Jaboulay Pyloroplasty

and reconstruction via gastroduodenoscopy, sutured technique ( Fig. 11-51 Fig. 11-52 Fig. 11-53 (Figure Not Available) Fig. 11-54 (Figure Not Available) Fig. 11-55 ) and stapled technique ( Fig. 11-56 and Fig. 11-57 ). Total Gastrectomy

The steps involved in total gastrectomy include the following sequence: division of short and left gastric vessels ( Fig. 11-58 Fig. 11-59 Fig. 11-60 ), pursestring suture and division of esophagus ( Fig. 11-61 ), creation of Roux-en-Y limb (Fig. 11-62 (Figure Not Available) ), use of EEA stapling device ( Fig. 11-63 and Fig. 11-64 ), completion of anastomosis ( Fig. 11-65 ), and enteroenterostomy. Stamm Gastrostomy

The steps involved in the Stamm gastrostomy include the following sequence: placement of pursestring sutures

Figure 11-1 Depiction of the normal vagal anatomy and the traditional incision sites for standard vagotomies. Truncal vagotomy, shown as the incision at level a, involves transection of the nerves as they traverse the diaphragmatic hiatus. Selective vagotomy (b) severs the vagal trunks after the takeoff of the hepatic and celiac branches. Proximal gastric vagotomy (also highly selective vagotomy and parietal cell vagotomy) (c) incises the esophagogastric vagal branches at the level of the stomach while preserving the hepatic and celiac branches, as well as innervation to the antrum and pylorus (the "crow's foot" of the nerves of Latarjet). (From Braasch, J.W.: Truncal vagotomy and Heineke-Mikulicz pyloroplasty including selective vagotomy. In Braasch, J.W., Sedgewick, C.E., Veidenheimer, M.C., and Ellis, F.H., Jr. [eds.]: Atlas of Abdominal Surgery. Philadelphia, W.B. Saunders, 1991, p. 48.)

Figure 11-2 The left lateral segment of the liver should be mobilized to allow full exposure of the gastroesophageal junction. The surgeon's right hand retracts the left lateral segment inferiorly to expose the left triangular ligament, which is thin and translucent. This ligament can be divided by electrocautery; mobilization need only proceed to midline for adequate exposure. Care should be taken to avoid the inferior phrenic vein as midline is approached. (From Mulholland, M.W.: Atlas of gastric surgery. In Bell, R.H., Jr., Rikkers, L.F., and Mulholland, M. W. feds. J: Digestive Tract Surgery. Philadelphia, Lippincott-Raven Publishers, 1996, p. 306.)

Figure 11-3 Incisional line for incision of the peritoneum to expose the distal esophagus and gastroesophageal junction. Palpation of the preoperatively placed nasogastric tube ensures that this location is correct. (From Pappas, T.N.: Truncal vagotomy. In Sabiston, D. C., Jr. fed.]: Atlas of General Surgery. Philadelphia, W.B. Saunders, 1994, p. 330.)

Lirve ot incision tn

Figure 11-4 Blunt, gentle encirclement of the esophageal hiatus after exposure. This should be attempted as cephalad as possible to capture the posterior vagus in the encirclement. Palpation of the nasogastric tube before this maneuver will help avoid errors. A Penrose drain or umbilical tape is then placed around the esophagus to aid in retraction. (From Pappas, T.N.: Truncal vagotomy. In Sabiston, D.C., Jr. [ed.]: Atlas of General Surgery. Philadelphia, W.B. Saunders, 1994, p. 330.)

Figure 11-5 Exposure of the anterior vagus nerve. This structure is often likened to a bowstring and is palpated by passing a finger across the distal esophagus. If the anterior vagus is not palpable, then it usually becomes more prominent, as shown here, with gentle downward traction on the stomach. If the nerve cannot be found with these maneuvers, then gentle downward traction can be placed on the hepatic branch of the anterior vagus nerve, which will expose the anterior trunk. The hepatic branch is usually visible within the gastrohepatic ligament. (From Pappas, T.N.: Truncal vagotomy. In Sabiston, D. C., Jr. fed.]: Atlas of General Surgery. Philadelphia, W.B. Saunders, 1994, p. 331.)

