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Figure 11-48 A, The mucosal suture is continued along the length of the anterior aspect of the anastomosis. B, An anterior layer of interrupted silk sutures completes the anastomosis. (A from Soybel, D.I., and Zinner, M.J.: Stomach and duodenum: Operative procedures. In Zinner, M.J., Schwartz, S.I., and Ellis, H. [eds.]: Maingot's Abdominal Operations. Stamford, CT, Appleton & Lange, 1997, p. 1112. B from Mulholland M. W.: Atlas of gastric surgery. In Bell, R.H., Jr., Rikkers, L.F., and MulhoIIand, M. W. [eds.]: Digestive Tract Surgery. Philadelphia, Lippincott-Raven Publishers, 1996, p. 352.)

Figure 11-51 For gastroduodenostomy reconstruction, the duodenum and the inferior gastric staple line are apposed through the placement of a posterior serosal layer of interrupted silk sutures. (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. 267.)

Figure 11-52 An inner mucosal closure is initiated with a continuous absorbable suture. (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. 268.)

Figure 11-55 For a stapled gastroduodenostomy, a gastrotomy is created with electrocautery on the anterior stomach at least 3 cm proximal to the staple closure. (From Siegler, H.F.: Gastric resection: Billroth I anastomosis [stapler]. In Sabiston, D.C., Jr. [ed.]: Atlas of General Surgery, Philadelphia, W.B. Saunders, 1994, p. 274.)

Figure 11-56 The end-to-end stapling device, without the anvil, is passed into the anterior gastrotomy with the rod advancing through the posterior gastric wall, again 3 cm proximal to the stapled edge. The anvil is introduced into the duodenum after the placement of a pursestring suture with an automatic device. The EEA is closed, fired, and withdrawn. (From Siegler, H.F.: Gastric resection: Billroth I anastomosis [stapler]. In Sabiston, D.C., Jr. [ed.]: Atlas of General Surgery. Philadelphia, W.B. Saunders, 1994, p. 275.)

Figure 11-57 The anastomosis is Inspected to ensure adequate hemostasis. The anvil is then removed and checked to ensure that tissue doughnuts from both the duodenum and the stomach are present. The gastrotomy is closed by the application of a TA stapling device. (From Siegler, H.F.: Gastric resection: Billroth I anastomosis [stapler]. In Sabiston, D.C., Jr. [ed.]: Atlas of General Surgery. Philadelphia, W.B. Saunders, 1994, p. 276.)

Figure 11-58 The initial steps in total gastrectomy are similar to those of distal gastrectomy. Total gastrectomy mandates a complete omentectomy. In total gastrectomy, the dissection continues cephalad to include division of the left gastroepiploic artery, as well as the short gastric vessels. (From Sedgewick, C.E.: Gastrectomy. 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. 36.)

Figure 11-59 The gastrohepatic ligament is entered as in a distal gastrectomy, with ligation of the right gastric artery. The inferior phrenic vein is ligated if encountered within the gastrohepatic ligament. (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. 360.)

Figure 11-61 A pursestring device is placed on the distal esophagus. The esophagus is divided, and the gastric specimen is removed. (From Siegler, H.F.: Total gastrectomy [stapler]. In Sabiston, D.C., Jr. [ed.]: Atlas of General Surgery. Philadelphia, W.B. Saunders, 1994, p. 309.)

Figure 11-60 Identification and ligation of the left gastric artery is best accomplished with cephalad retraction of the stomach. (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. 361.)

Figure 11-61 A pursestring device is placed on the distal esophagus. The esophagus is divided, and the gastric specimen is removed. (From Siegler, H.F.: Total gastrectomy [stapler]. In Sabiston, D.C., Jr. [ed.]: Atlas of General Surgery. Philadelphia, W.B. Saunders, 1994, p. 309.)

Figure 11-63 An EEA stapling device is introduced through the open end of the Roux-en-Y limb, and the rod exits 3 cm proximally along the antimesenteric border of the jejunum. The EEA device can be properly sized before the gastric resection by introducing the sizing instruments through a proximal gastrotomy just before removing the specimen. (From Ravitch, M.M., and Steichen, F.M.: Principles and Practice of Surgical Stapling. Chicago, Year Book Medical Publishers, 1987, p. 229.)

Figure 11-64 After EEA device placement, the anvil is positioned through the pursestring and into the distal esophagus. After the pursestring is secured, the EEA is fired to create an end-to-side esophagojejunostomy. The EEA is carefully removed and inspected for tissue doughnuts from the esophagus and the Jejunum. The anastomosis is inspected to ensure adequate hemostasis, and the open end of the jejunum is closed with a TA stapler. The nasoenteric tube is gently guided through the anastomosis. Anastomotic integrity is tested by insufflating air via the nasogastric tube after the operative field is filled with saline. The absence of bubbling from the anastomosis suggests an intact anastomosis. (From Ravitch, M.M., and Steichen, F.M.: Principles and Practice of Surgical Stapling. Chicago, Year Book Medical Publishers, 1987, 230.)

Figure 11-65 Alternatively, hand-sewn esophagojejunostomy can be performed. This is typically performed using two layers of 3-0 silk in interrupted fashion. (From Meyers, W.C.: Total gastrectomy. In Sabiston, D.C., Jr. [ed.]: Atlas of General Surgery. Philadelphia, W.B. Saunders, 1994, p. 304.)

Figure 11-66 Open gastrostomy is performed either primarily or as an adjunct to a separate abdominal procedure (A). The selected site on the anterior gastric wall is grasped with an Allis clamp, and (B) two concentric pursestring sutures are placed with nonabsorbable sutures. Electrocautery is used to create the gastrotomy within the pursestrings. (From Sedgewick, C.E.: Gastrostomy. 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. 26.)

Figure 11-67 A large mushroom-tipped or Foley catheter Is placed, and the pursestrings are tied. (From Sedgewick, C.E.: Gastrostomy. 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. 27.)

Figure 11-68 The tube is brought out through the abdominal wall at a site where the stomach will reach without tension. Three or four tacking sutures are placed through the abdominal wall and the seromuscular surface of the stomach. The sutures are tied, securing the stomach to the abdominal wall around the tube. (From Grant, J.P.: Stamm gastrostomy. In Sabiston, D.C., Jr. [ed.]: Atlas of General Surgery. Philadelphia, W.B. Saunders, 1994, p. 232)

Placement of firsl suture

Bibliography

Donahue P.E., Griffith, C., and Richter, H.M.: A 50-year perspective upon selective gastric vagotomy. Am. J. Surg., 172:9, 1996. Kum, C.K., and Goh, P.: Laparoscopic vagotomy: A new tool in the management of duodenal ulcer disease. Br. J. Surg., 79:977, 1992. Nichols, R.L.: Surgical antibiotic prophylaxis. Med. Clin. North Am., 79:509, 1995.

Roberts, J.P., and Debas, H.T.: A simplified technique for rapid truncal vagotomy. Surg. Gynecol. Obstet., 168:539, 1989. Schirmer, B.D.: Current status of proximal gastric vagotomy. Ann. Surg., 209:131, 1989.

Thomas, W.E.G., Thompson, M.H., and Williamson, R.C.N.: The long-term outcome of Billroth I partial gastrectomy for benign gastric ulcers. Ann. Surg., 189:189, 1982. Zucker, K.A., and Bailey, R.W.: Laparoscopic truncal and selective vagotomy for intractable ulcer disease. Semin. Gastrointest. Dis., 5:128, 1994.

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