Chapter 26. Stomach and Duodenum: Operative Procedures

The earliest recorded operations on the stomach were performed for penetrating injuries.1 In the late 1800s, experimental studies in the surgical laboratories of Billroth confirmed the feasibility of removing the pylorus, a concept developed by Michaelis in the early part of that century. In 1881, Rydygier performed the first successful pylorectomy, and in 1884 he performed the first gastroenterostomy. Both of these operations were performed for complications of benign peptic ulcer disease. In 1881, Billroth performed the first successful pylorectomy for malignancy. In this case, the duodenum was anastomosed to the lesser curvature of the stomach and the greater curvature was oversewn. The patient initially did well but died from disseminated abdominal carcinomatosis 4 months later. In 1885, Billroth performed a resection of a large pyloric carcinoma, using an anterior gastrojejunostomy for the reconstruction. In subsequent years, Billroth, his students, and others devised several approaches to gastroduodenal and gastrojejunal reconstruction.1–3 Following popularization of gastrojejunostomy for reconstruction after gastric resection or palliation of unresectable gastric malignancy, surgeons were confronted with early complications such as bleeding, anastomotic leak, intestinal obstruction, and late complications such as stomal ulceration, bilious vomiting, afferent and efferent limb obstructions, and dumping.4,5 At present, these problems remain only partially understood and controllable.

Pyloroplasty was initially devised by Heineke for treatment of congenital hypertrophic pyloric stenosis, and the results were poor. Jaboulay's side-to-side anastomosis of the distal greater curvature and duodenum in 1892, and the Faience extension of this anastomosis to include the pylorus itself were subsequently refined by Kocher. Kocher improved the technical ease of the operation by including a mobilization of the duodenum from its lateral peritoneal attachments. The first pyloromyotomy was performed for this lesion in 1912 by Ramstedt.

In the early part of the 20th century, a dramatic rise was observed in the incidence of duodenal ulceration. A period of intense clinical and laboratory investigation from 1920 through 1940 led to the recognition that surgically performed vagotomy could reduce gastric acidity under resting conditions and in response to luminal and humoral stimuli. The use of vagotomy for patients with complications of ulcer disease was pioneered by Latarjet, who reported 24 such cases in 1922. Latarjet himself recognized that vagotomy might lead to delayed gastric emptying and had added a drainage procedure, gastrojejunostomy. Confusion regarding the role of delayed gastric emptying in the pathogenesis of peptic ulcers, however, led many surgeons away from vagotomy and drainage as a treatment for recurrent peptic ulceration. It remained for Dragstedt and his colleagues at the University of Chicago to resurrect this concept in the 1940s.5 Subsequently, Farmer, Smithwick, and others introduced the combination of truncal vagotomy (TV) and hemigastrectomy, an operation that also removed the gastrin-producing antral mucosa.3 In the 1950s, Harkins' group in Seattle began to evaluate forms of vagotomy that left intact the celiac and hepatic branches (proximal selective vagotomy), along with or in combination with the preservation of vagal motor branches to the antrum (highly selective vagotomy [HSV] or parietal cell vagotomy). These modifications arose from an appreciation of the contributions of antral motility to proper digestion, as well as improved understanding of specific postvagotomy complications such as dumping and diarrhea. The popularization of HSV is largely attributable to the efforts of Johnston, Goligher, Amdrup, and others, who in the 1960s and 1970s demonstrated the feasibility of obtaining ulcer recurrence rates as low as those of conventional TV without the incidence of dumping and diarrhea that was associated with TV with drainage or gastrectomy.6,7 It is worth noting that surgeons have done more than developing new and interesting operative approaches to acid peptic disease. They played a major role in advancing current concepts of pathophysiology in ulcer disease and recurrence, and in understanding the physiological consequences of ulcer treatments, both medical and surgical.4,5

Even though the increasing use of medications that inhibit gastric acid secretion, such as proton pump inhibitors, has made elective antisecretory operations essentially nonexistent, these medications remain part of the surgeon's armamentarium in dealing with patients who remain refractory to maximal medical therapy for ulcer disease, and in some selected cases for patients with ulcer perforation and bleeding. To understand the importance of the technical details in the execution of antisecretory operations, it is necessary to fully appreciate the anatomy of the vagus nerve and the gastric microvasculature, as well as the physiology of acid secretion, mucosal barrier function, and gastric motility, which are expanded upon in the following text.

Tests of Vagal Control of Acid Secretion

Historically, vagal control of acid secretion has been assessed by measuring acid secretion in response to various stimuli. Acid secretion can be measured directly by the placement of a tube into the stomach, through which gastric juice is aspirated and the titratable acidity is measured by adding known quantities of 0.1 N NaOH. Gastric output is measured at baseline and after stimulation with pentagastrin or sham feeding. Measurements of gastric acid output pre– and post–vagotomy operations can be measured to assess the efficacy of vagotomy.8,9 Acid secretion also can be assessed semiquantitatively, using pH-sensitive dyes, such as Congo red, that coat the mucosa and turn color when acid is being secreted from the gastric glands.10,11 Although the former analytic methods permit accurate and quantitative assays of secretory capacity before and after the operation, the latter colorimetric methods can provide relatively rapid means of assessing secretory capacity of the stomach during the operation itself. These tests are rarely used today with the increasing use of medications that inhibit gastric acid secretion such as proton pump inhibitors and the consequent rarity of performing elective antiulcer gastric acid–reducing operations.

Vagal Regulation of Gastric Motility and Emptying

As stated by Professor David Johnson in a previous edition of this book, “… Only when one fully understands the physiologic rationale of highly selective vagotomy will be one sufficiently motivated to do it well.” This statement was made not in reference to the innervation of parietal cells that secrete HCl, but to the neural regulation of gastric motor function and emptying. The vagus dominates the motor activity of the normally functioning stomach in three ways. First, it mediates receptive relaxation and gastric accommodation; that is, the relaxation of the gastric fundus when intraluminal pressures in the proximal esophagus and stomach are increased by the presence of chyme. Second, the vagus mediates increases in antral myoelectrical activity that result from distention of the proximal stomach by chyme. Third, the vagus appears to mediate coordination of pyloric emptying with antral myoelectrical activity, in response to changes in proximal gastric motor activity, and perhaps in response to changes in composition and pH of duodenal content.12

It should be recognized that while truncal or selective vagotomy interrupts the vagal pathways to the antrum and pylorus, all three forms of vagotomy (truncal, selective, and highly selective) abolish receptive relaxation and gastric accommodation. It has been claimed that in the absence of pyloric scarring or stenosis, vagotomy only temporarily impairs gastric emptying. This rationale has been used to justify combinations of selective and relatively nonselective approaches, such as a posterior truncal and anterior highly selective (or anterior seromyotomy) vagotomy. Such arguments become important in thinking about potential adverse consequences of laparoscopic approaches to the vagus and the need for, and choice of, drainage procedures. The assumptions that antral/pyloric coordination will return after truncal vagotomy or that gastric emptying after pyloromyotomy is as good as that after pyloroplasty now seems valid.13–15 In addition, the spectrum of complications following such mixtures of approach has now been characterized and is not substantially different than those reported in symmetric operations.15,16 Nevertheless, for open or laparoscopic procedures, it is advisable to use the same caution in utilizing mixtures of approach or dispensing with drainage procedures after truncal or selective vagotomy.

Open Approaches to the Vagus

Patient Position, Incisions, and Exposure

To perform a complete vagotomy, access to the upper part of the stomach and lower esophagus is crucial. It is helpful for the operating surgeon, standing on the patient's right, to wear a headlight. When access to the duodenum is required, as in a gastrectomy, excellent exposure is available through a chevron incision. However, in most patients, both thin and obese, a midline incision carried up along the xiphoid will be adequate. In the obese, extension of the incision below the umbilicus facilitates exposure. Placing the patient in reverse Trendelenburg position is helpful. A nasogastric (NG) tube is placed with its tip at the most dependent portion of the greater curvature. The NG tube helps to keep the position of the esophagus in mind. A self-retaining retractor is required. We use an upper abdominal self-retaining retractor that provides excellent accessories for securing wide exposure to the upper abdomen, and by means of well-placed Mikulicz's pads, for holding the small bowel and transverse colon in the lower abdomen (Fig. 26-1). Some surgeons advocate routine mobilization of the left lobe of the liver by dividing the left triangular ligament. This mobilization is not always necessary and, when the lobe is floppy, can impede exposure. If this maneuver is performed, the lateral segment of the left lobe is held upward and to the right by a Richardson or Herrington-type retractor accessory. Care must be taken to place sponges or a pack between the retractor attachment and liver, and not to put much tension on the liver. Otherwise, fracture of the liver parenchyma and bleeding will result.

