GASTRECTOMY

Billroth I

Operative Technique

Patient supine under General Anesthesia

Asepsis and antisepsis technique

Sterile drapes placed

Midline incision made, carried from skin through subcutaneous tissue

Fascia cut and opened

Peritoneum entered

Intra-operative findings noted

Incision done on the avascular portion of the gastrohepatic ligament to the right of the lesser curvature

Index finger of left hand passed behind the lesser curvature and antrum of the stomach, emerging deep to the gastroepiploic arcade along the greater curvature of the stomach. This serves to elevate the greater omentum from the underlying mesocolon.

Branches from gastroepiploic arcade serially isolated, clamped divided and ligated, up along the greater curvature of the stomach until the halfway point between the pylorus and the diaphragm is reached.

Distal segment of gastroepiploic arcade from the antrum dissected.

Dissect the attachments between the back wall of the antrum and the pancreas, freeing the entire distal half of the gastric greater curvature.

On the lesser curvature, halfway between the esophagogastric junction and the pylorus, vascular bundle was divided and doubly ligated with silk 0 sutures

Stomach divided, Allen clamps applied for a distance of 3 – 4cm, at an angle 90^o to the greater curvature of the stomach and then divided. Another set of Allen clamps applied midway to the lesser curvature and divided.

Side of lesser curvature closed with continuous running suture using chromic 3.0. Then mucosa inverted using one layer of interrupted 4-0 silk Lembert sutures.

Right gastric artery identified, divided and doubly ligated

Specimen carefully pulled in an anterior direction exposing the posterior wall of the duodenum and the anterior portion of the pancreas

Vessels encountered carefully divided and ligated, until 1.5cm of the posterior duodenal wall has been freed from the underlying pancreas

Ampulla of vater identified

Duodenum divided

Gasroduodenal anastomosis created, corner Cushing sutures made then interrupted 4-0 silk seromuscular Lembert sutures placed on the remainder of the posterior layer

Gastoduodenal mucosal layer approximated using chromic 3-0 continuous Connell technique

Anterior layer reinforced with silk 4-0 interrupted Lembert sutures

Peritoneal lavage

Hemostasis

Complete sponge and instrument count

Peritoneum and fascia closed in one layer using Vicryl 0 continuous suture

External bolsters placed

Skin closed using interrupted silk 3-0 sutures

Dry sterile dressing placed