Anterior (let!) vagus n. exposed by traction with Finger Penrose dram

Figure 11-6 Ligation and excision of the anterior vagus nerve. A length of nerve of 2 cm is excised and sent to the pathology laboratory for histologic confirmation. (From Pappas, T.N.: Truncal vagotomy. In Sabiston, D.C., Jr. [ed.]: Atlas of General Surgery. Philadelphia, W.B. Saunders, 1994, p. 331.)

divided between clips

Figure 11-7 Exposure of the posterior vagus, which usually lies between the esophagus and the right crus of the diaphragm. The esophagus is retracted to the left and anteriorly, exposing the right crus. The Penrose should contain the posterior vagus nerve if the blunt encirclement was performed at or above the level of the diaphragm. With slight rotation of the esophagus, the nerve is identified by the surgeon's finger and delivered into view. If the vagus cannot be found, then palpation of the esophagus should be performed to locate the nerve before its separation from the esophagus. Alternatively; one could retract the celiac division of the posterior vagus if it is easily seen. (From Pappas, T.N.: Truncal vagotomy. In Sabiston, D.C., Jr. fed. J: Atlas of General Surgery. Philadelphia, W.B. Saunders, 1994, p. 332.)

Figure 11-8 Ligation of posterior vagus, with excision of a 2-cm portion that is sent to the pathology laboratory. (From Pappas, T.N.: Truncal vagotomy. In Sabiston, D.C., Jr. fed.J: Atlas of General Surgery. Philadelphia, W.B. Saunders, 1994, p. 332.)

Figure 11-9 Initial exposure for proximal gastric vagotomy. The gastrohepatic ligament is opened after confirmation of the absence of a replaced left hepatic artery. The anterior nerve of Latarjet is tented to expose its gastric branches. The hepatic branch is seen and preserved. The first assistant stabilizes the stomach to prevent avulsion of the short gastric vessels and a consequent splenic injury. (From Rossi, R.L.. Parietal cell vagotomy (highly selective vagotomy). In Braasch, J.W., Sedgewick, C.E., Veidenheimer, M.C., and Ellis, F.H., Jr. [eds.]: Atlas of Abdominal Surgery. Philadelphia, W.B. Saunders, 1991, p. 56.)

Figure 11-10 The dissection is initiated at 7 cm proximal to the pylorus, which will allow preservation of the anterior nerve of Latarjet and maintain antral and pyloric innervation. (From Rossi, R.L.: Parietal cell vagotomy (highly selective vagotomy). In Braasch, J. W., Sedgewick, C.E., Veidenheimer, M. C., and Ellis, F.H., Jr. [eds.J: Atlas of Abdominal Surgery. Philadelphia, W.B. Saunders, 1991, p. 57.)

Figure 11-11 Ligation of the neurovascular bundles, which proceeds cephalad toward the gastroesophageal junction and continues completely over the esophagus toward the angle of His to completely skeletonize the stomach body and fundus. (From Rossi, R. L.: Parietal cell vagotomy (highly selective vagotomy). In Braasch, J.W., Sedgewick, C.E., Veidenheimer, M.C., and Ellis, F.H., Jr. [eds.J: Atlas of Abdominal Surgery. Philadelpha, W.B. Saunders, 1991, p. 56.)

Figure 11-12 The posterior leaf of the gastrohepatic ligament is dissected in a similar manner through the window created by the anterior dissection. The dissection continues cephalad toward the esophagogastric junction and continues across the peritoneum overlying the anterior esophagus toward the angle of His. (From Rossi, R.L.: Parietal cell vagotomy (highly selective vagotomy). In Braasch, J.W., Sedgewick, C.E., Veidenheimer, M.C., and Ellis, F.H., Jr. feds. J: Atlas of Abdominal Surgery. Philadelphia, W.B. Saunders, 1991, p. 58.)

Figure 11-13 Fibers from the anterior vagus are gently swept off of the anterior surface of the esophagus and divided. The distal esophagus is skeletonized for 6 to 8 cm to completely divide vagal efferents, some of which travel intramurally to innervate the proximal stomach. Special attention should be directed toward division of the "criminal" nerves of Grassi, which loop off the posterior vagus and travel posteriorly to innervate the superior fundus. (From Rossi, R.L.: Parietal cell vagotomy(highly selective vagotomy). In Braasch, J.W., Sedgewick, C.E., Veidenheimer, M.C., and Ellis, F.H., Jr. [eds.]: Atlas of Abdominal Surgery. Philadelphia, W.B. Saunders, 1991, p. 59.)

Figure 11-14 Completed dissection, demonstrating sparing of the anterior and posterior trunks as well as innervation to the antrum. (From Rossi, R.L.: Parietal cell vagotomy (highly selective vagotomy). In Braasch, J. W., Sedgewick, C.E., Veidenheimer, M.C., and Ellis, F.H., Jr. [eds.J: Atlas of Abdominal Surgery. Phüadelphia, W.B. Saunders, 1991, p. 59.)

