HEMIGASTRECTOMY, BILLROTH I STAPLED

INDICATIONS

The Billroth I gastric resection along with truncal vagotomy is frequently performed for intractable duodenal ulcer or benign gastric ulcer. The procedure may be performed when hemigastrectomy is carried out for a variety of other reasons. It is hoped that this reconstruction to a normal configuration will result postoperatively in few symptoms and improved nutrition.

PREOPERATIVE PREPARATION

The stomach is aspirated preoperatively, and nasogastric suction is maintained. Antibiotics are given to patients with achlorhydria, since they may have significant bacterial colonization of the duodenum or stomach.

ANESTHESIA

Routine general anesthesia is given via a cuffed endotracheal tube.

POSITION

The patient is placed supine on the table in a modest reverse Trendelenburg position.

OPERATIVE PREPARATION

The skin of the lower chest and upper abdomen is shaved and prepared in the routine manner with antiseptic solutions.

DETAILS OF PROCEDURE

When there is evidence of malignancy, the stomach should be resected with the width of the hand

(7.5 to 10 cm) beyond the upper margins of the tumor. When the lesion is near the pylorus, at least 2.5 cm of the duodenum should be resected, along with the omentum and any lymph nodes about the right gastroepiploic veins.

The Billroth I procedure for control of peptic ulcer should include vagotomy (see Vagotomy and Vagotomy, Subdiaphragmatic Approach) as well as a hemigastrectomy. The stomach is transected at the third vein on the lesser curvature and on the greater curvature where the gastroepiploic arterial blood supply is nearest the greater curvature (see Gastrectomy, Subtotal, Figure 1). These anatomic landmarks ensure a complete antrectomy with control of the hormonal phase of gastric secretion.

As shown in Gastrectomy, Subtotal, the duodenum and stomach are mobilized. A modified Furniss clamp is placed across the duodenum at the appropriate level, and a purse-string suture of monofilament polypropylene on a straight needle is introduced (Figure 1). This automatically creates a purse string on the duodenal stump. The duodenum is divided and the previously selected site for division of the stomach should be cleared of fat in order to ensure good approximation of the anterior and posterior walls of the stomach by the TA90 stapler. The longer staples are usually needed for the thick walls of the stomach. Any bleeding points are controlled with additional sutures.

A GIA 60 gastrotomy is made for the intragastric introduction of the EEA instrument through the anterior gastric wall at right angles to and about 3 to 5 cm distant to the staple line closure of the distal stomach (Figure 1). Any bleeding from the margins of the gastrotomy are controlled by interrupted sutures of either silk or absorbable materials.

The closed end of the stomach is reflected to the left, and the posterior gastric wall is grasped with a Babcock forceps 3 to 5 cm from the midportion of the staple line closing the distal stomach. A gastric purse string using a nonabsorbable suture is placed full thickness through the gastric wall about the Babcock. The central point is opened with an electrocautery puncture. The EEA stapler of the appropriate size is entered into the stomach with its detachable pointed plastic trocar exiting the back wall of the stomach through the punctate opening in the center of the purse string. The plastic trocar is removed and replaced with the metal anvil cap. The gastric wall is then securely closed with the purse string (Figure 2). The cap is screwed onto the tip of the center rod and it is inserted into the duodenum (Figure 3). The monofilament polypropylene purse string around the end of the duodenum is snugged and securely tied (Figure 4). The wing nut on the near end of the EEA handle is turned until the stomach and the duodenum are firmly approximated. The safe zone indicator is checked to be certain that the thickness of the combined stomach and duodenum are within correct range of the staples. The safety is released, and the outside handles are squeezed. A double staggered, circular tow of staples is created, and an internal circular knife cuts the bowel walls within the staple lines simultaneously. The wing nut is loosened so that the anvils open, and the stapling instrument is gently removed (Figure 5). The doughnuts of tissue are carefully inspected to be certain there is no defect or discontinuity in the anastomosis. Several additional interrupted sutures may be placed to reinforce the anastomosis. The outer-wall gastrotomy opening is closed with a mucosa-to-mucosa TA60 (Figure 6).

