The Billroth I procedure requires extensive mobilization of the gastric pouch as well as the duodenum. This mobilization should include an extensive Kocher maneuver for mobilization of the duodenum. In addition, the greater omentum should be detached from the transverse colon, including the region of the flexures. In many instances the splenorenal ligament is divided, as well as the attachments between the fundus of the stomach and the diaphragm. Additional mobility is gained following the division of the vagus nerves and the uppermost portion of the gastrohepatic ligament. The stomach is mobilized so that it can be readily divided at its midpoint. The halfway point can be estimated by selecting a point on the greater curvature where the left gastroepiploic artery most nearly approximates the greater curvature wall (figure 1). The stomach on the lesser curvature is divided just distal to the third prominent vein on the lesser curvature.
Extensive mobilization of the duodenum is essential in the performance of the Billroth I procedure. Should there be a marked inflammatory reaction, especially in the region of the common duct, a more conservative procedure, such as a pyloroplasty or gastroenterostomy and vagotomy, should be considered. If it appears that the duodenum, especially in the region of the ulcer, can be well mobilized, the peritoneum is incised along the lateral border of the duodenum and the Kocher maneuver is carried out. Usually it is unnecessary to ligate any bleeding points in this peritoneal reflection. With blunt dissection the peritoneum can be swept away from the duodenal surface as the duodenum is grasped in the left hand and reflected medially (figure 2). It is important to remember that the middle colic vessels tend to course over the second part of the duodenum and are many times encountered rather suddenly and unexpectedly. For this reason the hepatic flexure of the colon should be directed downward and medially and the middle colic vessels identified early (figure 2). As the posterior wall of the duodenum and head of the pancreas are exposed, the inferior vena cava readily comes into view. The firm, white, avascular ligamentous attachments between the second and third parts of the duodenum and the posterior parietal wall are divided with curved scissors, down through and almost including the region of the ligament of Treitz (figure 2). This extensive mobilization is carried downward in order to ensure a very thorough mobilization of the duodenum. Following this, the omentum is separated from the colon, as described in Chapter 27. In obese patients it isusually much easier to start the mobilization by dividing the attachment between the splenic flexure of the colon and the parietes (figure 3). An incision is made along the superior surface of the splenic flexure of the colon as the next step in freeing up the omentum. This should be done in an avascular cleavage plane. The lesser sac is entered from the left side. Care should be taken not to apply undue traction upon the tissues extending up to the spleen, since the splenic capsule may be torn, and troublesome bleeding, even to the point of requiring splenectomy, may be encountered. The omentum is then dissected free throughout the course of the transverse colon.
A truncal vagotomy is carried out as described in Chapter 17. At this point considerable distance can be gained if the peritoneum attaching the fundus of the stomach to the base of the diaphragm is divided up to and around the superior aspect of the spleen. If the exposure appears difficult, it is advisable for the surgeon to retract the spleen downward with his right hand and, using long curved scissors in his left hand, divide the avascular splenorenal ligament (Chapter 90, figures 5 and 6). It must be admitted that sometimes troublesome bleeding does occur, which requires an incidental splenectomy, but in general great mobilization of the stomach is accomplished by this maneuver. Any bleeding from the splenic capsule should be controlled by conservative measures to minimize the need for splenectomy.
So far, the surgeon is not committed to any particular type of gastric resection but has ensured an extensive mobilization of the stomach and duodenum. The omentum should be reflected upward and the posterior wall of the stomach dissected free from the capsule of the pancreas, should any adhesions be found in this area. In the presence of a gastric ulcer, penetration through to the capsule of the pancreas may be encountered. These adhesions can be pinched off between the thumb and index finger of the surgeon and the ulcer crater allowed to remain on the capsule of the pancreas. A biopsy for frozen section study should be taken of any gastric ulcer since malignancy must be ruled out. The colon is returned to the peritoneal cavity. The right gastric and gastroepiploic arteries are doubly ligated (Chapter 26, figures 12 to 16), and the duodenum distal to the ulcer divided.
At least 1 or 1.5 cm of the superior as well as the inferior margins of the duodenum must be thoroughly cleared of fat and blood vessels at the point of resection of the stomach is decided upon (figure 4). The duodenum can be divided with a linear cutting or closed with a noncutting stapler.
In many instances, especially in the obese patient, it is advisable to further mobilize the stomach by dividing the thickened, lowermost portion of the gastrosplenic ligament without dividing the left gastroepiploic vessels. Considerable mobilization of the greater curvature of the stomach without traction on the spleen can be obtained if time is taken to divide carefully the extra heavy layer of adipose tissue that is commonly present in this area. Following this further mobilization of the greater curvature, a point is selected where the left gastroepiploic vessel appears to come nearer the gastric wall. This is the point in the greater curvature selected for the anastomosis, and the omentum is divided up to this point with freeing of the serosa of fat and vessels for the distance of the surgeon’s finger (figure 4). Traction sutures are applied to mark the proposed site of anastomosis. A site on the lesser curvature is selected just distal to the third prominent vein on the lesser curvature (figure 1). Again, two traction sutures are applied, separated by the width of the surgeon’s finger. This distance of about a centimeter on both curvatures assures a good serosal surface for closure of the angles.
It makes little difference how the stomach is divided, although there is some advantage to using a linear cutting or noncutting stapling instrument(figure 4). Before the stomach is divided, a row of interrupted 000 silk sutures may be placed almost through the entire gastric wall in order to (1) control the bleeding from the subsequent cut surface of the gastric wall, (2) fix the mucosa to the seromuscular coat, and (3) pucker and constrict the end of the stomach to create a pseudopylorus (figure 5).
The staple line can be oversewn omitting the point of anastomosis along the lesser curvature. This opening should be approximately 2.5 to 3 cm wide (figure 6). These sutures are then cut in anticipation of a direct end-to-end anastomosis with the duodenum (figure 7). If the margins of the lesser and greater curvatures of the stomach as well as the superior and inferior margins of the duodenum have been properly prepared, it is relatively easy to insert angle sutures of 00 silk. Successful closure of the angles depends upon starting the suture on the anterior gastric as well as the anterior duodenal wall rather than more posteriorly. Interrupted sutures of 00 silk are then taken to close the stomach and duodenum together. Slightly bigger bites are necessary on the gastric side as a rule rather than on the duodenal side, depending upon the discrepancy in size between the two openings (figure 8). The sutures should be tied, starting at the lesser curvature and progressing downward to the greater curvature. The angle sutures are retained while additional 000 silk or fine absorbable synthetic sutures are placed to approximate the mucosa (figure 9, a–a′ and b–b′). Some prefer a continuous synthetic absorbable suture to approximate the mucosa. The anterior mucosal layer is closed with a series of interrupted sutures of 000 silk or a continuous synthetic absorbable suture. The seromuscular coat is then approximated to the duodenal wall with a layer of interrupted sutures (figure 10). It has been found that a cuff of gastric wall can be brought over the duodenum, resulting in a “pseudopylorus,” if two bites are taken on the gastric side and one bite on the duodenal side. When this suture is tied (figure 10), the gastric wall is pulled over the initial mucosal suture line.
The vascular pedicles on the gastric side are anchored to the ligated right gastric pedicle along the top surface of the duodenum as well as the ligated right gastroepiploic artery pedicle (figure 10, a and b). A and B are then tied together to seal the greater curvature angle (figure 11). A similar type of approximation is effected along the superior surface in order to seal the angle and remove all tension from the anastomosis (figure 11). The stoma should admit one finger relatively easily. There should be no tension whatsoever on the suture line.
The upper quadrant is inspected for oozing and thoroughly irrigated with saline.