The Billroth I procedure for gastroduodenostomy is the most physiologic type of gastric resection because it restores normal continuity. Although long preferred by some surgeons in the treatment of gastric ulcer or antral carcinoma, its use for duodenal ulcer has been less popular. Control of acid secretion by vagotomy and antrectomy has permitted retention of approximately 50% of the stomach while ensuring the lowest ulcer recurrence rate of all procedures (FIGURE 1). This allows an easy anastomosis without tension, provided that both stomach and duodenum have been thoroughly mobilized. Furthermore, a poorly nourished patient 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.
The patient’s eating habits should be evaluated, and the relationship between her or his preoperative and ideal weights should be determined.
General anesthesia via an endotracheal tube is used.
The patient is laid supine on a 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. Sterile drapes are applied according to the surgeon’s specifications. Then a time-out is performed.
A midline 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. 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 the attachments between the fundus of the stomach and the diaphragm. Additional mobility is gained following 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.