Alternatively, some prefer to introduce the EEA into the open distal end of the stomach (Figure 7) and direct the rod through the center of a previously placed purse-string suture in the posterior gastric wall approximately 3 cm from the proposed line of resection. The duodenal opening is checked with a sizing instrument; the 28-mm EEA is most commonly used. The cap is applied to the rod, and it is introduced into the open end of the transected duodenum (Figure 8). The monofilament polypropylene purse-string suture around the duodenal wall is tied tightly (Figure 9).

 

 

The anvil and cap are approximated and the instrument is fired. The stapler is opened and then gently rocked back and forth and the line of staples stabilized with one hand as the tilted head of the instrument is slowly removed. Additional interrupted sutures may be indicated about the staple line (Figure 10). The posterior wall of the stomach may be opened longitudinally for a short distance to obtain better visualization of the suture line. Thereafter, the TA90 stapler with the longer gastric staples is applied to transect the avascular distal antrum of the stomach (Figure 11). This may be the preferred method, since the anterior-wall suture line created by the gastrotomy for introduction of the stapler is avoided (Figure 12).

 

 

CLOSURE

A small nasogastric (NG) tube may be inserted for decompression and later feedings. The incision is closed in a routine manner.

POSTOPERATIVE CARE

Daily weight, fluid, and electrolyte measurements are recorded until the patient is taking adequate fluids and nutrition by mouth. Clear liquids are permitted on the first postoperative day. Oral intake should be restricted if there is a feeling of fullness or if vomiting occurs. Measurement of gastric output or residuals after the NG tube is clamped for 4 hours may be useful in timing the restart of oral intake. Six daily small feedings with limitation of sweets and milk may be helpful for several weeks.

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HEMIGASTRECTOMY, BILLROTH I METHOD

INDICATIONS

The Billroth I procedure for gastroduodenostomy is the most physiologic type of gastric resection, since it restores normal continuity. Although long preferred by some in the treatment of gastric ulcer or antral carcinoma, its use for duodenal ulcer has been less popular. Control of the acid factor by vagotomy and antrectomy has permitted retention of approximately 50 percent of the stomach while ensuring the lowest ulcer recurrence rate of all procedures (Figure 1). This allows an easy anastomosis without tension, providing both stomach and duodenum have been thoroughly mobilized. Furthermore, the poorly nourished patient, especially the female, has an adequate gastric capacity for maintaining a proper nutritional status postoperatively. Purposeful constriction of the gastric outlet to the size of the pylorus tends to delay gastric emptying and decrease postgastrectomy complaints. Gastrin levels are determined.

PREOPERATIVE PREPARATION

The patient's eating habits should be evaluated, and the relationship between his or her preoperative and ideal weight should be determined. The retention of an adequate gastric capacity as well as reestablishment of a normal continuity tends to give the best assurance of a satisfactory nutritional status in undernourished patients, especially females.

ANESTHESIA

General anesthesia via an endotracheal tube is used rather routinely.

POSITION

The patient is laid supine on the flat table, the legs being slightly lower than the head. If the stomach is high, a more erect position is preferable.

OPERATIVE PREPARATION

The skin is prepared in a routine manner.

INCISION AND EXPOSURE

A midline or left paramedian incision is usually made. If the distance between the xiphoid and the umbilicus is relatively short, or if the xiphoid is quite long and pronounced, the xiphoid is excised. Troublesome bleeding in the xiphocostal angle on either side will require transfixing sutures of fine silk and bone wax applied to the end of the sternum. Sufficient room must be provided to extend the incision up over the surface of the liver, because vagotomy is routinely performed with hemigastrectomy and the Billroth I type of anastomosis, especially in the presence of duodenal ulcer.

