Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult
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CHAPTER 26 • Gastric Resection: Billroth I 279
Incision line
Pylorus
Incision
line
Right gastric
artery
Left gastric
artery
Gastroduodenal
artery
Splenic artery
Gastroepiploic
artery
MC
FIGURE 2 6–1
FIGURE 2 6–2
280 Section IV • The Abdomen
2. DISSECTION
◆ The greater curvature of the stomach is mobilized by serial division of the gastric branches
of the gastroepiploic vessels. The lesser curvature is then mobilized by serially dividing the
gastrohepatic ligament to the point of planned transection of the stomach. The left gastric
vessels are then identifi ed, clamped, and ligated (Figure 26-3).
◆ After the lesser curvature has been mobilized, proximal to the left gastric artery and distal
to the gastric duodenal artery, Kocher or Payr clamps are applied to the stomach and the
stomach is divided with a scalpel (Figure 26-4).
CHAPTER 26 • Gastric Resection: Billroth I 281
Ligate and divide
gastric artery
FIGURE 26 –3
Divide stomach
FIGURE 26 –4
282 Section IV • The Abdomen
◆ Excess gastric tissue is removed, which includes the crushed tissue from the placement of
the clamp (Figure 26-5).
◆ The lesser curvature side of the gastric division is then closed using a running nonabsorb-
able suture (Figure 26-6), this is carried down to the point of the Kocher clamp, which is
on the greater curvature side where the gastroduodenal anastomosis will be performed
(Figure 26-7).
Removing excess
gastric tissue
FIGURE 26 –5
FIGURE 26 –6
FIGURE 26 –7
CHAPTER 26 • Gastric Resection: Billroth I 283
◆ After the distal stomach is fully mobilized, the proximal duodenum is divided between
Kocher clamps just distal to the pylorus (Figure 26-8).
◆ The gastroduodenal anastomosis is then performed by placing interrupted seromuscular
sutures with 3-0 nonabsorbable sutures placed in Lembert fashion (Figure 26-9).
◆ Excess duodenal tissue is removed using electrocautery (Figure 26-10).
Pylorus
Incising distal
to pylorus
Portion of
stomach removed
FIGURE 26 –8
FIGURE 26 –9
Removing excess
duodenal tissue
FIGURE 26 –10
284 Section IV • The Abdomen
◆ The anastomosis is completed using a running full-thickness 3-0 absorbable suture such as
chromic or Vicryl (Figure 26-11).
◆ At the end of the posterior row, the sutures are brought out and the corner is turned by
converting to a running Connell suture. The continuous Connell suture is carried around
anteriorly and tied together (see Figure 26-11).
◆ The anterior suture line is then reinforced with interrupted seromuscular 3-0 silk sutures
(Figure 26-12).
◆ The completed gastroduodenal anastomosis is shown in Figure 26-13.
CHAPTER 26 • Gastric Resection: Billroth I 285
FIGURE 26 –11
FIGURE 26 –12
FIGURE 26 –13
286 Section IV • The Abdomen
◆ Figure 26-14 demonstrates transection of the duodenum using the stapler, usually a gastro-
intestinal anastomosis (GIA) stapler. The lesser and greater curvatures have been dissected
as noted previously, and the left gastric artery is divided between clamps.
◆ The proximal stomach is then stapled using the transanastomotic (TA) stapler device and
transected staying right on the staple line using the scalpel (Figure 26-15).
Ligate and divide
gastric artery
FIGURE 26 –14
Divide stomach
FIGURE 26 –15
CHAPTER 26 • Gastric Resection: Billroth I 287
◆ Figure 26-16 shows the stapled end of the stomach and the duodenal stump.
◆ As shown in Figure 26-17, preparation for the gastroduodenal anastomosis is performed by
trimming excess gastric tissue and opening the staple line on the greater curvature side of
the stomach. This is accomplished with electrocautery. The staple line is also removed from
the duodenal stump using electrocautery (see Figure 26-17).
Removing excess
gastric tissue
Duodenal stump
Preserved stomach
FIGURE 26 –16
FIGURE 26 –17
288 Section IV • The Abdomen
◆ The posterior gastroduodenal anastomosis is then performed by fi rst placing interrupted
3-0 silk sutures in Lembert fashion (Figure 26-18).
◆ The inner layer is performed using a running 3-0 nonabsorbable suture (Figure 26-19) and
then carried anteriorly in a Connell fashion (Figure 26-20).
◆ The anastomosis is completed with anterior interrupted 3-0 silk sutures placed in Lembert
fashion (Figure 26-21).