Truncal Vagotomy

Truncal vagotomy (TV) is performed in conjunction with some form of drainage procedure. In the elective setting, it is used in conjunction with antrectomy for definitive management of refractory symptoms of duodenal ulcer, pyloric channel ulcer (gastric ulcer type III), or gastric ulcers combined with duodenal (Dragstedt) ulcers. In the current era of highly effective antisecretory therapies such as omeprazole, and anti-Helicobacter antibiotics, the main indication for TV and antrectomy is in the setting of pyloric outlet obstruction with a long-standing history of ulcer symptoms or complications such as bleeding and perforation. TV and pyloroplasty are reserved for emergency operations for complications such as bleeding or perforation. Occasionally, TV plus gastroenterostomy will be an appropriate compromise when the duodenum is too scarred to permit safe antrectomy and duodenal closure. The anatomy of the vagal trunks and nerves of Latarjet has been reviewed17 and is shown schematically in Figs. 26-2 and 26-3.

Using a Mikulicz pad or carefully applied Babcock clamps, the assistant places downward traction on the greater curvature of the stomach, thereby placing traction on the gastroesophageal junction and lower esophagus. The first step is to incise the peritoneal covering of the gastroesophageal junction. The peritoneum is opened horizontally, from the angle at the lesser curvature to the cardiac notch at the greater curvature. The surgeon's thumb and right index finger are used in a blunt dissection to encircle the esophagus. When teaching this maneuver, it is not uncommon for the trainee to confuse the right crus of the diaphragm with the esophagus itself or even the posterior vagal trunk. Extra time spent at this juncture to correctly identify all structures is an essential aspect in teaching the operation. A Penrose drain can be passed around the junction in order to place more effective downward traction on the gastroesophageal junction. When encircling the esophagus, the surgeon stays wide of the esophagus in order to prevent inadvertent entry into the lumen and to include the vagal trunks. In the course of this maneuver, the posterior vagal trunk usually will be palpated as a taut cord.

A single anterior vagal trunk is usually identified in the anterior midportion of the esophagus, 2–4 cm above the gastroesophageal junction (Fig. 26-4). At this level, however, it is not uncommon for vagal fibers to be distributed between two or three smaller cords. These cords are palpable as much as they are visible and can be separated from surrounding esophageal muscle fibers using a nerve hook. These trunks are individually lifted up, and 2- to 4-cm segments of each are separated from surrounding tissues. A medium-sized clip is applied at the most superior end, and a clamp is applied inferiorly. The 2-cm length of nerve is resected and a clip is applied below the clamp; small bleeders are cauterized precisely. If it has not been done, the esophagus should be more widely mobilized for a distance of 4–5 cm above the gastroesophageal junction. Smaller, individual vagal fibers that ramify from the main trunks toward the lesser curvature and the cardiac notch then can be identified and cut or cauterized. The “criminal nerve” of Grassi, discussed in more detail in the section describing parietal cell vagotomy, also may be identified here, wrapping around the cardiac notch from its origin in the posterior trunk. The posterior vagal trunk itself usually will have been identified along the right edge of the esophagus. If the anterior vagus has already been divided, the esophagus is more mobile. This mobility allows the surgeon to place downward traction on the gastroesophageal junction, or along the most caudal portion of the greater curvature, thereby applying gentle tension on the EG junction, which causes the posterior vagus to “bowstring” and make it easier to identify. A 2- to 4-cm segment is separated from surrounding tissues, its margins marked with clips, and resected. Major branches of the anterior vagus and the posterior vagal trunk should be sent to pathology for examination in frozen section. Care should be taken to note the results of the pathologist's frozen section diagnosis in the dictated operative note.

Selective Vagotomy

Selective vagotomy (SV) is not commonly practiced in the United States, but it has found favor with European surgeons, who prefer not to cut the posteriorly derived vagal branch that innervates the small intestine and pancreas and anteriorly derived vagal branch that supplies the gallbladder and liver. There is evidence that preservation of such branches can avoid alterations in gallbladder motility that might lead to stasis and stone formation.18 However, it is not clear whether preservation of the small intestinal and pancreatic nerves protects against some symptoms of the dumping syndrome.19–22, SV involves interruption of both nerves of Latarjet and therefore does not avoid the need for a drainage procedure.22 Thus the main indication for SV may be in patients undergoing elective antrectomy with vagotomy for refractory ulcer symptoms or obstruction.

Exposure to the vagus, gastroesophageal junction, and esophagus is obtained in the same way that the surgeon would perform TV. Anteriorly, the nerve of Latarjet is identified by following the anterior vagal trunk as it descends from the esophagus to the lesser curvature of the stomach. Frequently, the descending branch of the left gastric artery is in close proximity to the site where the hepatic/gallbladder branches take off toward the liver in the gastrohepatic (lesser) omentum. A segment of the nerve of Latarjet is severed between clips and sent for examination on frozen section. The most expeditious way to perform this maneuver is to cross-clamp the portion of the lesser omentum that contains the artery and nerve, ligating and dividing these structures together (Fig. 26-5). The dissection continues upward along the lesser curvature, gastroesophageal junction, and esophagus. Division and ligation of blood vessels and nerves in this bundle avoids the hepatic/gallbladder branches and denervates the cardia, as was described for TV. This dissection opens up the plane for dissection and ligation of the posterior nerve of Latarjet.

Highly Selective Vagotomy

Generally accepted indications for highly selective vagotomy (HSV) include elective management of intractable symptoms of duodenal ulcer disease, emergency treatment for perforated duodenal ulcer, and emergency treatment of perforated gastric ulcer when the ulcer is to be excised in a wedge rather than resected in continuity with the distal stomach. HSV also has been advocated for management of bleeding gastric or duodenal ulcers, but this has not been widely practiced. Finally, there is published experience in pyloric outlet obstruction using HSV in combination with finger or endoscopic balloon dilation,19,23–25 but systematic audits of long-term persistence or recurrence rates of obstructing symptoms have yet to be reported.

A number of variations of the technique have been described and all are not reviewed here. However, it is worth cataloguing the decisions that the surgeon must make in preparing for and performing this operation. The first decision is whether to use Congo red dye for intraoperative testing of the completeness of vagotomy, in countries where it is approved for this application. It may be difficult, and sometimes contraindicated, to perform endoscopy in the setting of acute bleeding or perforation. If the test is to be used, the endoscopic equipment and reagents should be assembled in the operating room before the operation begins.26 Conceptually then, the operation is divided into four phases: (1) exposure and gastric mobilization; (2) dissection of the anterior leaf of the lesser omentum; (3) dissection of the posterior leaf of the lesser omentum; and (4) dissection of vagal fibers traveling to the stomach along the distal esophagus.

Exposure and Gastric Mobilization.

Exposure of the vagus nerves, esophagus, and gastroesophageal junction is obtained as described previously. A wide-bore (18F) NG tube should be placed by the anesthesia team. A number of authors have emphasized the importance of the stomach as a retractor in this operation. We recommend mobilization of the distal part of gastrocolic omentum. The dissection should be carried outside the gastroepiploic arcade, in order to avoid loss of any blood supply to the greater curvature. Congenital adhesions between the stomach and peritoneum overlying the pancreas are divided sharply. The goal of this dissection is to obtain sufficient mobility of the stomach so that it can be rotated upward and to the patient's right, thus permitting visualization of the posterior leaf of the lesser omentum and the posterior nerve of Latarjet through the lesser sac. The nerve can be seen running close to the descending branch of the left gastric artery. Vagal fibers can be seen running transversely toward the lesser curvature.

Dissection of the Anterior Leaf of the Lesser Omentum.

The anterior leaf of the lesser omentum now is dissected. The next decision point is to define the distal margin of the dissection of the branches of the nerve of Latarjet (Fig. 26-6). An important landmark is the incisura angularis. The “crow's foot” is the neurovascular bundle that innervates the junction of the corpus and antrum, and has three characteristic branches from which its name derives. These nerves contain motor branches to the antrum and secretory branches to the oxyntic mucosa. Thus, leaving this bundle intact makes the antisecretory operation less complete, but fully severing it may lead to disturbances in gastric emptying. Two approaches for defining the distal margin of the dissection have been advocated. First, one may arbitrarily begin the dissection at a predetermined point 6–7 cm proximal to the pylorus, a distance that usually corresponds to the most proximal of the three branches of the crow's foot. Alternatively, one may identify this most proximal branch and begin the dissection there. It is helpful to begin the dissection a few centimeters proximal to the agreed-upon distal margin, because strong traction during subsequent parts of the operation may cause traction injury on the antral motor branches and vessels that accompany them. These last few centimeters are dealt with last.

