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

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CHAPTER 32 • Gastrojejunostomy 339

◆ Interrupted 3-0 silk sutures, placed in Lembert fashion, complete the anterior portion of

the two-layer gastrojejunostomy (Figure 32-8).

◆ If a retrocolic gastrojejunostomy is thought to be necessary, sites for anastomosis to the

stomach and jejunum are identiﬁ ed as shown in the dashed lines in Figure 32-9. The

transverse colon is then lifted cephalad to visualize the mesentery and identify an avascular

area in which to bring the jejunal loop, as noted by the dashed lines.

Complete antecolic

gastrojejunostomy

FIGURE 32 –8

Transverse colon, and

stomach mobilized

cephalad

Sites for

anastomosis

FIGURE 32 –9

340 Section IV • The Abdomen

◆ A handsewn anastomosis is performed in the fashion already described using a two-layer

anastomosis with a posterior row of 3-0 silk interrupted sutures. The jejunal and gastric

stomas are then created using electrocautery (Figure 32-10).

◆ The inner layer of the anastomosis is accomplished using a running full-thickness absorb-

able suture (Figure 32-11).

Running closure

of posterior

mucosal layer

FIGURE 32 –11

Creating a gastric stoma

Jejunal stoma

FIGURE 32 –10

CHAPTER 32 • Gastrojejunostomy 341

◆ The retrocolic gastrojejunostomy is then completed using interrupted 3-0 silk seromuscular

sutures placed anteriorly (Figure 32-12).

◆ Similar techniques are used to perform a stapled anastomosis (Figure 32-13).

Completing retrocolic

gastrojejunostomy

FIGURE 32 –12

Transverse colon, and

stomach mobilized

cephalad

Site for

anastomosis

FIGURE 32 –13

342 Section IV • The Abdomen

◆ The jejunal and gastric stomas are created using electrocautery. The opening should be large

enough to allow entry of the stapling device (Figure 32-14).

◆ The retrocolic gastrojejunostomy is then completed using the GIA stapler (Figure 32-15).

Site of gastric stoma

Creating a jejunal stoma

FIGURE 32 –14

Completing retrocolic

gastrojejunostomy

with stapler

FIGURE 32 –15

CHAPTER 32 • Gastrojejunostomy 343

◆ The openings created in the stomach and jejunum are closed together using a GIA or a TA

stapler (Figure 32-16).

◆ Figure 32-17 demonstrates the completed retrocolic anastomosis.

3. CLOSING

◆ The midline incision is closed in the usual fashion.

Removing excess

gastrojejunal tissue

FIGURE 32 –16

FIGURE 32 –17

344 Section IV • The Abdomen

STEP 4: POSTOPERATIVE CARE

◆ Postoperative care is achieved as previously noted for other gastric procedures. A nasogas-

tric tube is usually maintained postoperatively on suction, and once bowel function returns,

the tube is removed and a diet initiated.

STEP 5: PEARLS AND PITFALLS

◆ If the retrocolic approach is used, most surgeons loosely suture the edges of the mesenteric

rent to the jejunum, to minimize risk of herniation of a bowel loop.

◆ Care should be taken to clearly identify the proximal jejunum in which to make the gastro-

jejunostomy. A rare but tragic error is to mistakenly perform the anastomosis between the

stomach and ileum.

SELECTED REFERENCES

1. Mercer DW, Robinson EK: Stomach. In Townsend CM Jr (ed): Sabiston Textbook of Surgery: The Biological

Basis of Modern Surgical Practice, 18th ed. Philadelphia, Saunders, 2008, pp 1223-1277.

2. Thompson JC: Gastrojejunostomy. In Thompson JC (ed): Atlas of Surgery of the Stomach, Duodenum and

Small Bowel. St Louis, Mosby-Year Book, 1992, pp 77-81.

345

STEP 1: SURGICAL ANATOMY

◆ The pylorus sits at the distal end of the stomach. It 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

◆ The diagnosis is conﬁ rmed when, in an infant or child with a history of postprandial, non-

bilious vomiting, the pyloric “olive” can be palpated. If this is not possible, hypertrophic

pyloric stenosis can be conﬁ rmed by sonography when the pyloric muscle width is greater

than 4 mm.

◆ These infants often present with hypochloremic metabolic alkalosis and dehydration. Intra-

venous hydration, correction of metabolic disturbances, and establishment of adequate

urine output are imperative before pyloromyotomy.