Figure 11-

1-15 Sites for port placement for laparoscopic highly selective vagotomy. Pneumoperitoneum is established in standard fashion. The camera is introduced through the umbilical port, retractors for the liver and the stomach are placed through the two superior ports, and the remaining ports are used for the dissection. Reverse Trendelenburg positioning is used to aid in exposure.

Figure 11-16 A fan-type retractor is used to retract the left lateral segment of the liver away from the gastroesophageal junction. Partial division of the left triangular ligament (inset) will allow for optimal retraction. (From Bailey, R. W., Zucker, K.A., and Flowers, J.L.: Vagotomy. In Ballantyne, G.A., Leahy, P.F., and Modlin, I.M. [eds.J: Laparoscopic Surgery. Philadelphia, W.B. Saunders, 1994, p. 409.)

Figure 11-17 A window is created in the avascular portion of the gastrohepatic ligament along the lesser curvature to approach the posterior aspect of the gastroesophageal junction. The stomach is retracted toward the left to aid in this dissection. (From Bailey, R.W., Zucker, K.A., and Flowers, J.L.: Vagotomy. In Ballantyne, G.A., Leahy, P.F., and Modlin, I.M. [eds.J: Laparoscopic Surgery. Philadelphia, W.B. Saunders, 1994, p. 409.)

Figure 11-18 The right crus of the diaphragm is retracted to the patient's right, allowing for identification of the posterior vagal trunk behind the esophagus. The nerve is isolated and exposed for ligation. (From Bailey, R. W., Zucker, K.A., and Flowers, J.L.: Vagotomy. In Ballantyne, G.A., Leahy, P.F., and Modlin, I.M. [eds.J: Laparoscopic Surgery. Philadelphia, W.B. Saunders, 1994, p. 411.)

Figure 11-19 The main trunk of the posterior vagus is clipped and ligated; the proximal extent of ligation should be as close as possible to the esophageal hiatus. (From Bailey, R.W., Zucker, K.A., and Flowers, J.L.: Vagotomy. In Ballantyne, G.A., Leahy, P.F., and Modlin, I.M. [eds.J: Laparoscopic Surgery. Philadelphia, W.B. Saunders, 1994, p. 411.)

Figure 11-20 The anterior vagal trunk is located in the peritoneum on the anterior esophagus and then gently elevated to provide optimal exposure. (From Ballantyne, G.H.: Adas of Laparoscopic Surgery. Philadelphia, W.B. Saunders, 2000, p. 167.)

Figure 11-20 The anterior vagal trunk is located in the peritoneum on the anterior esophagus and then gently elevated to provide optimal exposure. (From Ballantyne, G.H.: Adas of Laparoscopic Surgery. Philadelphia, W.B. Saunders, 2000, p. 167.)

30D telescope

Figure 11-21 Anterior vagal branches to the distal esophagus and stomach are clipped and ligated. This continues caudally but spares the anterior nerve of Latarjet, Innervating the distal 7 cm of stomach proximal to the pylorus. (From Ballantyne, G.H.: Atlas of Laparoscopic Surgery. Philadelphia, W.B. Saunders, 2000, p. 171.)

Figure 11-22 The Heineke-Mikulicz is the most widely used pyloroplasty. In a strict sense, a Heineke-Mikulicz pyloroplasty is a two-layer closure, whereas most surgeons actually perform the one-layer modification: the Weinberg pyloroplasty. This procedure is acceptable if there is minimal scarring at the pylorus and no foreshortening of the proximal duodenum. After kocherization of the duodenum, a longitudinal incision is centered over the anterior pylorus and extends 2 to 3 cm proximally and distally. (From Meyers, W.C.: Heineke-Mikulicz pyloroplasty. In Sabiston, D.C., Jr. [ed.]: Atlas of General Surgery. Philadelphia, W.B. Saunders, 1994, p. 251.)

Longitudinal line of incision through anterior wall of pyforus

Figure 11-23 After the incision, silk sutures are placed superiorly and inferiorly at the pylorus for traction and orientation. (From Braasch, J.W.: Truncal vagotomy and Heineke-Mikulicz pyloroplasty including selective vagotomy. In Braasch, J. W., Sedgewick, C.E., Veidenheimer, M.C., and Ellis, F.H., Jr. [eds.J: Atlas of Abdominal Surgery. Philadelphia, W.B. Saunders, 1991, p. 51.)