The assistant provides downward and leftward traction on the greater curvature, thus placing tension on the anterior nerve of Latarjet as it runs along the lesser curvature. The hepatic fibers usually are visualized without difficulty in the upper part of the lesser omentum. It is helpful to “score” the serosa of the lesser curvature, from the incisura to the cardia, and then transversely across the gastroesophageal junction. The incision is performed with dissecting scissors or a no. 15 knife, not electrocautery. This maneuver widens the gap between the nerve and the gastric wall. Individual vessels run transversely from the lesser omentum onto the lesser curvature. These structures are ligated in continuity with 3-0 silk ligatures before division. (We avoid the use of hemostats in this dissection.) This part of the operation is performed gently and should not cause blood loss. The dissection proceeds along the lesser curvature until the gastroesophageal junction is reached. The left anterior aspect of the esophagus is now uncovered, and, for the moment, the dissection stops. Care should be taken not to continue up the right side to avoid interrupting the main anterior vagus.

Dissection of the Posterior Leaf of the Lesser Omentum.

The posterior leaf of the lesser omentum then is dissected. Care should be taken in setting up exposure for this part of the operation. In one approach, the stomach is rotated upward and to the patient's right. Alternatively, the posterior leaf can be reached by working through the anterior leaf as illustrated in Fig. 26-7. Using the thumbs and fingers, the gastroesophageal junction is “rolled” counter clockwise so that the posterior wall moves to the right and the anterior wall moves to the left. The nerve branches and their accompanying vessels then are ligated in continuity and divided. The dissection should not be carried to less than 6 cm from the pylorus. To avoid the main left gastric vessels, this approach to the dissection should be carried about two-thirds of the distance along the lesser curvature. After reaching the left gastric vessels, the surgeon returns to the anterior approach, ligating and dividing the remainder of the posterior leaf through the window in the anterior leaf.

Dissection of the Distal Esophagus.

The goal of this dissection is to clear the distal esophagus of all nerve fibers for a distance of approximately 5 cm above the gastroesophageal junction. The importance of this part of the dissection is well documented.27 It should be noted that the prior dissection of the lesser omentum has allowed the main vagal trunks to move upward and to the patient's right, thereby minimizing the risk of damaging the main trunks in this part of the dissection. The operative technique requires that this dissection stay close to the lesser curvature and esophagus. Any dissection toward the tissues to the right (ie, toward the main vagal trunks) should be avoided.

This part of the procedure begins with the dissection of the left side of the esophagus (Fig. 26-8). Denuding the surface can be performed gently, using a finger or “peanut” dissector to isolate the adventitia that contains nerves, vessels, and lymphatics. This dissection is where the “criminal nerve” of Grassi is likely to be encountered. Tissues are ligated in continuity and divided. This dissection should also clear 2 or 3 cm of the cardia, just distal to the gastroesophageal junction, and small fibers running to the greater curvature will be divided here. It is usually not necessary to divide any of the short gastric arteries.

The anterior aspect of the esophagus is now cleared of vagal fibers (Fig. 26-9). Gentle traction and lifting of the fibers will isolate them for division between ligatures or by cautery. We prefer ligation in continuity with fine (4-0 or 5-0) silk to avoid injury to the esophageal muscle. The posterior aspect is now reexposed with downward traction of the gastroesophageal junction and a counter clockwise rotation of the distal esophagus. Working through the window of the anterior leaflet, the upward branches of the left gastric artery are visualized as they pass to the cardia and the gastroesophageal junction. They are ligated in continuity and divided. The dissection continues upward along the cardia and gastroesophageal junction, until it is possible to encircle the lower esophagus with a Penrose drain. Downward traction on the gastroesophageal junction is provided by this drain, and additional nerve fibers are seen in the adventitia. Smaller fibers are cauterized while held away from the esophageal muscularis, whereas larger ones are ligated with clips or fine silk and divided. Throughout this dissection, the positions of the nerves of Latarjet and the main trunks should be checked.

The final part of the operation involves completion of the distal dissection to the crow's foot and checks for hemostasis. A number of authors have in the past suggested that reperitonealization of the lesser curvature be performed. Although we do not routinely do this, the rationale for this maneuver is that the devascularization that is part of HSV may lead to small areas of necrosis of the gastric wall and localized perforations. Such leaks have been reported in about 0.2% of patients.28,29 Also, it has been argued that reperitonealization might impede reestablishment of vagal nerve connections to the gastric wall.30 The reperitonealization would thus protect against such leaks. The reperitonealization can be performed by inversion of the serosa of the lesser curvature with running or continuous 3-0 long-acting absorbable suture. Alternatively, a vascularized pedicle of omentum can be used to cover the deserosalized lesser curvature. Bleeding complications have been reported with this latter method, but it minimizes tension within the gastric wall.

Reoperative Approaches to the Vagus Nerves

Approximately two-thirds of patients with duodenal or pyloric channel ulcer recurrence after an initial antisecretory operation (TV, SV, or HSV) have evidence of persistent (or possibly reestablished) vagal innervation.9,31,32 Although many such recurrences are amenable to medical regimens, a small fraction ultimately may be considered for reoperation, especially if surgery is required to control an acute complication such as bleeding or perforation following a period of ulcer-related symptoms. Prior surgery will have made the standard approaches to the lesser curvature and gastroesophageal junction hazardous, which is often caused by dense adhesions to a previously mobilized left lobe of the liver. Thus, two approaches to the vagus, both nonselective, may be considered for completion of the failed vagotomy, especially if it was performed in conjunction with antrectomy. It should be stressed that when such a reoperation is contemplated, especially in a nonemergent setting, it is prudent to obtain some form of acid secretion profile to document the hypersecretory state. Also, because of the nonselective nature of the completion vagotomy, an antrectomy or drainage procedure must be performed.

In the setting in which standard access is difficult due to prior surgery, Barroso and associates have utilized a transabdominal suprahepatic approach to the vagi.33 A high midline incision is used, with mechanical retraction to elevate the subcostal margin. An 18F NG tube is placed. The triangular, left coronary, and falciform ligaments and adhesions are divided, permitting downward retraction of the left lobe. Using the NG tube, the esophagus and hiatus are located. The esophagus and vagi are dissected at the level of the diaphragm at the hiatus and incised anteriorly for a distance of 3–5 cm, exposing the esophagus at the lower mediastinum. The trunks are easily identified and ligated in the untouched lower thoracic esophagus. The hiatus is closed with interrupted nonabsorbable sutures.

A transthoracic approach to this region has also been used,34 and with the advent of thoracoscopy it may become increasingly attractive for this limited set of patients. Specific issues in anesthesia for this approach have been reviewed.35 The operation is performed through the left chest, entered via the eighth intercostal space. An NG tube is positioned with its tip in the stomach. After division of the inferior pulmonary ligament, the base of the left lung is retracted upward and laterally. The mediastinal pleura overlying the esophagus is incised for a distance of 8 cm. The esophagus is then mobilized and encircled with a Penrose drain. Vessel loops are used to retract individual vagal trunks as they are identified. The supradiaphragmatic anterior vagus nerve may have multiple branches above the level of the diaphragm, but rarely are there multiple branches at a level 4 cm above the diaphragm.30 In contrast, the posterior vagus has multiple branches above the level of the diaphragm, but is a single trunk at this level more than 90% of the time (Fig. 26-10). Thus, the best opportunity for a complete vagotomy lies 4 cm above the diaphragm for the posterior trunk. A circumferential dissection of the 6 cm of esophagus just above the diaphragm is carried out, with technique similar to that performed during the HSV. Tube thoracostomy is required for 2–3 days postoperatively.

In the context of bilateral truncal or selective vagotomies, the purpose of a drainage procedure is to preserve the pylorus but bypass or render it ineffective. The options for drainage include (1) gastroenterostomy; (2) pyloric dilation; (3) pyloromyotomy; and (4) pyloroplasty. Generally, these techniques are used when TV or SV is performed, but they also may be used with HSV in order to treat obstruction resulting from peptic acid scarring. We discuss techniques for performing gastrojejunostomy in the subsequent discussion of gastric resection.

Pyloric Dilation

In open procedures, the simplest technique reported for performing pyloric dilation is to perform a small gastrotomy, approximately 3–4 cm in length, proximal to the pylorus. A finger is introduced through the pylorus, forcing it to widen. The gastrotomy then is used with a single layer of 3-0 silk interrupted sutures or staples. A second technique, advocated for use in laparoscopic cases, is to use a balloon. The balloon, 15 mm in length, may be positioned through a gastrotomy, endoscopically, or with radiologic control, and inflated to 45 psi (pounds per square inch) for 10 minutes.25,36,37 Other dilators are available for positioning over a wire and inflation to higher pressures, which may prevent pyloric spasm. Advocates of pyloric dilation after laparoscopic TV or SV have suggested that a drainage procedure is not required as often as previously thought or may only be necessary in the early postoperative phase and not permanently.25,36–38 Thus, it is argued that dilation can be repeated postoperatively and in the outpatient setting. Most surgeons, however, subscribe to the need for some form of formal drainage procedure after SV or TV.

