Plate 21

The Billroth I gastric resection along with truncal vagotomy is frequently 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 to a normal configuration will result postoperatively in few symptoms and improved nutrition.

The stomach is aspirated preoperatively, and nasogastric suction is maintained. Antibiotics are given to patients with achlorhydria, since they may have significant bacterial colonization of the duodenum or stomach.

Routine general anesthesia is given via a cuffed endotracheal tube.

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 the routine manner with antiseptic solutions.

When there is evidence of malignancy, the stomach should be resected with the width of the hand (7.5 to 10 cm) beyond the upper margins of the tumor. When the lesion is near the pylorus, at least 2.5 cm of the duodenum should be resected, along with the omentum and any lymph nodes about the right gastroepiploic veins.

The Billroth I procedure for control of peptic ulcer should include vagotomy (Plates 16, 17, and 18) as well as a hemigastrectomy. The stomach is transected at the third vein on the lesser curvature and on the greater curvature where the gastroepiploic arterial blood supply is nearest the greater curvature (Plate 23, Figure 1). These anatomic landmarks ensure a complete antrectomy with control of the hormonal phase of gastric secretion.

As shown on Plates 23, 24, and 25, the duodenum and stomach are mobilized. A modified Furniss clamp is placed across the duodenum at the appropriate level, and a purse-string suture of monofilament polypropylene on a straight needle is introduced (Figure 1). This automatically creates a purse string on the duodenal stump. The duodenum is divided and 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 (TA 90). The longer staples are usually needed for the thick walls of the stomach. Any bleeding points are controlled with additional sutures.

A cutting linear stapler (GIA 60) gastrotomy is made for the intragastric introduction of the circular stapler (EEA) instrument through the anterior gastric wall at right angles to and about 3 to 5 cm distant to the staple line closure of the distal stomach (Figure 1). Any bleeding from the margins of the gastrotomy is controlled by interrupted sutures of either silk or absorbable materials.

The closed end of the stomach is reflected to the left, and the posterior gastric wall is grasped with a Babcock forceps 3 to 5 cm from the midportion of the staple line closing the distal stomach. A gastric purse string using a nonabsorbable suture is placed full thickness through the gastric wall about the Babcock. The central point is opened with an electrocautery puncture. The circular stapler (EEA) of the appropriate size is entered into the stomach with its detachable pointed plastic trocar exiting the back wall of the stomach through the punctate opening in the center of the purse string. The plastic trocar is removed and replaced with the metal anvil cap. The gastric wall is then securely closed with the purse string (Figure 2). The cap is screwed onto the tip of the center rod and it is inserted into the duodenum (Figure 3). The monofilament polypropylene purse string around the end of the duodenum is snugged and securely tied (Figure 4). The wing nut on the near end of the circular stapler (EEA) handle is turned until the stomach and the duodenum are firmly approximated. The safe zone indicator is checked to be certain that the thickness of the combined stomach and duodenum are within correct range of the staples. The safety is released, and the outside handles are squeezed. A double staggered, circular tow of staples is created, and an internal circular knife cuts the bowel walls within the staple lines simultaneously. The wing nut is loosened so that the anvils open, and the stapling instrument is gently removed (Figure 5). The doughnuts of tissue are carefully inspected to be certain there is no defect or discontinuity in the anastomosis. Several additional interrupted sutures may be placed to reinforce the anastomosis. The outer-wall gastrotomy opening is closed with a mucosa-to-mucosa noncutting linear stapler (TA 60) (Figure 6).

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