Figure 11-24 The longitudinal incision is closed transversely, widening the pyloric channel. The closure is usually performed with a single layer of interrupted nonabsorbable sutures, each placed as shown. (From Mulholland, M.W.: Atlas of gastric surgery. In Bell, R.H., Jr., Rikkers, L.F., and Mulholland, M.W. [eds.J: Digestive Tract Surgery. Philadelphia, Lippincott-Raven Publishers, 1996, p. 316.)

Figure 11-28 The mucosal stitch is continued anteriorly to complete the anastomosis. (From Mulholland, M.W.: Atlas of gastric surgery. In Bell, R.H., Jr., Rikkers, L.F., and Mulholland, M.W. [eds.J: Digestive Tract Surgery. Philadelphia, Lippincott-Raven Publishers, 1996, p. 318.)

Figure 11-29 Nonabsorbable sutures are placed in Lembert fashion over the closure, completing the anastomosis. (From Sawyers, J.L.: Selective vagotomy and pyloroplasty. In Nyhus, L.M., Baker, R.J., and Fischer, J.E. [eds.J: Mastery of Surgery. Boston, Little, Brown and Company, 1997, p. 888.)

Figure 11-30 A Jaboulay pyloroplasty is used when pylorus is too scarred to attempt to manipulate it. In actuality, a Jaboulay pyloroplasty is a gastroduodenostomy that does not traverse the pylorus. After a Kocher maneuver to mobilize the duodenum, traction sutures are placed that allow the normal duodenum distal to the scarring to appose the distal antrum. Interrupted silk sutures are placed posteriorly before matching incisions are made. (From Meyers, W.C.: Jaboulay pyloroplasty. In Sabiston, D.C., Jr. [ed.]: Atlas of General Surgery. Philadelphia, W.B. Saunders, 1994, p. 259.)

Figure 11-31 Parallel Incisions are made In the duodenum and stomach and closed in two layers with mucosal absorbable suture and outer nonabsorbable suture. The pylorus is not incised or dilated. (From Meyers, W.C.: Jaboulaypyloroplasty. In Sabiston, D.C., Jr. fed. J: Atlas of General Surgery. Philadelphia, W.B. Saunders, 1994, p. 260.)

Killian Dreieck
Figure 11-32 Lembert serosal sutures complete the anastomosis. (From Meyers, W.C.: Jaboulay pyloroplasty. In Sabiston, D.C., Jr. [ed.]: Atlas of General Surgery. Philadelphia, W.B. Saunders, 1994, p. 260.)

Figure 11-33 Selection of the site in the transverse mesentery to create a window for the gastrojejunostomy. The transverse colon is retracted upward to allow inspection for an avascular area to the left of the middle colic vessels. A vertical incision is created to allow delivery of the distal stomach. (From Peete, W.P.J.: Gastrojejunostomy. In Sabiston, D.C., Jr. [ed.]: Atlas of General Surgery. Philadelphia, W.B. Saunders, 1994, p. 348.)

Figure 11-34 The gastric site that is chosen should be in the distal antrum for optimal drainage, be of normal tissue, and be free of large vessels. The stomach is delivered through the mesenteric defect and secured in place with interrupted sutures between the transverse mesocolon and the antrum. These sutures also close the mesenteric defect. The most proximal portion ofjejunum that reaches the antrum without tension is placed in apposition to the stomach. (From Peete, W.P.J.: Gastrojejunostomy. In Sabiston, D.C., Jr. [ed.]: Atlas of General Surgery, Philadelphia, W.B. Saunders, 1994, 349.)

Jaboulay Pyloroplasty

Figure 11-35 The jejunum is fixed in position with traction sutures. Interrupted nonabsorbable sutures are then placed in seromuscular fashion from the inferior gastric wall to the antimesenteric border of the jejunum. (From Peete, W.P.J.: Gastrojejunostomy. In Sabiston, D.C., Jr. fed.J: Atlas of General Surgery, Philadelphia, W.B. Saunders, 1994, p. 350.)

Figure 11-36 Matching incisions in the stomach and jejunum are created with electrocautery. (From Peete, W.P.J.: Gastrojejunostomy. In Sabiston, D.C., Jr. [ed.]: Atlas of General Surgery. Philadelphia, W.B. Saunders, 1994, p. 351.)

Figure 11-37 A continuous mucosal suture with 3-0 absorbable material is placed. The suture starts posteriorly and is performed most easily with a double-armed stitch. (From Peete, W.P.J.: Gastrojejunostomy. In Sabiston, D.C., Jr. [ed.J: Atlas of General Surgery, Philadelphia, W.B. Saunders, 1994, p. 351.)

