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INDICATIONS

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The Billroth I gastric resection along with truncal vagotomy is frequently performed for intractable duodenal ulcer or benign gastric ulcer. The procedure may be performed when hemigastrectomy is carried out for a variety of other reasons. It is hoped that this reconstruction to a normal configuration will result postoperatively in few symptoms and improved nutrition.

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PREOPERATIVE PREPARATION

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The stomach is aspirated preoperatively, and nasogastric suction is maintained. Antibiotics are given to patients with achlorhydria, since they may have significant bacterial colonization of the duodenum or stomach.

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ANESTHESIA

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Routine general anesthesia is given via a cuffed endotracheal tube.

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POSITION

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The patient is placed supine on the table in a modest reverse Trendelenburg position.

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OPERATIVE PREPARATION

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The skin of the lower chest and upper abdomen is shaved and prepared in the routine manner with antiseptic solutions.

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DETAILS OF PROCEDURE

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When there is evidence of malignancy, the stomach should be resected with the width of the hand (7.5–10 cm) beyond the upper margins of the tumor. When the lesion is near the pylorus, at least 2.5 cm of the duodenum should be resected, along with the omentum and any lymph nodes about the right gastroepiploic veins.

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The Billroth I procedure for control of peptic ulcer should include vagotomy (Chapters 22 and 23) as well as hemigastrectomy. The stomach is transected at the third vein on the lesser curvature and on the greater curvature where the gastroepiploic arterial blood supply is nearest the greater curvature (Chapter 26, figure 1). These anatomic landmarks ensure a complete antrectomy with control of the hormonal phase of gastric secretion.

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As shown in Chapter 26, the duodenum and stomach are mobilized. A modified Furniss clamp is placed across the duodenum at the appropriate level, and a purse-string suture of monofilament polypropylene on a straight needle is introduced (figure 1). This automatically creates a purse string on the duodenal stump. The duodenum is divided and the previously selected site for division of the stomach should be cleared of fat in order to ensure good approximation of the anterior and posterior walls of the stomach by the noncutting linear stapler. The longer staples are usually needed for the thick walls of the stomach. Any bleeding points are controlled with additional sutures.

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A gastrotomy is made with a cutting linear stapler (figure 1) or electrocautery for the intragastric introduction of the circular stapler instrument through the anterior gastric wall at right angles to and about 3 to 5 cm proximal to the staple line closure of the distal stomach (figure 2).

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The closed end of the stomach is reflected to the left, and the posterior ...

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