DETAILS OF PROCEDURE

The Billroth I procedure requires extensive mobilization of the gastric pouch as well as the duodenum. This mobilization should include an extensive Kocher maneuver for mobilization of the duodenum. In addition, the greater omentum should be detached from the transverse colon, including the region of the flexures. In many instances the splenorenal ligament is divided, as well as the attachments between the fundus of the stomach and the diaphragm. Additional mobility is gained following the division of the vagus nerves and the uppermost portion of the gastrohepatic ligament. The stomach is mobilized so that it can be readily divided at its midpoint. The halfway point can be estimated by selecting a point on the greater curvature where the left gastroepiploic artery most nearly approximates the greater curvature wall (Figure 1). The stomach on the lesser curvature is divided just distal to the third prominent vein on the lesser curvature.

Extensive mobilization of the duodenum is essential in the performance of the Billroth I procedure. Should there be a marked inflammatory reaction, especially in the region of the common duct, a more conservative procedure, such as a pyloroplasty or gastroenterostomy and vagotomy, should be considered. If it appears that the duodenum, especially in the region of the ulcer, can be well mobilized, the peritoneum is incised along the lateral border of the duodenum and the Kocher maneuver is carried out. Usually it is unnecessary to ligate any bleeding points in this peritoneal reflection. With blunt finger and gauze dissection the peritoneum can be swept away from the duodenal surface as the duodenum is grasped in the left hand and reflected medially (Figure 2). It is important to remember that the middle colic vessels tend to course over the second part of the duodenum and are many times encountered rather suddenly and unexpectedly. For this reason the hepatic flexure of the colon should be directed downward and medially and the middle colic vessels identified early (Figure 2). As the posterior wall of the duodenum and head of the pancreas are exposed, the inferior vena cava readily comes into view. The firm, white, avascular ligamentous attachments between the second and third parts of the duodenum and the posterior parietal wall are divided with curved scissors, down through and almost including the region of the ligament of Treitz (Figure 2). Thisextensive mobilization is carried downward in order to ensure a very thorough mobilization of the duodenum. Following this, the omentum is separated from the colon, as described in Gastrectomy, Subtotal—Omentectomy. In obese patients it is usually much easier to start the mobilization by dividing the attachment between the splenic flexure of the colon and the parietes (Figure 3). An incision is made along the superior surface of the splenic flexure of the colon as the next step in freeing up the omentum. This should be done in an avascular cleavage plane. The lesser sac is entered from the left side. Care should be taken not to apply undue traction upon the tissues extending up to the spleen, since the splenic capsule may be torn, and troublesome bleeding, even to the point of requiring splenectomy, may be encountered.

The omentum is then dissected free throughout the course of the transverse colon.

The left lobe of the liver is then mobilized, and a vagotomy carried out as described in Vagotomy, Subdiaphragmatic Approach, Figures 1, 2, 3, 4, 5, 6, 7, and 8. At this point considerable distance can be gained if the peritoneum attaching the fundus of the stomach to the base of the diaphragm is divided up to and around the superior aspect of the spleen. If the exposure appears difficult, it is advisable for the surgeon to retract the spleen downward with his right hand and, using long curved scissors in his left hand, divide the avascular splenorenal ligament (see Splenectomy, Figures 5 and 6). It must be admitted that sometimes troublesome bleeding does occur, which requires an incidental splenectomy, but in general greatmobilization of the stomach is accomplished by this maneuver. Any bleeding from the splenic capsule should be controlled by conservative measures to minimize the need for splenectomy.

So far, the surgeon is not committed to any particular type of gastric resection but has ensured an extensive mobilization of the stomach and duodenum. The omentum should be reflected upward and the posterior wall of the stomach dissected free from the capsule of the pancreas, should any adhesions be found in this area. In the presence of a gastric ulcer, penetration through to the capsule of the pancreas may be encountered. These adhesions can be pinched off between the thumb and index finger of the surgeon and the ulcer crater allowed to remain on the capsule of the pancreas. A biopsy for frozen section study should be taken of any gastric ulcer since malignancy must be ruled out. The colon is returned to the peritoneal cavity. The right gastric and gastroepiploic arteries are doubly ligated (see Gastrectomy, Subtotal, Figures 12, 13, 14, 15, and 16), and the duodenum distal to the ulcer divided.

