Plate 19
###### Figure 5

The Billroth I procedure for gastroduodenostomy is the most physiologic type of gastric resection, since it restores normal continuity. Although long preferred by some in the treatment of gastric ulcer or antral carcinoma, its use for duodenal ulcer has been less popular. Control of the acid factor by vagotomy and antrectomy has permitted retention of approximately 50 percent of the stomach while ensuring the lowest ulcer recurrence rate of all procedures (Figure 1). This allows an easy anastomosis without tension, providing both stomach and duodenum have been thoroughly mobilized. Furthermore, the poorly nourished patient, especially the female, has an adequate gastric capacity for maintaining a proper nutritional status postoperatively. Purposeful constriction of the gastric outlet to the size of the pylorus tends to delay gastric emptying and decrease postgastrectomy complaints. Gastrin levels are determined.

The patient's eating habits should be evaluated, and the relationship between his or her preoperative and ideal weight should be determined. The retention of an adequate gastric capacity as well as reestablishment of a normal continuity tends to give the best assurance of a satisfactory nutritional status in undernourished patients, especially females.

General anesthesia via an endotracheal tube is used rather routinely.

The patient is laid supine on the flat table, the legs being slightly lower than the head. If the stomach is high, a more erect position is preferable.

The skin is prepared in a routine manner.

A midline or left paramedian incision is usually made. If the distance between the xiphoid and the umbilicus is relatively short, or if the xiphoid is quite long and pronounced, the xiphoid is excised. Troublesome bleeding in the xiphocostal angle on either side will require transfixing sutures of fine silk and bone wax applied to the end of the sternum. Sufficient room must be provided to extend the incision up over the surface of the liver, because vagotomy is routinely performed with hemigastrectomy and the Billroth I type of anastomosis, especially in the presence of duodenal ulcer.

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 ...

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