Plate 25

Transfixing silk traction sutures are applied to the superior and inferior borders of the duodenum adjacent to its retained blood supply. These traction sutures are helpful when the narrow crushing large vascular clamp is applied to the duodenum, as well as in the subsequent closure of the duodenal stump (Figure 14). After the blood supply about the pylorus has been divided and tied, the stomach is held upward in order to free any adhesions between the first portion of the duodenum and the pancreas (Figure 14). At this time the transverse colon can be returned to the abdomen and retracted out of the operating field. The field is then walled off by several warm, moist sponges.

A thin-bladed, noncrushing clamp of the vascular type (Potts) is then applied across the duodenum at the prepared level (Figure 15). A Kocher clamp is applied to the gastric side. There should be at least 1 cm of cleansed serosal surface at either border of the duodenum, between the noncrushing clamp and the traction sutures. This amount of prepared duodenal wall is necessary to ensure a safe subsequent closure of the duodenal stump. If the adjacent ligature does not permit 1 cm of cleared serosa between it and the margin of the clamp, small served clamps should be applied to the interfering vascular attachments, and such attachments should be divided and ligated. The duodenum is divided with a knife. The clamp applied to the gastric side is covered with a piece of gauze, and the stomach is retracted to one side. The duodenal stump is then retracted laterally in order to determine whether a sufficient amount of the serosa of the posterior wall has been cleared away to permit a safe closure of the duodenal stump. At least 1 cm distal to the clamp, the duodenum should be freed from the pancreas in order that subsequent sutures in the serosa may be placed under full vision. Individual clamping and subsequent ligation of the small vascular attachments must be carried out without damaging the gastroduodenal artery (Figure 16). The placement of deep sutures to control bleeding should be rigorously avoided in this area because of the potential danger of pancreatitis.

There are many ways of closing the duodenal stump. However, it should be remembered that a very firm closure is necessary, since blowing-out of the duodenal stump is not an uncommon fatal complication of gastric surgery caused by failure to clear a sufficient amount of duodenum, especially along the upper border. The tendency of the “cloverleaf” deformity associated with the ulcer to produce a diverticulum-like extension beyond the superior margin must be corrected in many instances to ensure a closure of the stump in this area. Failure to free up and excise this deformity tends to make inversion of the mucosal layer very difficult. The superior margin as well as the inferior margin of the duodenum adjacent to the clamp may be grasped with Babcock forceps preliminary to removal of the noncrushing clamp (Figure 17). As the noncrushing clamp is removed, the bleeding margin of the duodenal stump is grasped with two or three Babcock or Allis forceps (Figure 18). The duodenum is then closed with interrupted 0000 silk sutures or a continuous absorbable suture (Figures 18 and 19). The mucosal suture line should then be inverted by applying a row of interrupted mattress sutures of 00 silk, which tends to pull the anterior wall downward toward the pancreas (Figure 20). A cleaned serosal surface should be available at both the superior and inferior margins when this layer of interrupted serosal sutures is finally inverted.

As a final safety measure to reinforce the closure, interrupted sutures may be taken in the anterior wall of the duodenum and, superficially, in the capsule of the pancreas (Figures 21 and 22). While the duodenal stump is being closed, the common duct should be visualized and its relationship determined from time to time, so that there is no possibility of its accidental angulation, injury, or obstruction as a result of inverting the duodenal stump. The gallbladder, if present, should be compressed to provide evidence of a nonobstructed common duct. If uncertainty exists, contrast dye may be placed into the gall-bladder using a fine-gauge needle and the site oversewn with a 000 suture. Compression of the gallbladder will force the dye into the common duct and duodenum as shown on an x-ray film of the region.

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