W Robert Rout

Good exposure is essential for operations on the stomach and duodenum. An upper midline incision from the xiphoid to the umbilicus offers a highly satisfactory and versatile approach for the common operations on the stomach and duodenum. It can be easily extended into an abdominothoracic incision when desired for total gastrectomy or operations on the cardiac end of the stomach. This is accomplished by extending the incision laterally to the left at the upper end of the vertical incision ( Fig. 20-1 ), cutting across the ninth costal cartilage, and incising laterally the eighth intercostal space into the left thoracic cavity. The diaphragm can then be divided down to the esophageal hiatus. This gives an excellent exposure of the lower esophagus ( Fig. 20-2 ), the full length of the stomach, and the proximal duodenum. Another method that may be used to extend a midline incision upward is to split the lower sternum in the midline upward to the level of the fourth or fifth intercostal space, taking care not to enter either pleural cavity ( Fig. 20-3 ).

A right or left upper paramedian incision is also satisfactory for most operations on the stomach or duodenum. A right transrectus incision provides adequate exposure for these procedures but has the serious defect of destroying much of the nerve and blood supply to the rectus muscle, resulting too frequently in postoperative hernia. Figure 20-1 Midline incision, which may be extended by splitting the sternum upward as high as the fourth intercostal space (Wangensteen) or by extending the incision laterally through the sixth intercostal space.

Wangfen^tcerte extension

Figure 20-2 The exposure of the stomach obtained by a combined thoracoabdominal incision.

Wangfen^tcerte extension

4th space

6th space

Figure 20-2 The exposure of the stomach obtained by a combined thoracoabdominal incision.

Figure 20-4 Blood vessels about the pyloric end of the stomach and duodenum, with special reference to the pyloric vein.
Figure 20-7 Blood supply of the stomach, duodenum, spleen, and pancreas. The stomach is shown reflected upward, and the pancreatic duct is exposed. (From Jones, T. and Shepard, W.C.: A Manual of Surgical Anatomy, Philadelphia, W.B. Saunders, 1945, with permission.)

Figure 20-8 The duodenojejunal junction. The superior mesenteric vein and artery have been removed to show the detail of arterial supply to the bowel. The artery shown here gives off an anomalous branch to the pancreas and a special jejunal trunk. (From Edwards, E.A., Malone, P.D., and MacArthur, J.D.: Operative Anatomy of Abdomen and Pelvis. Philadelphia, Lea & Febiger, 1975, p. 133, with permission.)

Figure 20-9 Initial dissection for mobilization of the right side of the colon, small Intestine, and mesentery. A, Initial lateral Incision elevates the cecum. B, Subsequent extent of the mobilization Is designed to expose the third and fourth portions of the duodenum.
Figure 20-10 Exposure of the third and fourth portions of the duodenum.

Figure 20-11 Digital exploration of the duodenum. (From Eusterman, G.B., and Balfour, D.C.: The Stomach and Duodenum. Philadelphia, W.B. Saunders, 1935, with permission.)

Figure 20-13 Bimanual palpation of the posterior wall of the stomach. The fingers of the left hand are shown passing through the gastrohepatic omentum, and those of the right hand through the transverse mesocolon. The fingers meet on the posterior stomach wall within the lesser peritoneal cavity (lesser sac).

Figure 20-13 Bimanual palpation of the posterior wall of the stomach. The fingers of the left hand are shown passing through the gastrohepatic omentum, and those of the right hand through the transverse mesocolon. The fingers meet on the posterior stomach wall within the lesser peritoneal cavity (lesser sac).

Figure 20-14 Transverse closure of a longitudinal gastrotomy incision. A traction suture was placed centrally on both the superior and inferior margins of the longitudinal incision, and traction on them has converted the incision into a transverse one.

Left paramedian

References

1. Cattell, R.B., and Braasch, J.W.: A technique of the exposure of the third and fourth portions of the duodenum. Surg. Gynecol. Obstet., 111:378, 1960.

2. Schwartz, H.S.: Acute meprobamate poisoning with gastrotomy and removal of a drug-containing mass. N. Engl. J. Med., 295:1177, 1976.

Chapter 21 - Abdominal Incisions

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