Plate 30

The Billroth II gastric resection is one of the most commonly performed procedures for malignancy of the stomach or for the control of gastric hyper secretion in the treatment of ulcer. The extent of the resection varies, with a two-thirds to three-fourths resection being the most common. When the left gastric vessels are ligated, 75 percent or more of the stomach is resected with the major blood supply coming from the gastrosplenic circulation. In the presence of carcinoma involving the body of the stomach, all the lymph nodes along the lesser curvature up to the esophagus are resected. The greater omentum is also removed, along with any lymph nodes about the right gastroepiploic vessels. When a malignancy is near the pylorus, 2 to 3 cm at least of the duodenum distal to the pylorus should be resected (see discussion in Plate 23). Sometimes only a rim of gastric mucosa remains attached to the esophagus, which may require reconstruction with sutures rather than with the stapler.

General anesthesia is administered endotracheally.

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 a routine manner with antiseptic solutions.

An upper midline incision is made. If a high resection is indicated, the xiphoid process is resected and the left lobe of the liver may be freed and folded toward the right side after dividing the triangular ligament.

The entire omentum is usually freed from the transverse colon, including both flexures in the presence of malignancy (see Plate 27, Omentectomy). The blood vessels can be controlled by the vascular double clip and cut device (LDS) instrument, which fires two staples and divides the intervening tissue with a knife. However, it is technically easy to remove the greater omentum by the technique shown in Plate 27, Figures 1, 2, 3, 4, and 5. The superior and inferior borders of the duodenum are partially freed to permit mobilization and ligation of the duodenal opening by a non cutting linear stapler (TA 30 or 55). A Kocher clamp is applied across the pyloric end of the stomach or duodenum just beyond the point where the staple line is divided with a knife (Figure 1). The duodenum should be disturbed as little as possible when a posterior penetrating ulcer is known to be present, lest perforation into the ulcer crater occur with subsequent leakage.

The lesser and greater curvatures at the level selected for resection are freed of fat in preparation for the placement of the linear stapler (RLG 90) (Figure 1). The nasogastric tube is retracted before the stapler is applied. Straight Kocher clamps are applied from either curvature, and the stomach is divided with a scalpel applied against the stapler. Additional sutures may be required to control bleeding in the staple line. The extent of stomach removed and the performance of vagotomy are both related to the indications for the resection.

The jejunum just beyond the ligament of Treitz is selected for the anastomosis. It must be sufficiently long to easily reach the gastric pouch, but extra-long loops are avoided. While the loop of jejunum may be brought up through an opening made in the avascular portion of the transverse mesocolon to the left of the middle colic vessels (retrocolic position), many bring the loop of jejunum up over the transverse colon (antecolic position). A thick, fat omentum should either be resected or split to permit the shortest loop of bowel to be used.

There are various options for performing the anastomosis between the gastric pouch and the jejunum. The anastomosis may span the full width of the stomach, with the stoma made either anterior or posterior to the suture line closing the stomach. Usually the proximal jejunum is anchored to the lesser curvature (Figure 2). An anastomosis to the posterior gastric wall is commonly made. The jejunum is anchored to the full width of the posterior gastric wall, perhaps 3 cm proximal to the line of staples occluding the stomach. Babcock forceps or sutures can be used to fix the jejunum in place parallel to the gastric wall. Stab wounds are made either with a scalpel or cautery on the greater curvature end to permit the introduction of the cutting linear stapler (PLC 50) blades (Figure 2). The size of the anastomosis is governed by the depth to which the blades are inserted (Figure 3). When the cutting linear stapler (PLC 50) blades are removed, the staple lines are inspected for bleeding, which may require a few sutures for control. Finally, the stab wounds are approximated with traction sutures (Figure 4) or Allis clamps and stapled shut with the RL50 instrument (Figure 5). Additional interrupted sutures are added when bleeding is present, and the jejunum may be anchored to the lesser curve to remove any possible tension on the suture lines. The patency of the stoma is tested by finger palpation (Figure 6). The nasogastric catheter is then passed for some distance into the distal jejunum to provide early decompression followed within a day or two by the administration of liquid diet upon resumption of peristaltic activity of the gastrointestinal tract.

Routine closing of the incision is used.

Fluid and electrolyte balances are maintained and the blood volume is restored. Liquids in small amounts are permitted within 24 hours. Antibiotics are given, especially if there has been gastric stasis or malignancy. Early ambulation is encouraged. The stomach tube is removed as soon as there is clinical evidence of gastric emptying.