The Billroth II gastric resection is one of the most commonly performed procedures for malignancy of the stomach or for the control of gastric hypersecretion in the treatment of ulcer. The extent of the resection varies, with a two-thirds to three-fourths resection being the most common. When the left gastric vessels are ligated, 75% or more of the stomach is resected with the major blood supply coming from the gastrosplenic circulation. In the presence of carcinoma involving the body of the stomach, all the lymph nodes along the lesser curvature up to the esophagus are resected. The greater omentum is also removed, along with any lymph nodes about the right gastroepiploic vessels. When a malignancy is near the pylorus, 2 to 3 cm at least of the duodenum distal to the pylorus should be resected (see discussion in Chapter 26). Sometimes only a rim of gastric mucosa remains attached to the esophagus, which may require reconstruction with sutures rather than with the stapler. Consideration should be made for laparoscopic resection in cases without a contraindication such as extensive previous operations or large bulky tumors.
General anesthesia is administered endotracheally.
The patient is placed supine on the table in a modest reverse Trendelenburg position.
The skin of the lower chest and upper abdomen is shaved and prepared in a routine manner with antiseptic solutions. Preoperative antibiotics are administered.
An upper midline incision is made. If a high resection is indicated, the xiphoid process is resected and the left lobe of the liver may be freed and folded toward the right side after dividing the triangular ligament.
The entire omentum is usually freed from the transverse colon, including both flexures in the presence of malignancy (see Chapter 27, Omentectomy). It is technically easy to remove the greater omentum by the technique shown in Chapter 27, figures 1 to 5. The superior and inferior borders of the duodenum are partially freed to permit mobilization and ligation of the duodenal opening by a non-cutting linear stapler or a cutting linear stapler if there is adequate length. A Kocher clamp is applied across the pyloric end of the stomach or duodenum just beyond the point where the staple line is divided with a knife if using a non-cutting linear stapler (figure 1). The duodenum should be disturbed as little as possible when a posterior penetrating ulcer is known to be present, lest perforation into the ulcer crater occur with subsequent leakage.
The lesser and greater curvatures at the level selected for resection are freed of fat in preparation for the placement of the linear stapler in ...