Chapter 29: Gastrectomy, Subtotal

INDICATIONS

Subtotal gastrectomy is indicated in the presence of malignancy, in the presence of gastric ulcer that persists despite intensive medical therapy, and sometimes in the presence of pernicious anemia, suspicious cells by gastric cytology, or equivocal evidence for and against malignancy by repeated gastroscopic observation with direct biopsy. It may be used to control acid secretion in cases of intractable duodenal ulcer. A more conservative procedure should be considered in underweight patients with duodenal ulcer, especially females. Likewise, block excision of a gastric ulcer with multicentric frozen-section studies should be done for proof of malignancy before performing a radical resection on the assumption that the lesion may be malignant.

PREOPERATIVE PREPARATION

The preoperative preparation is determined largely by the type of lesion presenting and by the complication it produces. Sufficient time should be taken to improve the patient’s nutrition, if possible, especially if there has been considerable weight loss in a patient with obstruction. Fluid and electrolyte imbalance should be treated with intravenous fluids and electrolytes as necessary. The increased incidence of pulmonary complications associated with upper abdominal surgery makes it imperative that elective gastric surgery be carried out only in the absence of respiratory infection, and active pulmonary physiotherapy potentially with bronchodilators, expectorants, and incentive spirometry should be started in all patients, but especially in those with chronic lung disease. Preoperative antibiotics should be given.

ANESTHESIA

General anesthesia with endotracheal intubation should be used. Excellent muscular relaxation without deep general anesthesia can be attained with muscle relaxants. Epidural catheter placement may be considered for analgesia and for pain relief after surgery.

POSITION

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

OPERATIVE PREPARATION

The skin is prepared in the routine manner. Sterile drapes are applied according to the surgeon’s specifications. Then a time-out is performed.

INCISION AND EXPOSURE

A midline incision extending from the xiphoid to the umbilicus may be used. Additional exposure can be obtained by excising the xiphoid using electrocautery. Placement of a self-retaining retractor or a broad-bladed, fairly deep retractor placed against the liver down to the gastrohepatic ligament will aid in visualization.

DETAILS OF THE PROCEDURE

The surgeon should focus her and his attention on the arterial blood supply (FIGURE 1). Although the stomach will retain viability despite extensive interference with its blood supply, the duodenum lacks such a liberal anastomotic blood supply, and great care must be exercised in the latter instance to prevent postoperative necrosis in the duodenal stump. The blood supply to the lesser curvature of the stomach can be totally ...