Figure 11-38 The anastomosis continues anteriorly. (From Mulholland, M.W.: Atlas of gastric surgery. In Bell, R.H., Jr., Rikkers, L.F., and Mulholland, M.W. [eds.J: Digestive Tract Surgery. Philadelphia, Lippincott-Raven Publishers, 1996, p. 325.)

Anterior

Figure 11-39 The double-layer anastomosis is completed with an anterior seromuscular layer of interrupted silk 3-0 sutures. (From Mulholland, M. W.: Atlas of gastric surgery. In Bell, R.H., Jr., Rikkers, L.F., and Mulholland, M. W. [eds.J: Digestive Tract Surgery. Philadelphia, Lippincott-Raven Publishers, 1996, p. 326.)

Anterior serosal suture

Figure 11-40 Partial gastrectomy is initiated with a full Kocher maneuver that mobilizes the duodenum. The next goal is entry into the lesser sac to allow early evaluation of the posterior stomach and to aid in division of the greater omentum. With cephalad retraction of the greater omentum, an avascular plane above the transverse colon can be entered. The maneuver is performed left of midline to avoid encroachment on the middle colic vessels. (From Mulholland, M.W.: Atlas of gastric surgery. In Bell, R.H., Jr., Rikkers, L.F., and Mulholland, M. W. [eds.J: Digestive Tract Surgery. Philadelphia, Lippincott-Raven Publishers, 1996, p. 342.)

Figure 11-41 The gastrocolic omentum is then dissected from the stomach. The dissection begins at the pylorus with ligation of the right gastroepiploic artery and proceeds cephalad along the greater curvature. The gastroepiploic vessels may be preserved for benign diseases. For a 50% gastric resection, the dissection ends halfway between the pylorus and the esophagogastric junction and spares the left gastroepiploic vessels and the short gastric vessels. For a subtotal gastrectomy, the left gastroepiploic vessels are divided as well as a portion of the short gastric vessels. The posterior antrum is then separated from the anterior pancreas and base of the transverse mesocolon by division of fine connective tissue attachments. (From Jones, R.S.: Gastric resection: Billroth I anastomosis. In Sabiston, D.C., Jr. [ed.]: Atlas of General Surgery. Philadelphia, W.B. Saunders, 1994, p. 263.)

Transverse Mesocolon Pics

Figure 11-42 The gastrohepatic ligament is incised, and the lesser curvature is dissected. The right gastric vessels are ligated close to the stomach. In situations of pyloric inflammation, care must be taken to avoid injury to both the hepatic artery and the common bile duct. (From Sedgewick, C.E.: Gastrectomy. In Braasch, J.W., Sedgewick, C.E., Veidenheimer, M.C., and Ellis, F.H, Jr. [eds.]: Atlas of Abdominal Surgery. Philadelphia, W.B. Saunders, 1991, p. 37.)

Figure 11-43 The proximal duodenum is divided with care to avoid injury to the common bile duct. The closure is reinforced with interrupted 3-0 silk sutures at the discretion of the surgeon. (From Mulholland, M.W.: Atlas of gastric surgery. In Bell, R.H., Jr., Rikkers, L.F., and Mulholland, M.W. [eds.]: Digestive Tract Surgery. Philadelphia, Lippincott-Raven Publishers, 1996, p. 348.)

Figure 11-44 The proximal stomach is divided with a TA-90 stapling device. Gastric resection can also be accomplished with two applications of a GIA stapling device. (From Stapling Techniques in General Surgery. Norwalk, CT, United States Surgical Corporation, 1988, p. 59*. Trademark of United States Surgical. Copyright © 1974,1980, 1988, 2001 United States Surgical. Reprinted with permission of United States Surgical, a Division of Healthcare Group LP.)

Figure 11-45 The gastric staple line is oversewn superiorly with either continuous or running suture. Traction sutures are useful to steady the remnant within the operative field. (From Mulholland, M.W.: Atlas of gastric surgery. In Bell, R.H., Jr., Rikkers, L.F., and Mulholland, M. W. [eds.J: Digestive Tract Surgery. Philadelphia, Lippincott-Raven Publishers, 1996, p. 350.)

Figure 11-46 A proximal loop ofjejunum is apposed to the stomach. The jejunum can be delivered through an incision in the transverse mesocolon or anterior to the transverse colon. Interrupted sutures arc placed in seromuscular fashion between the posterior gastric wall and the antimesenteric border of the jejunum. (From Jones, R.S.: Gastric resection: Billroth II. In Sabiston, D.C., Jr. [ed.]: Atlas of General Surgery. Philadelphia, W.B Saunders, 1994, p. 284.)

Site of jejunal opening for stapler

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