Pyloromyotomy

Pyloromyotomy is performed using the same techniques as those described in the setting of hypertrophic pyloric stenosis in the infant (Fig. 26-11). An incision is made to score the anterior surface of the stomach from 1 to 2 cm proximal to 1 cm distal to the pyloric ring. The separation of pyloric muscles is accomplished mainly with a fine-tip hemostat and the knife. Cautery is avoided and only used in the muscularis, not the submucosa. When this procedure is performed in the setting of esophagogastrectomy, the pylorus is usually soft and unscarred. In the setting of chronic duodenal ulcer disease, the pylorus is often scarred, and it is difficult to perform the gentle, meticulous dissection of muscle layers, which is required, and at the same time to avoid entering the mucosa. Laparoscopic versions of this procedure also have been advocated in the setting of laparoscopic TV or SV.39 Occasionally omentum is placed over the myotomy.

Pyloroplasty

The most expeditiously performed pyloroplasty is the Heineke-Mikulicz procedure (Fig. 26-12).40 This is difficult to perform if the pyloric region is very scarred. The operation usually is performed in the setting of emergency surgery for bleeding or perforation of a gastric or duodenal ulcer. A vagotomy is performed, usually after bleeding has been controlled. If the indication is a bleeding or perforated duodenal or pyloric channel ulcer, the incision for pyloroplasty may include the ulcer or be used to gain access to the ulcer. The incision is thus the planned pyloroplasty incision.

It is not always necessary to perform a Kocher maneuver; however, duodenal mobilization is usually helpful in relieving any tension on the intended suture line. Unless the duodenal bulb is unusually mobile, we recommend this as the initial step. In this maneuver, the peritoneum along the right border of the duodenum is incised from the lateral border of the common bile duct to the junction of the second and third portions of the duodenum. After duodenal mobilization, 3-0 silk stay sutures are placed untied, superior and inferior to the site of the intended incision, which then is made on the anterior surface in a longitudinal direction, using electrocautery, from 2 cm distal to the pyloric muscle to 3 cm proximal to the pylorus. The closure of the pyloroplasty is performed vertically, in order to minimize narrowing of the lumen. The Gambee stitch (see Fig. 26-12) is a single-layer inverting suture used in this setting. The suture, usually performed with 3-0 or 2-0 silk, begins on the outside and is (1) placed full thickness (serosa to mucosa) on the same side; (2) brought, on the same side, back through the mucosa to the submucosa; (3) carried through the submucosa to the mucosa on the opposite side; and (4) brought full thickness from mucosa to serosa on that side. When the pylorus is scarred and the tissues inflexible, it is often helpful to tie the sutures after they have been placed, rather than as they are being placed. The stay sutures then are removed, after completion of the pyloroplasty. A tongue of vascularized omentum (as shown for pyloromyotomy in Fig. 26-11) may be brought up to cover the closure and it is sutured to the gut wall with 3-0 absorbable (polyglactin 910) sutures.

The Finney pyloroplasty1 can be used when scarring has involved the pylorus and duodenal bulb and would not permit a tension-free, patulous Heineke-Mikulicz pyloroplasty. The Finney pyloroplasty is in essence a side-to-side gastroduodenostomy (Fig. 26-13). When this operation begins, dense adhesions often are encountered surrounding the pylorus and duodenal bulb. These must be lysed systematically. The Kocher maneuver then is performed, carrying the mobilization distally. Complete mobility of the duodenum and freedom from surrounding adhesions are essential to this operation.

A 2-0 silk stay suture is placed on the upper anterior surface of the pyloric ring. Another stay suture is placed on the greater curvature of the stomach approximately 10 cm proximal to the pylorus, and a third stay suture is placed approximately 10 cm distal to the pylorus. Traction cranially on the pyloric suture and caudally on the other two sutures brings the anterior surfaces on the stomach and duodenum into apposition. The apposed surfaces are sutured together using interrupted 3-0 silk Lembert seromuscular sutures. Using electrocautery, an inverted U-shaped incision is made beginning on the gastric side just distal to the traction suture, traveling longitudinally through the pylorus, then distally to a point just proximal to the traction suture. If the ulcer is present on the anterior surface of the duodenal bulb, it is excised. The posterior inner layer between the stomach and the duodenum then is sutured closed with a continuous over-and-over 3-0 Vicryl, chromic catgut suture, or DDS. This closure is begun at the superior edge, carried caudally, and then converted into a Connell inverting technique as the suture is brought around the inferior edge to begin closing the anterior portion of the inner layer. The anterior outer layer then is closed using interrupted 3-0 seromuscular inverting sutures (Lembert) sutures. Some surgeons use 3-0 Maxon or PDS suture material for single-layer continuous closure, as additional insurance against a suture line leak.

The common indications for gastric resections include peptic ulcer disease and tumors of the stomach. Safe performance of gastric resection requires an understanding of the following: (1) the physiology of vagal innervation and gastric emptying; (2) the surface and vascular anatomy of the stomach; (3) the principles of reconstruction following resection, specifically the Billroth I (B-I) gastroduodenostomy, the Billroth II (B-II) gastrojejunostomy, and the Roux-en-Y configuration; (4) the principles of surgical stapling techniques as well as hand-sewn suturing techniques; and (5) the specific early and late postoperative complications that arise from different gastric resections and different forms of reconstruction. Degrees of resection are correlated to the surface anatomy, as shown in Fig. 26-14. This discussion is divided into three sections. The first section describes techniques for performing wedge resections and closure of gastric wall for ulcers, polyps, or tumors derived from neuroendocrine elements or stromal tissue. Carcinomas are not amenable to wedge resection and should be removed, for cure or palliation, by formal regional resection. The second section describes techniques for distal gastric resection, focusing on antrectomy or hemigastrectomy (with or without vagotomy) for peptic ulcer disease and when the major decision involves the choice of B-I or B-II reconstruction. The third section describes techniques used in management of gastric carcinoma, focusing on proximal, subtotal, or total resection, and the techniques of regional node dissection.

Wedge Resection of the Stomach

Exposure is gained through an upper midline incision, carried from the xiphoid to the umbilicus. A Bookwalter or other self-retaining mechanical retractor is highly desirable, especially for lesions located on the lesser curvature or the proximal stomach. The technique of wedge resection depends on the location of the lesion. When a gastric tumor, such as a carcinoid or gastrointestinal stromal tumor (GIST), is located on the greater curvature of the stomach, it is important to note the proximity to the pylorus or gastroesophageal junction. Wedge resection may not be possible if the lesion lies too close (within 2 cm) to these borders, because the closure might narrow the lumen and cause partial obstruction to the flow of chyme. Formal resection may then be necessary. If proximity to these borders is not a problem, omental adhesions to the tumor are left in contact with the lesion. Farther away from the tumor, the portion of the omentum that is adherent is divided between clamps and will come with the specimen. Branches of the gastroepiploic arteries that supply the gastric wall adjacent to the tumor are ligated in continuity with 3-0 silk ligatures and divided. The gastroepiploic artery need not be divided, unless it is adherent to the surface of the tumor. At a distance of 2 cm from the base of the tumor, the serosa of the gastric wall is scored using cautery, inscribing a circle. The cautery then is used to deepen the incision through the muscularis. As the muscularis is divided, submucosal bleeders will pop through, requiring precise cauterization to secure hemostasis. When the tumor and the surrounding gastric wall have been excised, the gastrotomy is closed longitudinally in two layers. The inner layer is a full-thickness hemostatic layer sewn continuously using 3-0 chromic or Vicryl suture and the outer layer used interrupted seromuscular 3-0 silk Lembert sutures. An omental patch is not necessary, unless there are specific concerns about the blood supply to the closure. When situated favorably, such lesions are also amenable to laparoscopic resection41–43 and to combined endoscopic-laparoscopic approaches involving intraluminal resections.44,45 As long as the lumen is not compromised, stapled or open excision is possible.