At least 1 or 1.5 cm of the superior as well as the inferior margins of the duodenum must be thoroughly cleared of fat and blood vessels adjacent to the Potts vascular clamp in preparation for the angle sutures. This is especially important on the superior side in order to avoid a diverticulum-like extension from the superior surface of the duodenum with an inadequate blood supply for a safe anastomosis. After the duodenal stump has been well prepared for anastomosis, the end that has been closed with the Potts clamp is covered with a moist, sterile gauze while the site of resection of the stomach is decided upon (Figure 4).

In many instances, especially in the obese patient, it is advisable to further mobilize the stomach by dividing the thickened, lowermost portion of the gastrosplenic ligament without dividing the left gastroepiploic vessels. Considerable mobilization of the greater curvature of the stomach without traction on the spleen can be obtained if time is taken to divide carefully the extra heavy layer of adipose tissue that is commonly present in this area. Following this further mobilization of the greater curvature, a point is selected where the left gastroepiploic vessel appears to come nearer the gastric wall. This is the point in the greater curvature selected for the anastomosis, and the omentum is divided up to this point with freeing of the serosa of fat and vessels for the distance of the surgeon's finger (Figure 4). Traction sutures are applied to mark the proposed site of anastomosis. A site on the lesser curvature is selected just distal to the third prominent vein on the lesser curvature (Figure 1). Again, two traction sutures are applied, separated by the width of the surgeon's finger. This distance of about a centimeter on both curvatures assures a good serosal surface for closure of the angles.

It makes little difference how the stomach is divided, although there is some advantage to using a linear stapling instrument. Regardless of the crushing clamp that is to be applied, the curvatures of the stomach should be fixed by the application of Babcock forceps to prevent rotation of the tissues when the clamp is closed. Before the stomach is divided, a row of interrupted 0000 silk sutures may be placed almost through the entire gastric wall in order to (1) control the bleeding from the subsequent cut surface of the gastric wall, (2) fix the mucosa to the seromuscular coat, and (3) pucker and constrict the end of the stomach (Figure 5).

Additional sutures of fine silk are taken around the edge of the mucosal opening until the end of the stomach has been puckered to fit relatively snugly around the surgeon's index finger. This opening should be approximately 2.5 to 3 cm wide (Figure 6). These sutures are then cut in anticipation of a direct end-toend anastomosis with the duodenum (Figure 7). If the margins of the lesser and greater curvatures of the stomach as well as the superior and inferior margins of the duodenum have been properly prepared, it is relatively easy to insert angle sutures of 00 silk. Successful closure of the angles depends upon starting the suture on the anterior gastric as well as the anterior duodenal wall rather than more posteriorly. Interrupted sutures of 00 silk are then taken to close the stomach and duodenum together. Slightly bigger bites are necessary on the gastric side as a rule rather than on the duodenal side, depending upon the discrepancy in size between the two openings (Figure 8). The sutures should be tied, starting at the lesser curvature and progressing downward to the greater curvature. The angle sutures are retained while additional 0000 silk or fine absorbable synthetic sutures are placed to approximate the mucosa (Figure 9, A–A' and B–B'). Some prefer a continuous synthetic absorbable suture to approximate the mucosa. No clamps are applied to the stomach or duodenum to control bleeding, since the sutures on the gastric side, if properly placed, should provide complete hemostasis as far as the stomach is concerned. Bleeding from the duodenal side is controlled by placing interrupted 0000 silk sutures. The anterior mucosal layer is closed with a series of interrupted sutures of 0000 silk or a continuous synthetic absorbable suture. The seromuscular coat is then approximated to the duodenal wall with a layer of interrupted mattress sutures (Figure 10). It has been found that a cuff of gastric wall can be brought over the duodenum, resulting in a "pseudo-pylorus," if two bites are taken on the gastric side and one bite on the duodenal side. When this suture is tied (Figure 10), the gastric wall is pulled over the initial mucosal suture line.

