Gastric resection

Preparation and organ mobilization

The surgery is performed under endotracheal anesthesia with the patient in the supine position. The first crucial step is gastric mobilization, which requires careful handling of the ligamentous apparatus and blood vessels.

• Along the greater curvature: The surgeon puts the gastrocolic ligament (lig. gastrocolicum) on tension and opens it in an avascular zone. Vessels are divided between clamps. On the left, branches of the a. gastroepiploica sinistra are ligated, and on the right, the a. gastroepiploica dextra. Important: near the pylorus, the arterial branch supplying the transverse colon must be preserved to prevent its necrosis.
• Along the lesser curvature: An opening is made in the avascular zone of the hepatogastric ligament (lig. hepatogastricum), the leaves of the lesser omentum are incised, and the left gastric artery (a. gastrica sinistra) is ligated.
• In the region of the hepatoduodenal ligament: Extreme caution must be exercised when ligating the right gastric artery. The common bile duct, portal vein, and hepatic artery passing through this area must not be caught in the clamp under any circumstances.

Billroth I resection

With this technique, an end-to-end gastroduodenal anastomosis is formed — the gastric stump is sutured directly to the duodenum.

Advantages:

1. The natural, anatomophysiological pathway for food transit is preserved.
2. The gastric stump continues to perform its reservoir function (food enters in portions).
3. The mucosa of the jejunum does not come into contact with acidic gastric contents, which prevents the development of stomal peptic ulcers.

Disadvantages and risks: The main issue is potential tissue tension. In addition, a junction of the suture lines of the gastric stump and duodenum forms at the upper part of the anastomosis. This weak spot is called the "anatomical lock" (or "angle of sorrow"). To prevent suture cutout, this zone is reinforced with a special purse-string suture encompassing the walls of both organs.

Billroth II resection (Hofmeister-Finsterer modification)

If Billroth I is not feasible, Billroth II is used. The essence of the method: the duodenal stump is closed securely, and the stomach is joined to a jejunal loop in an end-to-side fashion.

Technical features:

• A loop of the jejunum (taken 7–10 cm from the flexura duodenojejunalis) is brought into the upper floor of the abdominal cavity through an opening in the transverse mesocolon.
• The duodenal stump is treated with iodine and closed (using a continuous suture, purse-string method, Moynihan method, or Yudin's "snail" technique for complex penetrating ulcers). The stump is then reperitonealized on top by suturing it to the pancreatic capsule.
• The width of the created anastomosis must be smaller than the diameter of the gastric stump, so the upper part of the stump (on the side of the lesser curvature) is closed securely.

This method eliminates the risk of tissue tension, but creates a non-physiological pathway for food (the duodenum is excluded from passage) and carries the risk of suture failure in the closed duodenal stump.

Formation of the anastomosis and "spur"

Suturing the organs requires a strict sequence. First, the posterior lip of the anastomosis is formed: an outer row of interrupted seromuscular sutures is placed, followed by an inner continuous catgut suture through all layers. The anterior lip is closed with an inverting Schmieden suture (or mattress suture), over which a second row of seromuscular sutures is placed for reperitonealization.

In the Billroth II operation, a crucial step is the creation of the "spur". The afferent loop of the jejunum is sutured to the closed lesser curvature of the stomach (above the level of the anastomosis itself) with several interrupted sutures. This accomplishes two objectives:

1. Reinforces the vulnerable suture junction.
2. Creates a valve that physically prevents the reflux of gastric contents into the afferent loop of the intestine.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Technique of atypical closure of the duodenal stump (S.S. Yudin's "snail" method) for low penetrating ulcers.
• Step-by-step technique for placing the inverting Schmieden suture on the anterior lip of the anastomosis.
• Rules for reperitonealizing deserosized areas of the lesser curvature of the stomach.
• Features of the blood supply to the duodenal stump (preservation of branches of the superior pancreaticoduodenal artery).
• Method of transecting tissues of the stomach crushed by the Payr clamp prior to placing the inner row of sutures.

Other topics in the "Abdominal Surgery" section

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