procedure with endoscopy, contrast studies, or technetium-99

sulfur colloid meals.

CHAPTER

Jaboulay Side-to-Side

Gastroduodenostomy

Carlos A. Angel

CHAPTER 25 • Jaboulay Side-to-Side Gastroduodenostomy 273

STEP 3: OPERATIVE STEPS

1. INCISION

◆ The operation can be performed through a limited midline supraumbilical laparotomy. The

skin incision is made with the knife, and the rest of the layers are divided with electrocau-

tery, taking care to stay in the midline and paying close attention to hemostasis. Once the

peritoneum is opened, the surgeon’s ﬁ ngers or a malleable retractor can be used to protect

the intestines from enterotomies.

2. DISSECTION

◆ After wide mobilization of the duodenum with a generous Kocher maneuver, the pylorus is

grasped with a Babcock forceps and a 3-0 silk stitch is placed approximately 7 cm distal from

this point to approximate the antrum and duodenum (Figures 25-1 and 25-2). Approximately

6 to 8 cm of duodenum and antrum are approximated with 3-0 silk, interrupted seromuscular

sutures (see Figure 25-2). The duodenum is incised down to the mucosa on both duodenal

and antral sides. Bleeding points are cauterized (Figure 25-3). Antral and duodenal mucosas

are sharply opened. Bleeding is controlled with cautery (Figure 25-4). The mucosa is approxi-

mated with a continuous, simple stitch of 3-0 absorbable suture, starting with the posterior

portion and ﬁ nishing anteriorly (Figures 25-5 and 25-6). The anastomosis is completed with

interrupted 3-0 silk seromuscular stitches (Figure 25-7).

3. CLOSING

◆ The incision is closed in layers using 2-0 polyglactin in a running fashion. The subcutane-

ous tissue is reapproximated with a running 3-0 polyglactin suture. The skin can be stapled

together or closed with a running subcuticular suture of 4-0 undyed absorbable monoﬁ la-

ment and adhesive strips.

STEP 4: POSTOPERATIVE CARE

◆ The patient should have already received a preoperative dose of a prophylactic antibiotic

such as cefazolin. Two additional doses are in order after the operation. Hydration will

be maintained with an intravenous infusion of a balanced dextrose and electrolyte solu-

tion. Intravenous analgesics are used until the patient resumes enteral feeds. The deci-

sion to decompress the stomach with a nasogastric tube is up to the individual surgeon,

and the current tendency is to use these tubes sparingly. Certainly, if the repair was

deemed to be tenuous, a nasogastric tube could prove to be very helpful. After 2 to

3 days (on average), enteral feeds can be slowly and gradually resumed. The presence

of bile in the gastric aspirate does not necessarily represent a persistent postoperative

paralytic ileus, because it could be the result of the pyloroplasty itself and it should not

be a reason for undue delays in resumption of enteral feeds. Pain, abdominal distention,

tachycardia, and guarding should prompt the surgeon to order a contrast study to

investigate for leaks in the suture line.

Text continued on p. 277

274 Section IV • The Abdomen

Antrum

Grasped with

Babcock forceps

Pylorus

Duodenum

Pancreas

FIGURE 25 –1

Duodenum

First row of

interrupted sutures

Incision through

prepyloric area

FIGURE 25 –2

CHAPTER 25 • Jaboulay Side-to-Side Gastroduodenostomy 275

Antrum

Grasped with

Babcock forceps

Duodenum

FIGURE 25 –3

Duodenum

Opening of

mucosa on

both sides

Antrum

FIGURE 25 –4

276 Section IV • The Abdomen

Antrum

Grasped with

Babcock forceps

Closure of

posterior

mucosal layer

Duodenum

FIGURE 25 –5

Duodenum

Closure of

mucosal layer

Antrum

FIGURE 25 –6

CHAPTER 25 • Jaboulay Side-to-Side Gastroduodenostomy 277

Duodenum

Layer of interrupted

seromuscular

stitches

Antrum

STEP 5: PEARLS AND PITFALLS

◆ As mentioned, avoidance of tension on the suture line is essential. This is accomplished

by a generous Kocher maneuver. Avoid approximating the antrum and duodenum in

such a manner that both structures have to be excessively rolled inward to approximate

the anterior layers. This can be achieved by placing the posterior seromuscular stitches

as posterior as possible (taking care not to involve the ampulla of Vater in the suture

line), giving ample room to perform the incisions in both the duodenum and antrum

and complete the anastomosis with minimal tension.

COMPLICATIONS

◆ As with any pyloroplasty, alkaline reﬂ ux, alkaline gastritis, and dumping syndrome can be

problematic. Suture line leaks can result from undue tension or the approximation of

acutely inﬂ amed or poorly perfused tissues.

SELECTED REFERENCES

1. Mercer DW: Stomach. In Townsend CM, Beauchamp RD, Evers MB, Mattox KL (eds): Sabiston Textbook

of Surgery, 17th ed. Philadelphia, Saunders, 2004, pp 1265-1317.

2. Warner BW: Pediatric surgery. In Townsend CM, Beauchamp RD, Evers MB, Mattox KL (eds): Sabiston

Textbook of Surgery, 17th ed. Philadelphia, Saunders, 2004, pp 2097-2132.

FIGURE 25 –7

278

STEP 1: SURGICAL ANATOMY

◆ The blood supply to the stomach is abundant. The right gastric artery, a branch from the

hepatic artery, courses along the lesser curvature of the stomach to meet the left gastric

artery, which is a branch of the celiac axis. The right gastroepiploic artery, a branch of the

gastroduodenal artery, courses along the greater curvature of the stomach to meet the left

gastroepiploic artery, which is a branch of the splenic artery. In addition, the stomach

receives short gastric branches from the splenic artery. The venous drainage of the stomach

is into the portal venous system (Figure 26-1).

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ The Billroth I procedure for gastroduodenostomy is the most physiologic type of gastric

resection, because it restores normal gastroduodenal continuity. It has been the preferred

treatment of gastric ulcer or antral cancer by a number of surgeons; however, its use for

duodenal ulcer has been less popular. The principal contraindications to a Billroth I oper-

ation include edema from acute or recurrent inﬂ ammation and scarring and deformation

secondary to chronic disease.

STEP 3: OPERATIVE STEPS

1. INCISION

◆ An upper midline incision or subcostal incision is an acceptable option for performing this

procedure. The line of division varies according to the extent of resection required. The

dashed line indicates an approximate 50% gastric transection with a line from the lesser

curvature slightly proximal to the incisura angularis (Figure 26-2).

CHAPTER

Gastric Resection: Billroth I

B. Mark Evers