The vascular pedicles on the gastric side are anchored to the ligated right gastric pedicle along the top surface of the duodenum as well as the ligated right gastroepiploic artery pedicle (Figure 10, A and B). A and B are then tied together to seal the greater curvature angle (Figure 11). A similar type of approximation is effected along the superior surface in order to seal the angle and remove all tension from the anastomosis (Figure 11). Cushing silver clips placed at the site of anastomosis will aid in identifying this area when future x-rays are obtained. The stoma should admit one finger relatively easily. There should be no tension whatsoever on the suture line.

The upper quadrant is inspected for oozing and thoroughly irrigated with saline.

POSTOPERATIVE CARE

Two liters of Ringer's lactate are given and the blood volume restored during the first 24 hours. The nasogastric tube is allowed to drain by gravity or is attached to low-pressure suction. Frequent irrigations of the tube with small amounts of saline are necessary to avoid obstruction and resultant gastric distention. Losses from the nasogastric tube are accurately recorded. Daily serum electrolyte levels are determined as long as intravenous fluids are given, and every two to three days thereafter.

When bowel activity has resumed, clear liquids are given by mouth and the nasogastric tube is clamped. Four hours after each of the first several meals the tube is unclamped and gastric residual measured. If there is no evidence of retention, a progressive feeding regimen is begun. This consists of five or six small feedings per day of soft food, moderately restricted in volume, high in protein, and relatively low in carbohydrate. Although many patients after gastric surgery dislike dairy products, the majority will tolerate milk, eggs, custards, toast, and cream soups, as the first step of the diet. Other soft foods are added as rapidly as the tolerance of the individual will permit. By the tenth day, a feeling of fullness may develop caused by mild retention and a tendency to overeat. Self-restriction of the dietary intake for a few days is indicated.

The patient's weight is recorded daily. The progressive regimen forms a basis for the discharge diet. Instructions are given to the patient to eat frequently, avoid concentrated carbohydrates, and to add "new" foods, including spices, and other food restricted preoperatively, one at a time. Eventually, the only limitations to the individual's diet are those imposed by his or her own intolerance.

Intermittent and regular follow-up discussions are essential over a long period of time to answer the many problems encountered by patients before the operation can be considered a complete success. Return to an unlimited diet and maintenance of ideal weight with freedom from gastrointestinal complaints are the goals.

 

VAGOTOMY, SUBDIAPHRAGMATIC APPROACH

The long-term results of vagotomy are closely related to the completeness of the vagotomy and to efficient drainage or resection of the antrum (see Vagotomy, Figures 1, 2, 3, and 4).

PREOPERATIVE PREPARATION

A careful evaluation of the adequacy and extent of the medical management is made. Secretion determination with continuous suction may be done to ascertain the gastric secretory status of the patient. Fasting serum gastrin levels are indicated. Proof of the presence of a duodenal ulcer and determination of the amount of gastric retention are established by endoscopy, by a barium meal, by fluoroscopy and roentgenologic studies, and by fasting aspirations through a stomach tube. Constant nasogastric suction is maintained during the operation.

ANESTHESIA

General anesthesia, supplemented with curare for relaxation, is satisfactory. The insertion of an endotracheal tube provides smoother operating conditions for the surgeon and easy control of the airway for the anesthesiologist.

POSITION

The patient is placed flat on the operating table, with the foot of the table lowered to permit the contents of the abdomen to gravitate toward the pelvis.

OPERATIVE PREPARATION

The skin is prepared in the usual manner.

INCISION AND EXPOSURE

A high midline incision is extended up over the xiphoid and down to the region of the umbilicus (Figure 1). In some patients the exposure is greatly enhanced by removal of a long xiphoid process. A thorough exploration of the abdomen is carried out, including visualization of the site of the ulcer. The location of the ulcer, especially if it is near the common duct, the extent of the inflammatory reaction, and the patient's general condition should all be taken into consideration in evaluating the risk of gastric resection in comparison to a more conservative drainage procedure.

