++
The Billroth I gastric resection, along with truncal vagotomy, is 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 provides a more physiologic configuration resulting in fewer postoperative symptoms and improved nutrition.
+++
PREOPERATIVE PREPARATION
++
The stomach is aspirated preoperatively, and nasogastric suction is maintained. Prophylactic antibiotics are given to all patients for gram-positive cocci and gram-negative bacilli.
++
Routine general anesthesia is given via a cuffed endotracheal tube.
++
The patient is placed supine on the table in a modest reverse Trendelenburg position.
+++
OPERATIVE PREPARATION
++
Prophylactic antibiotics are administered. The skin of the lower chest and upper abdomen are shaved and prepared in the routine manner with antiseptic solutions. Sterile drapes are applied according to the surgeon’s specifications. Then a time-out is performed.
+++
DETAILS OF THE PROCEDURE
++
When there is evidence of malignancy, the stomach should be resected to at least 4 cm from the gross tumor to achieve negative margins. When the lesion is near the pylorus, at least 2.5 cm of the duodenum should be resected, along with the omentum. Adequate D2 lymphadenectomy should be considered if it can be undertaken safely (see FIGURE 1 in Chapter 29).
++
The Billroth I procedure for control of peptic ulcer should include vagotomy as well as hemigastrectomy. The duodenum is transected after the pyloric valve with a cutting linear stapler, being mindful not to proceed distal and encroach on the ampulla of Vater. The stomach is also transected using a cutting linear stapler at the third vein on the lesser curvature and on the greater curvature where the gastroepiploic arterial blood supply is nearest the greater curvature (FIGURE 1). These anatomic landmarks ensure a complete antrectomy with control of the hormonal phase of gastric secretion.
++
As shown in Chapter 29, the duodenum and stomach are mobilized. The duodenal staple line is removed, a modified Furniss clamp is placed across the duodenum at the appropriate level, and then a purse-string suture of monofilament polypropylene on a straight needle is introduced (FIGURE 1). This creates a purse string on the duodenal stump. This can also be undertaken with an automatic purse-string device. 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.
++
A gastrotomy is made with a cutting linear stapler (...