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Figure 5-2a A, The anatomy of the anterior vagal trunk, anterior nerve of Latarget, and "crow's foot" is shown. The proposed line of dissection is shown between the nerve of Latarget and the lesser curvature of the stomach, extending cephalad above the gastroesophageal junction. The novice should begin dissection by dividing the peritoneum overlying the esophageal hiatus and encircling the esophagus with a Penrose drain. The anterior and posterior vagal nerve trunks can then be identified at the level of the distal esophagus and retracted by vessel loops. Surgeons with great experience in parietal cell vagotomy may bypass these initial steps. B, Next, the lesser omentum is divided in an avascular plane between the liver and the anterior nerve of Latarget. The lesser omentum is retracted to the patient's right. Countertraction on the anterior gastric wall to the patient's left leaves the lesser omentum taut and allows for careful dissection, control, and division of each individual neurovascular bundle between the anterior nerve of Latarget and the gastric wall, as shown. This process is repeated until the full extent of anterior denervation is accomplished. Also, the distal esophagus is skeletonized for a distance of 5 to 6 cm, dividing the nerves of Grassi.

Figure 5-2a A, The anatomy of the anterior vagal trunk, anterior nerve of Latarget, and "crow's foot" is shown. The proposed line of dissection is shown between the nerve of Latarget and the lesser curvature of the stomach, extending cephalad above the gastroesophageal junction. The novice should begin dissection by dividing the peritoneum overlying the esophageal hiatus and encircling the esophagus with a Penrose drain. The anterior and posterior vagal nerve trunks can then be identified at the level of the distal esophagus and retracted by vessel loops. Surgeons with great experience in parietal cell vagotomy may bypass these initial steps. B, Next, the lesser omentum is divided in an avascular plane between the liver and the anterior nerve of Latarget. The lesser omentum is retracted to the patient's right. Countertraction on the anterior gastric wall to the patient's left leaves the lesser omentum taut and allows for careful dissection, control, and division of each individual neurovascular bundle between the anterior nerve of Latarget and the gastric wall, as shown. This process is repeated until the full extent of anterior denervation is accomplished. Also, the distal esophagus is skeletonized for a distance of 5 to 6 cm, dividing the nerves of Grassi.

Figure 5-3 The omental patch technique for closing a perforated duodenal ulcer. Sutures are placed across the perforation, and the omental fat Is sewn Into the defect. (From Sabiston, D.C. Jr.: Adas of General Surgery. Philadelphia, W.B. Saunders, 1994, p. 327.)

Figure 5-4a A, The resection lines for antrectomy, showing resection of the distal stomach, pylorus, and proximal duodenum. B, The reconstruction performed as a Billroth I gastroduodenostomy. Truncal vagotomy Is also depicted.

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