The next step is to mobilize the left lobe of the liver. This maneuver is especially useful in obese patients where good exposure enhances the probability of complete vagotomy. If the operator stands on the right side of the patient, it is usually easier to grasp the left lobe of the liver with the right hand and with the index finger to define the limits of the thin, relatively avascular left triangular ligament of the left lobe of the liver. In many instances the tip of the left lobe extends quite far to the left (Figure 2). By downward traction on the left lobe of the liver, and with the index finger beneath the triangular ligament to define its limits and to protect the underlying structures, the triangular ligament is divided with long, curved scissors. The assistant stands on the patient's left side and can usually do this more easily than the surgeon (Figure 3). It should be unnecessary to tie any bleeding points; however, occasionally the tip of the left lobe may require several ties to control slight oozing on the liver side. The left lobe of the liver is then folded either downward or upward so that the region of the esophagus is clearly exposed (Figure 4). A moist, warm gauze pad is placed over the liver, and an S retractor is inserted to maintain even pressure throughout the rest of the procedure (Figure 5). In many instances the exposure is adequate without mobilization of the left lobe of the liver.

DETAILS OF PROCEDURE

The region of the esophagus is palpated. The peritoneum immediately over the esophagus is grasped with toothed forceps, and an incision is made in the peritoneum at right angles to the long axis of the esophagus (Figure 5). The incision may be extended laterally to ensure mobilization of the fundus of the stomach. Curved scissors are then directed gently upward to free the anterior surface of the esophagus from the surrounding tissue. This can be done by blunt dissection, using the index finger, which has been covered with a piece of gauze (Figure 6). Traction sutures of fine silk may be introduced into this peritoneal cuff to assist in visualizing the area. After 1 in. or more of the anterior wall of the esophagus has been freed from the surrounding structures, the index finger should be introduced beneath the esophagus from the left side. It is frequently necessary to loosen some adhesions in this area by sharp dissection. Usually, little difficulty is encountered in gently passing the index finger beneath the esophagus and its indwelling nasogastric tube and completely freeing it from the surrounding structures. Just to the right of the esophagus, the index finger will usually encounter resistance from the uppermost limit of the hepatogastric ligament (Figure 7). This portion of the structure should be divided, since its division affords more mobilization of the esophagus and tends to provide exposure of the posterior or right vagus nerve. The major portion of the hepatogastric ligament in this area is quite avascular and thin, so that it can be perforated easily with scissors or the index finger. A pair of right-angle clamps is then applied to the uppermost portion of the ligament, and the contents of these clamps divided with long, curved scissors (Figure 8). This exposes the region posterior to the esophagus and ensures adequate exposure of the hiatal region.