When tumors are located on the lesser curvature, or it is necessary to perform a gastrotomy in order to stop ongoing bleeding from a gastric ulcer, the excision can be performed from the mucosal side of the lesion (Fig. 26-15). Once the inside borders of the lesion have been identified, it is important to obtain optimal exposure of the lesion from the serosal aspect. It may be necessary to sacrifice one or both nerves of Latarjet or the left or right gastric arteries, and this determination can only be made from the outside of the stomach. A stapled option also exists if the lesion can be excised without narrowing the lumen. If the lesion is located on the lesser curvature and cannot be removed without sacrifice of both nerves of Latarjet, a pyloroplasty should be performed. In such cases, our preference is that the resection is extended to include the distal stomach and a B-I or B-II reconstruction (Fig. 26-16). One variation on this latter approach for high-lying bleeding or perforated gastric ulcers is Pauchet's operation, a modification of an operation described by Shoemaker. This procedure involves removal of the antrum and a tongue of the corpus that extends upward to include the ulcer (Fig. 26-16E).46

Distal Gastric Resections and Reconstruction

Vagotomy and Antrectomy

An antrectomy for duodenal or pyloric channel ulcer removes about 35% of the distal stomach and must include the entire non–acid-secreting portion. The incision is made in the upper midline and a Bookwalter or other self-retaining mechanical retractor is helpful. An NG tube is positioned under the surgeon's guidance, with its tip in the midportion of the stomach. TV is performed first, as described earlier. The incisura is a reasonable landmark for the proximal margin of resection on the lesser curvature, while the terminal portions of the right gastroepiploic artery indicate the margin on the greater curvature.

The distal stomach is mobilized in the following fashion: first, the lesser sac is entered by incising the gastrocolic ligament. These attachments are sometimes avascular but usually are divided between clamps and ligated with 3-0 silk ligatures. The stomach may thus be lifted upward, revealing the posterior gastric wall. Congenital adhesions from the posterior wall and pancreas capsule are divided sharply. The dissection is carried distally along the greater curvature (Fig. 26-17), dividing the small branches of the gastroepiploic artery to the gastric wall. The dissection reaches the main right gastroepiploic artery, which sometimes has to be divided between Kelly clamps and ligated with 2-0 silk ligatures. When possible, the dissection should be carried between the gastric wall and artery, thereby preserving the main gastroepiploic artery as additional collateral blood supply to the suture lines and coming anastomosis. When the dissection reaches the pylorus, small bleeders should be divided between fine hemostats and ligated with fine silk ligatures. The dissection should be meticulous and gentle, because pancreatic tissue lurks in this area and inflammation can be activated in this dissection. The dissection should be carried about 1 cm past the pylorus if a B-I reconstruction is anticipated. If B-II is anticipated, the dissection need only be carried far enough to comfortably place the transverse linear stapler past the pylorus or to oversew the duodenum by a hand-sewn technique.

The assistant's left hand is used to lift the distal stomach forward and inferiorly. The more flimsy tissues of the lesser omentum are divided along the lesser curvature, using electrocautery. Starting at the incisura and working toward the pylorus, the tissues of substance are divided between clamps and ligated with 3-0 silk ligatures. This dissection generally will include the descending branch of the left gastric artery. When the right gastric artery is reached, it is divided and ligated with 2-0 silk ligatures. At this point (Fig. 26-18), we prefer to divide the stomach. This is accomplished with a 90-mm GIA stapler or the gastric TA-90. If the latter stapler is used, the stomach distal to the staple line is occluded with a crushing intestinal clamp and the gastric wall is divided. The clamp is then used as a handle for manipulating the distal stomach. The final portion of the dissection involves gentle dissection of the posterior duodenal wall from the pancreas. Because this dissection may involve separation of pancreas elements from the posterior duodenal wall, cautery is used minimally or not at all and tissues are separated gently with fine hemostats and ligated with 4-0 silk. If a B-I anastomosis is anticipated, the duodenum is divided using the electrocautery, just distal to the pyloric ring. If a B-II anastomosis is anticipated, the transverse TA-30 stapler is placed flush with the pyloric ring. After firing the stapler, a knife is used to sever the pylorus from the staple line. The specimen then is removed to a sterile table. The staple line can be inverted with 3-0 silk Lambert sutures or covered with an omental patch, if there is a concern about vascular supply or tension in the staple line. The specimen then can be opened and turned inside out to reveal the gastric mucosa. The proximal border of the resection should contain transverse and obliquely oriented rugae characteristic of the acid-secreting gastric corpus and distinguishable from the longitudinally oriented antral folds. This maneuver verifies complete removal of the antrum.

Billroth-I Reconstruction.

When distal gastrectomy is performed for type I gastric ulcer, B-I anastomosis is preferable. A B-I anastomosis can be used safely for duodenal or pyloric channel ulcer, if scarring of the duodenal bulb and pylorus are minimal. If this form of reconstruction is planned, a Kocher maneuver should be performed prior to distal gastrectomy. This will help to minimize tension on the anastomosis. As shown in Fig. 26-19, the lower portion of the gastric staple line is removed by excision of gastric wall just posterior to the staple line. The length of the staple line to be removed is the width of the duodenal stump. The gastroduodenostomy is performed in two layers (Fig. 26-20). The posterior layer of interrupted 3-0 silk Lembert seromuscular sutures is placed first. The inner 3-0 Vicryl sutures are placed next to each other, sewn away from each other in an over-and-over fashion until the sutures are brought around the edges to the anterior aspect. Connell sutures are used to invert the inner anterior layer. The anterior outer layer is closed with interrupted 3-0 silk Lambert sutures. The junction of the sewn anastomosis and superior portion of the gastric staple line has been called the “angle of sorrow” because of the complication of leakage where these suture/staple lines meet. A number of authors recommend inversion of the upper staple line by 3-0 silk Lembert sutures and a special covering suture for this junction. A second strategy is to cover this area with a tongue of omentum.

A B-I anastomosis also may be performed using mechanical stapling techniques. As shown in Fig. 26-21, the duodenum is transected just distal to the pylorus with the knife and a purse-string suture is positioned circumferentially around its edge. The anvil of the circular stapler, usually a size 25 mm, is secured in the duodenal stump by the purse string. The circular stapler is inserted through an anterior gastrotomy and fired through the posterior wall of the stomach (Fig. 26-22). It is important that the margin of the stapled suture line be placed 3 cm proximal to the stapled gastric closure, to provide maximum blood supply to both staple lines. The anterior gastrotomy then is closed with a TA-55 stapler or sutured closed in two layers.

Billroth-II Reconstruction.

When scarring or undue tension precludes B-I anastomosis following distal gastrectomy, a B-II gastrojejunostomy is indicated. Before describing our technique, it is worth pointing out the decisions that one will make in performing this reconstruction.

Closure of the Duodenal Stump.

The first set of decisions focus on the technique used for closure of the duodenal stump. Careful attention should be given to mobilizing the duodenal stump and obtaining a secure tension-free closure. If the duodenum is relatively free of scar or inflammation, this presents no problem and the TA-55 or TA-60 stapler may be used for closure as described previously. If heavily scarred, dissection of the duodenum and performance of the antrectomy may be abandoned in favor of a safer vagotomy and gastroenterostomy.

If one is committed to the antrectomy and scarring prevents mobilization of the pylorus and duodenal bulb, one may rarely find a need to perform a Bancroft procedure, in which the most distal portion of the pyloric channel and antrum are left in situ after resection of the more proximal antrum (Fig. 26-23). The mucosa of the retained segment is stripped,47 removing all gastrin-secreting tissue that could cause a retained antrum syndrome. In the classic approach for this procedure, the greater and lesser curvatures are mobilized without dissecting too far into the tissues surrounding the pylorus. About 7–8 cm from the pylorus, the seromuscular coat of the antrum is incised circumferentially down to the level of the submucosa. Using sharp dissection, the muscle coat is separated from underlying mucosa. This dissection can be facilitated by submucosal injection of 1:100,000 epinephrine solution, as has been described for the mucosal proctectomy in ileal pouch–anal anastomosis procedures.48 When the pyloric channel opening is reached, a fine purse-string absorbable suture (3-0 chromic catgut or Vicryl) picks up small bites of submucosa at the pyloric ring. Transfixion and ligation of the mucosa is tempting, but it should be avoided as this would lead to mucosal ischemia and subsequent perforation. A small margin of mucosa is left to be invaginated into the pylorus as the purse string is gently closed and tied. The proximal margins of the seromuscular cuff are excised, leaving just enough to close over the purse string. Omentum is used to cover this closure, if possible.

One other important circumstance to be prepared for is the closure of the duodenum distal to a posteriorly perforated or deeply penetrating ulcer. In this setting, the ulcer crater is left in situ (Fig. 26-24). In other settings, the anterior wall of the duodenum can be sutured to the ulcer base, with care being taken to suture-ligate any exposed vessels. The suture line can be protected by a vascularized tongue of omentum.

Position of the Jejunal Loop: Antecolic or Retrocolic.

