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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