The contents of these clamps are then ligated with 00 silk sutures. Downward traction is maintained on the esophagus while it is further freed from the surrounding structures by blunt dissection with the index finger. The vagus nerves are not always easily identified, but their location is more quickly discovered by palpation (Figure 9). As a tip of the index finger is passed over the esophagus, the tense wirelike structure of the nerve is easily identified. It should be remembered that one or more smaller nerves may be found, both anteriorly and posteriorly, in addition to the large left and right vagus nerves. Additional small filaments may be seen crossing over the surface of the esophagus in its long axis. The left vagus nerve is usually located on the anterior surface of the esophagus, a little to the left of the midline, while the right vagus nerve is usually located a little to the right of the midline, posteriorly (Figures 10 and 10A). The left vagus is then grasped with a blunt nerve hook, such as the de Takats nerve dissector, and with curved scissors is dissected free from the adjacent structures (Figure 11). The nerve can be separated from the esophagus easily by blunt dissection with the surgeon's index finger. It is usually possible to free at least 6 cm of the nerve (Figure 12). The nerve is crimped with a silver/tantalum clip and is divided with long, curved scissors as high as possible. It is unnecessary to ligate the ends of the vagus nerve unless bleeding occurs from the gastric end (Figure 13). The use of silver clips at the point where the vagus nerves divide minimized bleeding and serves to identify the procedures on subsequent roentgenograms. After the left vagus nerve has been resected, the esophagus is rotated slightly, and the traction is directed more to the left. It is usually not difficult to dissect free the right or posterior vagus nerve with the index finger or nerve hook (Figure 14). In some instances it has been found that the nerve has been separated from the esophagus at the time it was initially freed from the surrounding structures. The nerve, in such instances, appears to be resting against the posterior wall of the esophageal hiatus. The tendency to displace the right vagus nerve posteriorly during the blind process of freeing the esophagus no doubt accounts for the fact that this large nerve may be overlooked while all filaments about the esophagus are meticulously divided. This is the nerve most commonly found to be intact at the time of secondary exploration for a clinical failure of the vagotomy. A careful search should be made for additional nerves, since it is not uncommon to find more than one. A minimum of 6 cm of the right or posterior vagus nerve should be resected (Figure 15). Although the nerves may be clearly identified, the surgeon should not be satisfied until another careful search has been made completely around the esophagus. By traction on the esophagus and by direct palpation, any constricting band should be freed and resected, and a careful inspection should be made throughout the circumference of the esophagus. The operator will find that many of the little filaments that he dissects, in the belief that they are nerves, will prove to be small blood vessels that will require ligation. A final survey should always be made to be absolutely certain that the large right vagus nerve has not been displaced posteriorly, thus escaping division. A frozen section examination may be obtained to verify that both nerves have been removed. In order to correct esophageal reflux associated with an incompetent lower esophageal sphincter, some surgeons perform fundoplication around the lower esophagus. The mobilized fundus is approximated by four or five sutures about the lower end of the esophagus with a large stomach tube in place to prevent excessive constriction. (See Fundoplication.)

Traction should be released and the esophagus allowed to return to its normal position. The area should be carefully inspected for bleeding. No effort is made to reapproximate the peritoneal cuff over the esophagus to the cuff of peritoneum at the junction of the esophagus with the stomach. Finally, the esophagus is retracted upward and to the left by a narrow S retractor in order to expose the crus of the diaphragm. Two to three sutures of No. 1 silk may be placed to approximate the crus of the diaphragm as in the repair of a hiatus hernia if the hiatus appears patulous (Figures 16 and 17). Sufficient space about the esophagus must be retained to admit one finger or the passage of a 54 French or larger esophageal dilator into the stomach. All packs are removed from the abdomen, and the left lobe of the liver is returned to its normal position. It is not necessary to reapproximate the triangular ligament of the left lobe.

Vagotomy must always be accompanied either by a gastric resection or a drainage of the antrum by posterior gastroenterostomy or division of the pylorus by pyloroplasty. Since gastric emptying may be unduly delayed following vagotomy, efficient gastric drainage by gastrostomy should be considered.

POSTOPERATIVE CARE

Constant gastric suction is maintained for a few days until it has been determined that the stomach is emptying satisfactorily. If evidence of gastric dilatation develops, constant gastric suction is instituted. Occasionally, a moderate diarrhea will develop, which may be temporarily troublesome. The general care is that of any major upper abdominal procedure. Inability to swallow solid food because of temporary cardiospasm may occur for a few days in the early postoperative period. Six small feedings consistent with an ulcer diet should be recommended in order to combat the distention that may occur with an atonic stomach. Sweet juice, as well as hot and cold liquids, should be avoided, especially at breakfast. Smoking and coffee or tea consumption should be minimized until the patient is symptom-free and ideal weight is attained. The return to an unrestricted diet is determined by the patient's progress.

Copyright ©2006 The McGraw-Hill Companies. All rights reserved. Privacy Notice. Any use is subject to the Terms of Use and Notice. Additional Credits and Copyright Information.