The second decision in performing a B-II reconstruction is whether to bring the loop of jejunum behind (retro) or in front of (ante) the transverse colon. In performing the gastrectomy for benign disease, there is no clear evidence that this makes any difference and we prefer the retrocolic position. For malignant disease, it has generally been held that the retrocolic position may be predisposed to obstruction owing to enlargement of lymph nodes or serosal implants in the transverse mesocolon. Whether or not this predisposition exists, positioning the jejunal limb in front of the colon requires a somewhat longer mesentery. As long as the anastomosis will not be under tension, the antecolic position will permit emptying as effective as that through a retrocolic anastomosis. If a retrocolic position is chosen, the window in the transverse mesocolon should be wide enough to permit both the afferent and efferent limbs of the jejunum to slide comfortably through. When this window is closed following construction of the anastomosis, it is preferable to tack the mesentery above, on the gastric side, rather than on the jejunal side. This will prevent kinking and obstruction of the jejunal limbs and positions the anastomosis below the mesentery.

Length of the Afferent Limb.

The third decision is the choice of the segment of jejunum used for the anastomosis. In general, the segment should be as close to the ligament of Treitz as possible and still reach the stomach without tension. This generally leaves 10–20 cm of the proximal jejunum as the afferent limb. The shorter this length, the less likely the possibility of an afferent limb syndrome developing. The incidence of other complications such as alkaline reflux gastritis, dumping, or postvagotomy diarrhea should not be influenced by the length of the afferent limb.

Anastomosis: Site on the Gastric Wall and Technique.

Schematically illustrated in Fig. 26-25 are a number of described variations on the B-II reconstruction. We describe here one hand-sewn and one stapled technique for anastomosis. As shown in Fig. 26-26, a portion of the gastric staple line is excised with electrocautery, taking a small wedge of stomach behind the staple line. The superior portion of the staple line can be reinforced with 3-0 silk Lembert sutures at this time or can be reinforced later by tacking the afferent limb of jejunum, just beyond the anastomosis, to the gastric wall. The proximal jejunal limb is brought, untwisted, through a window in the transverse mesocolon (Fig. 26-27). Traction seromuscular sutures (2-0 or 3-0 silk) are placed at both corners of the anastomosis. The gastrojejunal anastomosis is performed in two layers (Fig. 26-28), between the most caudal part of the stomach and the jejunal limb. The outer layer is composed of 3-0 silk Lembert seromuscular sutures. The inner layer is performed in the posterior row by running two 3-0 Vicryl sutures in opposite directions around the corners and then in Connell fashion for the anterior row. Placement of the anastomosis on the posterior gastric wall, about 2–3 cm from the gastric staple line, also will provide a suitably dependent position for drainage of gastric contents. The window in the transverse mesocolon is closed, as illustrated in Fig. 26-29.

Illustrated in Figs. 26-30 and 26-31 is the technique for stapled gastroenterostomy. As before, the jejunal limb is placed in the retrocolic position. Traction sutures are placed on the gastric wall posterior to the anastomosis, bringing the jejunal limb into apposition. The 55-mm GIA stapler is fired after its two limbs are placed through a small gastrotomy and small enterotomy, respectively. The open end of the anastomosis is then closed with a TA-55 stapler. It should be noted that these staple lines, especially from the TA-55, are difficult to reinforce without undue tension. The blood supply of the gastric and intestinal walls is ample, and reinforcement with Lembert sutures generally is not necessary.

Subtotal and Total Gastric Resections

The main indications for subtotal (70–80%) gastric resection are carcinoma of the antrum or pylorus or primary gastric lymphoma. However, in cases of ulcers that lie very proximal on the lesser curvature, the proximity to the gastroesophageal junction prevents excision without significant narrowing of the gastric inlet. Similarly, the main indication for total gastric resection is a bulky carcinoma of the body or distal fundus, and rarely, otherwise unmanageable symptoms of an unresectable gastrinoma. Indications for near-total (>90%) gastric resection include the uncommon settings of the Roux stasis syndrome and gastroparesis unresponsive to medical management, as well as carcinoma or lymphoma of the body of the stomach. The approaches for subtotal and near-total gastrectomy are discussed here only briefly, focusing on issues of exposure and techniques for resection of the stomach itself and reconstruction. The principles of resection for gastric carcinoma will be presented subsequently in conjunction with the discussion of radical total gastrectomy for carcinoma.

Subtotal and Near-Total Gastric Resections

In principle, a subtotal gastrectomy is simply an extended antrectomy or hemigastrectomy. A few technical issues are worth noting. First, the exposure provided by midline incision is usually not as adequate as that provided by a chevron incision. Second, the left gastric artery always is ligated and divided in this dissection, and, once the level of gastric transection has been determined, the branches of the left gastroepiploic artery and short gastric arteries are ligated in continuity and divided up to this predetermined level. Third, in opting for a near-total gastric resection, a 1- to 2-cm cuff of gastric wall is left behind and is the margin for the anastomosis. For this operation, it is desirable to preserve the uppermost one or two short gastric vessels, in order to ensure the adequacy of the blood supply for the gastric side of the anastomosis.

One final issue is that a greater extent of lymph node dissection has shown in some series, both Japanese and Western series, improvement in survival for gastric cancer after resection49,50 although with increased morbidity in some51 but not necessarily in all52 centers. Extended lymphadenectomy (D2 resection) involves dissection and removal of the perigastric lymph nodes, as well as those of the celiac axis, and the hepatoduodenal ligament.53,54 Skeletonization of the celiac artery and its branches (left gastric artery, common hepatic artery, and splenic artery) is required to achieve adequate lymphadenectomy if it is desired. However, further studies are needed before it can be routinely recommended outside of highly specialized centers with surgeons who have specific expertise in this dissection.52 Finally, although it is often possible to reconstruct with a standard gastrojejunostomy, we prefer a Roux-en-Y reconstruction because this minimizes tension on the suture line and theoretically reduces the risk of anastomotic obstruction by persistence or recurrence of tumor.

Total Gastrectomy for Carcinoma

The goals of total gastrectomy for carcinoma are (1) clearing of margins on both esophageal and duodenal sides; (2) removal of local and regional lymph node–bearing tissues, including those surrounding the right and left gastric arteries, right gastroepiploic artery, and short gastric arteries; (3) removal of the omentum en bloc with the stomach; and (4) removal of the lymphatic tissues overlying the pancreatic capsule. Extended lymph node dissection (D2 resection) can be done here as described in the prior section.40–43 However, as before, its potential survival benefit, as shown in some studies, must be weighed against its increased morbidity. After total gastric resection, we favor a Roux-en-Y reconstruction with a direct esophagoenterostomy rather than a jejunal pouch, although the techniques for both forms of reconstruction will be described.

Illustrated in Fig. 26-32 is the final specimen in an en bloc resection. Generally, an upper midline or chevron incision will provide good exposure. A thoracoabdominal incision (Fig. 26-33) is rarely necessary but can provide better exposure when the patient's habitus suggests a deep hiatus. This latter incision also should be considered when preoperative endoscopy suggests that the tumor is close enough to the cardia so that the distal thoracic portion of the esophagus might be included with the resection. If this latter approach is chosen, the abdominal portion of the incision is performed first, in order to assess resectability. The patient is placed in a left thoracotomy position. The incision is carried from the line of the eighth rib obliquely toward the umbilicus. If resection appears feasible, the incision is extended over the eighth rib to the posterior angle. Occasionally, the seventh rib will provide better exposure. A separate rib retractor for the chest and a self-retaining retractor without a ring for the abdominal portion provide the best retraction. The diaphragm is divided toward the hiatus, but the muscle does not always have to be divided completely. Thus it may be possible to spare the neurovascular bundle. Significant bleeding is encountered and it requires suture ligation with 2-0 or 0-0 Vicryl.

In the abdominal approach, the Bookwalter retractor is used. Extra care in positioning retractors on the left lobe of the liver, diaphragm, and small intestine, for optimal exposure of the hiatus is time well spent. The dissection is begun by dividing the omentum from the transverse colon (Fig. 26-34). This relatively avascular plane can be separated using the electrocautery. Deviation from this plane will injure the colon or require tedious ligation and division of omental blood vessels. The lesser sac is then entered, allowing assessment of the retroperitoneum, with regard to local tumor extension and lymph node involvement. The distal portion of the gastrectomy is then performed. The origin of the right gastric artery at the common hepatic artery is identified, ligated in continuity with 2-0 silk ligatures, and divided.

Lymphatic-bearing tissues are swept toward the gastric side. The right gastroepiploic artery is identified, usually by palpation, and traced as far to its base as possible. It is usually possible to trace the artery to its origin at the gastroduodenal artery, which is similarly ligated in continuity and divided. Using the electrocautery, the lesser omentum is incised near the liver and its tissues are swept toward the lesser curvature, from the duodenum to the esophagus. Any small vessels are ligated with 3-0 ligatures. The dissection is carried onto the peritoneal surface of the esophagus. The duodenum may then be divided using the GIA stapler or a TA-55 stapler that is fired twice, once on the duodenum and once directly on the pylorus. The duodenum is divided just distal to the pyloric ring (Fig. 26-35).