◆ The operation is performed with the patient under general endotracheal anesthesia. Gastric

contents are suctioned thoroughly. Rapid sequence induction is used to prevent aspiration

of gastric contents.

◆ The patient is placed supine on the operating table. A folded towel under the thoracic

vertebrae facilitates exposure to the pylorus. The abdomen is painted with iodine solution.

CHAPTER

Pyloromyotomy

Carlos A. Angel

STEP 3: OPERATIVE STEPS

1. INCISION

◆ A transverse incision 2 to 3 cm long is made in the right upper quadrant. This incision

can be made midway between the xiphoid and umbilicus, just off the midline to the right

side. The anterior rectus fascia is opened in the direction of the incision, the rectus muscle

is divided transversely using electrocautery, and the posterior rectus fascia and peritoneum

are opened in the direction of the incision. If necessary, on the lateral side, the incision

may be extended by division (for a short distance) of the internal oblique and transversus

abdominis muscles to facilitate the delivery of the pyloric olive from the abdominal cavity

(Figure 33-1). Alternatively, a transumbilical approach may be performed by making a

semicircular incision superior to the umbilicus with a small cephalad extension (like a

Mercedes Benz star). The skin is undermined, and the rectus fascia is opened in the mid-

line for a distance of approximately 2.5 cm. The peritoneum is opened, and the pyloric

tumor is delivered into the operating ﬁ eld by gentle traction on the antrum. After the

pyloromyotomy, closure is performed with running 5-0 polyglactin sutures for the fascia,

the most cephalad portion of the skin is reapproximated to the umbilicus, excess skin is

trimmed on both the right and left sides, and skin closure is completed with 6-0 polyglac-

tin sutures leaving a very well-hidden small semi-circular supraumbilical scar. Since there

is more extensive dissection and undermining of the skin with this incision, I routinely

administer a pre-operative dose and two post-operative doses of intravenous cefazolin to

these patients.

Section IV • The Abdomen346

CHAPTER 33 • Pyloromyotomy 347

FIGURE 33–1

348 Section IV • The Abdomen

2. DISSECTION

◆ Upon entering the abdomen, the surgeon uses a small, malleable retractor over a moist gauze

to retract the liver and the falciform ligament cephalad and to the right side of the patient.

This maneuver usually exposes the greater curvature of the stomach. If the stomach is not

exposed, gentle caudal traction on the transverse colon will expose the greater curvature of

the stomach. Any attempts to grasp the pyloric tumor directly must be avoided because the

tumor is friable and will easily tear and bleed. With the stomach ﬁ rmly grasped (a sponge

will help, because the stomach is slippery), the surgeon applies gentle to-and-fro rocking

traction to deliver the pylorus out of the incision (Figure 33-2). Palpation of the tumor will

allow precise identiﬁ cation of the pyloroduodenal junction, because the tumor feels ﬁ rm and

the duodenum is very soft. There is a relative avascular plane on the anterior surface of the

pylorus. A superﬁ cial serosal incision is made over this avascular plane, extending it distally

just proximal to the pyloroduodenal junction and proximally to the junction of the antrum

and pylorus; the length of this incision is 2 to 3 cm (Figure 33-3). There is a critical zone of

folded duodena mucosa in a very superﬁ cial position at the pyloroduodenal junction. This is

the area where perforations more commonly occur. Using a knife handle or another blunt

instrument, the surgeon splits the brittle pyloric muscle in the middle of the pyloromyotomy

down to the submucosa by gently pushing over the incision while supporting the pylorus

with the other hand. No attempts are made to split the muscle toward the duodenal side.

Using a pyloric spreader or a hemostat (ensuring that the tips are well above the mucosa),

the surgeon spreads the muscle beginning in the middle of the incision and then proceeding

distally and proximally (Figure 33-4). Hemostasis is performed with a ﬁ ne-tipped cautery at

low setting; touching the mucosa with the cautery must be avoided. Completeness of the

pyloromyotomy is conﬁ rmed when the two halves of the muscle move independently from

each other (Figure 33-5). Now the pylorus is placed back in the abdomen and a clean gauze

is placed on top of the pyloromyotomy for 2 minutes and subsequently inspected for the

presence of bile, gastric juice, or excessive bleeding. Closure is performed in layers with run-

ning 5-0 or 6-0 polyglactin sutures. The skin is closed with a running 6-0 polyglactin subcu-

ticular sutures after inﬁ ltration with 0.25% bupivacaine and is dressed with Steri-Strips.

FIGURE 33–2