With the distal portion of the stomach divided, full access to the left gastric artery is obtained posteriorly through the lesser sac. This approach optimizes visualization of the celiac axis and its branches. With the assistant retracting the stomach upward and anteriorly, a number of congenital adhesions between the posterior gastric wall and the peritoneum overlying the pancreas are observed (Fig. 26-36). If tumor is invading this plane, a decision must be made regarding inclusion of the body and tail of the pancreas in the specimen. The plane made by the peritoneum overlying the pancreas is a natural plane, and there may be sense in taking this peritoneum with the en bloc specimen. This layer can be dissected off the anterior face of the pancreas and swept gently to the front toward the left gastric vessels and splenic hilum. If a curative resection appears to be feasible but would require removal of the body and/or tail of the pancreas, we do not see this as a contraindication to resection. The origin of the left gastric artery is then identified at the celiac axis, ligated in continuity using 2-0 silk, and divided (Fig. 26-37). The stump of the artery is suture-ligated as well. From the celiac axis side, the tissue surrounding the artery contains lymphatics and is swept toward the lesser curvature. When the tumor is located in the more proximal body and corpus, the case for inclusion of the spleen with the en bloc specimen has not been persuasive,55,56 a recent meta-analysis suggesting no oncologic benefit57 for removal of a spleen not apparently involved by direct extension. Inclusion of the spleen is indicated if there are obvious tumor-bearing nodes or if there is direct invasion of the splenic hilum. Through the lesser sac, the tail of the pancreas is identified. The splenic artery and vein are separated, suture-ligated, and divided individually. At this point, the short gastric vessels are then part of the en bloc specimen and are not dissected or divided.

The posterior aspect of the esophagus then comes into view as the stomach and spleen are lifted upward. Posteriorly, the front of peritoneal tissue can be dissected bluntly until the superior border of the pancreas is reached. The peritoneum is continuous with the peritoneum investing the gastric side of the gastroesophageal junction. If this layer has not been included with the dissection, the peritoneum must be divided here, exposing the gastroesophageal junction posteriorly. Figure 26-38 demonstrates the stomach completely mobilized except for its attachment to the esophagus. A noncrushing clamp is placed on the mobilized esophagus and the specimen is resected. To minimize spillage of luminal contents, a second clamp is placed on the gastric side or the TA-55 stapler may be fired below the line of resection and above the gastroesophageal junction.

Our preferred technique for reconstruction is a simple Roux-en-Y, with an end-to-side esophagojejunal anastomosis with the Roux limb. Using the GIA stapler, a section of jejunum is divided 10–15 cm beyond the ligament of Treitz (Fig. 26-39). The Roux limb is brought antecolic up to the esophagus. An enteroenterostomy is constructed between the jejunum on the duodenal side of the Y and the jejunum, 40–45 cm distal to the Roux limb staple line (Fig. 26-40). The enteroenteral anastomosis can be performed using hand-sewn two-layer technique or stapling technique. The esophagojejunal anastomosis is performed using interrupted 3-0 silk sutures for both the inner and outer layers, as shown in Fig. 26-41. The completed reconstruction is shown in Fig. 26-42. This figure emphasizes the antecolic position of the anastomosis when the operation is performed for malignant disease. Areas of potential internal herniation in the mesentery are closed with absorbable 3-0 sutures.

A jejunal pouch (Hunt-Lawrence pouch) also may be constructed, with the idea of anastomosing the esophagus in end-to-side fashion with the antimesenteric border of the pouch.58,59 The technique is illustrated in Figs. 26-43 through 26-45 and can be performed expeditiously using surgical staplers. The pouch is constructed with the goal of providing a reservoir function. Alternatively, a number of surgeons expressed a preference for leaving an island of undivided intestine at the bend in the pouch. This should theoretically optimize the blood supply to the anastomosis. The circular stapler can be passed through the open end of the Roux limb in order to perform the end-esophagus to side-jejunum anastomosis. The linear stapler then can be fired in such a way as to leave the island of undivided intestine. One important point is that the pouch can be made too long, giving rise to stasis and ineffective clearance of food from the pouch into the intestine. The pouch should not be more than 15 cm in length.

Laparoscopic Approaches

Laparoscopic Approaches to the Vagus Nerve

As noted previously, the advent of laparoscopic approaches has led surgeons to reconsider traditional approaches to peptic ulcer disease. The advantages of minimally invasive approaches revolve largely around the minimal postoperative discomfort and rapid recovery, with a potential benefit in reduced cost of surgery versus the cost of long-term medication.60 At the same time, rapid advances have occurred in our understanding of the role of Helicobacter pylori and mucosal growth, and angiogenic factors in ulcer healing and recurrence. In addition, limitations in access and suturing techniques have increased the difficulty of access to the lesser sac and of performing drainage procedures. These considerations have led surgeons to question the rationale for routine drainage whenever TV has been performed.15,37 A number of approaches have evolved to address these difficulties and have been given credibility in the laparoscopic experience. One such approach has been to combine truncal vagotomy with pyloric dilation or seromyotomy.26,16,21 Another has been to combine a posterior truncal vagotomy with an anterior highly selective vagotomy or with an anterior seromyotomy.16 The important elements of the laparoscopic approach to the vagi are discussed here.

Patient Position and Port Placement

The patient is placed on the operating room table with legs in stirrups and apart (Fig. 26-46). Video monitors are placed on either side at the head; often, the surgeon works best when standing between the legs, with the camera operator on the right and the first assistant on the patient's left. The scrub nurse/technician and instrument table are placed at the patient's right foot. A large esophageal tube or even a gastroscope is placed in the stomach to facilitate visualization of the distal esophagus. Frequent aspiration of the gastric contents is crucial to maintain total collapse of the stomach and the best visualization. We recommend an open technique to gain access to the peritoneum, insufflating to a pressure of 14 mm Hg. Five ports are placed in the following locations: (1) a 12-mm laparoscope port at the superior edge of the umbilicus or placed 5 cm above and lateral to the left of midline; (2) a 5-mm irrigation/suction and dissection port in the subxiphoid position, just to the right of midline; (3) a 10-mm port for retraction and grasping forceps midway between the umbilicus and xiphoid, to the right of the rectus, and possibly as far as the midclavicular line; (4) a 10-mm port for grasping forceps midway between the umbilicus and xiphoid, almost to the anterior axillary line on the left; and (5) a 12-mm operating port just lateral to the rectus 3 cm above the umbilicus. A number of surgeons prefer the angled 30-degree laparoscope for this operation.

Laparoscopic Truncal Vagotomy

The left lobe of the liver is retracted using a probe placed via the subxiphoid port or the 10-mm fan retractor placed via the higher right-side port (Fig. 26-47). Visualization is improved when tissues from the hiatus are dissected away from the esophagus and lesser curvature (Figs. 26-48 and 26-49). One can encounter a coronary hepatic vein or accessory hepatic artery in this dissection. These do not always need to be sacrificed. The right crus of the diaphragm usually is seen here and can be retracted with one of the blades of the liver retractor (Fig. 26-50). A Babcock clamp or other atraumatic grasper is used to retract the anterior greater curvature (distal to the cardia) to the patient's left. A hook coagulator or dissecting forceps is used to incise the lesser omentum, entering the lesser sac just above the takeoff of the hepatic branch of the anterior vagus nerve. A plane is developed between the right crus and the esophagus and continued posteriorly. Continued dissection along the wall of the esophagus reveals the posterior trunk, which is ligated between clips and divided (Fig. 26-51). The excised nerve segment is sent for frozen-section examination. The next step is identification of the anterior vagal trunk(s). The phrenoesophageal membrane usually has been entered and incision is extended toward the left, first by scoring the membrane with scissors and then bluntly pushing away the membrane with a cotton dissector. The visualization of major anterior trunks is often easier in the laparoscopic approach, owing to magnification and excellent video optics. These branches also are ligated and divided between clips (Fig. 26-52), with frozen-section confirmation of the nerve segment. Smaller anterior branches are identified and cauterized after being held away from the esophageal wall. It is possible to dissect tissues on either side of the esophagus for a distance of 5–6 cm, thereby ensuring division of any nerve branches to the lesser curvature and cardia. The main difficulty can occur in visualizing the angle of His and possibly missing major vagal branches, including the “criminal nerve.” With the use of a traction forceps placed through the subxiphoid port and a cotton dissector placed via the left grasping forceps, it is possible to expose the left edge of the gastroesophageal junction and cauterize or clip any branches.

Anterior Proximal Vagotomy or Seromyotomy

A laparoscopic dissection of the posterior leaf is feasible.61,62 However, the combination of posterior TV and an anterior selective operation is appealing, because it avoids the difficult maneuver of working through the lesser sac in order to visualize the posterior lesser omentum and nerves accompanying the ascending left gastric artery branches. For HSV, dissection is begun at the crow's foot, approximately 6 cm from the pylorus. Retraction of the greater curvature is performed using a Babcock clamp (Fig. 26-53). With the magnification available through the scope, the proximal branch of the crow's foot is often, but not always, relatively easy to identify. The anterior leaf of the lesser omentum is approached by dividing and ligating the neurovascular bundle between clips. Electrocautery is used sparingly, and preferably not at all. The serosa overlying the gastroesophageal junction is scored as in the open procedure. Dissection of the distal 5 cm of esophagus and cardiac branches is carried out as described previously for TV.

The goal of an anterior seromyotomy, as described originally by Taylor et al63 and then others,13,26,64 is to sever the neurovascular bundles dividing the serosa and muscularis that transmit these nerves to the mucosa. The anterior surface of the stomach is retracted and placed on stretch using the right and left grasping ports. The outline of the seromyotomy is scored using a coagulator hook or spatula, on the anterior surface of the stomach, 1 cm from the visible border of the lesser curvature. Moving caudad and parallel to the lesser curvature, a line is traced from the gastroesophageal junction to the first branch of the crow's foot, or arbitrarily 6 cm from the pylorus. The hook coagulator is most suitable for performing the seromyotomy, using monopolar current for electrocoagulation. The hook cuts through successive layers of gastric wall, of the serosa, outer oblique muscle fibers, middle longitudinal fibers, and inner circular fibers. The two grasping ports then are used to place traction on the two edges of the gastric wall, exposing the deep circular fibers that may split as much from traction as from cautery. The darker submucosa/mucosa layer pops through the muscularis. This layer is inspected for any evidence of full-thickness cautery injury or perforation. With a complete seromyotomy, the gap between the cut edges should be about 6–8 mm. Alternatively, a laparoscopic surgical stapling device can be used for creation of a modified seromyotomy.26

A number of decent-sized vessels may be encountered in the dissection. Prolonged cauterization may provide hemostasis but risks a full-thickness burn and subsequent perforation. The hook can be used to isolate these vessels and lift them for clipping in continuity. Recent advances in the design of needle holders may make it possible to suture these vessels in continuity before division by scissors. Surgical stapling devices can be used for this purpose, as well as newer devices such as the harmonic scalpel, which utilizes ultrasonic energy for coagulating vessels, or electrothermal bipolar coagulator devices. After creation of the seromyotomy, the integrity of the mucosa should be verified by moderate expansion of the stomach using the NG tube for insufflation. Some authors use methylene blue solution (1 vial per 200 mL), placed intragastrically, for this maneuver. The seromyotomy then is closed using a continuous suturing technique. A tongue of omentum may be mobilized and secured over the seromyotomy as a patch, secured with sutures placed through either edge of the seromyotomy.

Laparoscopic Approaches to the Gastric Resection

The patient is positioned the same way as for laparoscopic antisecretory surgery, with the patient supine with legs in stirrups and apart as shown in Fig. 26-46. Port placement is similar with five ports placed in the following locations: (1) a 12-mm laparoscope port at the superior edge of the umbilicus or placed 5 cm above and lateral to the left of midline; (2) a 5-mm irrigation/suction and dissection port in the subxiphoid position, just to the right of midline; (3) a 10-mm port for retraction and grasping forceps midway between the umbilicus and xiphoid, to the right of the rectus and possibly as far as the midclavicular line; (4) a 10-mm port for grasping forceps midway between the umbilicus and xiphoid, almost to the anterior axillary line on the left; and (5) a 12-mm operating port just lateral to the rectus 3 cm above the umbilicus. A 30- or 45-degree angled laparoscope is useful for gastric resections, as it allows improved visualization of the stomach from multiple perspectives. If resections high in the lesser curvature are planned, retraction of the left lobe of the liver using a probe placed via the subxiphoid port or the 10-mm fan retractor placed via the higher right-side port (see Fig. 26-51) is useful as described for laparoscopic TV.

Wedge resections of benign but symptomatic masses on the greater curvature can be done by grasping the greater curvature with a Babcock or other atraumatic grasper and use of a laparoscopic stapling device to resect the involved portion of stomach. Occasionally intraoperative endoscopic confirmation of the position of intraluminal masses not readily apparent intraoperatively is useful. Wedge resections on the lesser curvature are more difficult due to the presence of the left lobe of the liver, which usually needs to be retracted, and the proximity of the esophagus and vagus nerves. However, with careful attention to the gastroesophageal junction, wedge resections of the lesser curvature can be done. Intraluminal approaches can also be utilized.44,45 If the vagus nerve or its major branches are sacrificed in lesser curvature resections, a laparoscopic or endoscopic drainage procedure is recommended (endoscopic pyloric dilation or laparoscopic pyloric seromyotomy).

Distal, subtotal, and total gastrectomy procedures have all been adapted for laparoscopic approaches. With recent advances in equipment and concentrated experience, all approaches seem to be finding increasing application, with promising results in selected patients.65–68 In laparoscopic subtotal or total gastrectomy, port placement is similar to that for wedge resections and antisecretory procedures (Fig. 26-54). Gastric mobilization, resection, and reconstruction are done in a similar fashion to that of the open procedures. After entry into the abdominal cavity and port placement, the left lobe of the liver is mobilized and retracted laterally with a fan retractor or probe through the subxiphoid port if the lesser curvature cannot be adequately visualized or if extensive dissection of the lesser curvature is required. The stomach is grasped with a laparoscopic Babcock clamp, and the distal stomach is mobilized by incising the gastrocolic ligament, which is taken bluntly if the plane is avascular and with the harmonic scalpel or electrothermal bipolar coagulator device if small vessels are encountered. The dissection is carried distally along the greater curvature, dividing the small branches of the gastroepiploic artery to the gastric wall similarly with the harmonic scalpel or electrothermal bipolar coagulator device. Others have used endoscopic vascular staplers to take much of gastrocolic omentum and its vessels. Once the proximal portion of the gastric dissection is reached, the stomach is divided with laparoscopic staplers at our institution (2.5-mm stapler load on US Surgical, Norwalk, CT, or laparoscopic staplers on Ethicon, Somerville, NJ). The gastric resection is then completed by division of the distal stomach at or just past the pylorus with a laparoscopic stapler. Reconstruction is completed as a B-II gastrojejunal anastomosis. Babcock clamps are used to locate the jejunum at the ligament of Treitz and bring a freely mobile portion of jejunum typically 20–30 cm distal to the ligament of Treitz up to the proximal gastric remnant in an antecolic or retrocolic fashion through an avascular window in the transverse colon mesentery. The gastric remnant and jejunum are aligned together, being careful not to twist the jejunal mesentery, and then secured to each other at the proximal and distal suture lines by interrupted 3-0 Vicryl sutures placed either with an Endo Stitch (Auto Suture Company, Norwalk, CT) or with a laparoscopic needle driver. After the gastric and jejunal limbs are aligned, Bovie cautery is used to place enterotomies in the proximal gastric remnant and jejunum. A laparoscopic stapler is placed into the gastric and jejunal limbs and then deployed to form the anastomotic staple line. The proximal portion of the anastomosis is then closed using a laparoscopic stapler or suture-closed using an Endo Stitch device or with a laparoscopic needle driver. For total gastrectomy, the esophagojejunal anastomosis is performed using the stapling device as illustrated in Fig. 26-55. The mesenteric defect in the transverse colon is then closed if a retrocolic anastomosis has been performed.

Laparoendoscopically Assisted Sentinel Node Navigation.

One of the concerns with laparoscopic gastrectomy procedures, done in patients with gastric cancer, is to determine whether a radical lymphadenectomy would be required. For early-stage gastric lesions (clinical and radiologic stage T1N0), sentinel node identification and so-called “sentinel node navigation” of the operation69–71 have been advocated. Both single- and double-tracer methods have been described.72 For complementary tracer injection, a method similar to that described recently by Orsenigo, et al would be utilized.73,74 On the day prior to operation, endoscopy is performed to inject radioactive tracer (99Tc-colloid, 2 mL total) at four equally spaced points in direct proximity to the tumor; at the beginning of the actual operation, blue dye (2% patent blue, 2 mL divided among four sites) is injected endoscopically. The accumulation of radioactive tracer in the nodal basin occurs over a period of 2–20 hours, while the transfer of blue dye to the sentinel node occurs very quickly. As a result, the sentinel node seems reliably identified when the blue node contains at least 10-fold higher radioactive counts than background.73 It has been suggested that the radical lymphadenectomy may be limited to a D1 dissection if the sentinel node is clearly identified and clearly negative, but long-term outcomes in controlled trials are not yet fully known.75