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The first 25 slides, exactly as they appear. The full deck has 185 content slides.
General Surgery
Stomach and Duodenum Operative Procedures
Built from Maingot's Abdominal Operations
What’s inside
14 sections · 185 slides
Overview
- Scope of these operations
- Families of operation covered
- Words used throughout
Historical perspective
How gastric surgery was invented, and what it taught
- Earliest operations on the stomach
- Billroth's first resections for cancer
- Milestones in gastric surgery
- Complications that followed gastrojejunostomy
- Origins of pyloroplasty and pyloromyotomy
- Discovery that cutting the vagus lowers acid
- From truncal to highly selective vagotomy
- Why highly selective vagotomy caught on
Vagotomy: the physiology behind the cut
What the vagus does, and what is lost when it is divided
- Place of antisecretory operations today
- Measuring acid output directly
- Colour tests of acid secretion
- Vagal control of gastric motility
- The three motor jobs of the vagus
- “
- What every form of vagotomy costs
- Judging the mixed approaches
Open approaches to the vagus
Exposure of the hiatus, and division of the trunks
- Exposure of the upper abdomen
- Choice of incision and position
- Mobilising the left lobe of the liver
- Three levels at which the vagus is divided
- Indications for truncal vagotomy
- Distribution of the anterior vagus nerve
- Reading the anterior nerve of Latarjet
- Posterior nerve of Latarjet
- Encircling the oesophagus
- Finding and dividing the anterior trunk
- Clearing the small fibres
- Division of both vagal trunks
Selective and highly selective vagotomy
Sparing branches, and denervating only the acid-making stomach
- What selective vagotomy preserves
- What selective vagotomy does not solve
- Dividing the anterior gastric branches
- Taking artery and nerve together
- Indications for highly selective vagotomy
- Outlet obstruction and the decisions before starting
- The four phases of the operation
- Phase one: exposure and gastric mobilisation
- The crow's foot as the distal landmark
- Choosing the distal margin
- Line of dissection of the anterior leaf
- Ligating the vessels of the lesser curve
- Line of dissection of the posterior leaf
- Working through the anterior-leaf window
- Limits of the posterior dissection
- Phase four: clearing the distal oesophagus
- Clearing the left side of the oesophagus and the angle of His
- Hunting the criminal nerve of Grassi
- Anterior gastric branches on the oesophagus
- Clearing the back of the oesophagus
- The argument over reperitonealisation
- How the lesser curve is covered
Reoperation on the vagus nerves
Completing a failed vagotomy when the field is hostile
- Recurrent ulcer after antisecretory surgery
- Planning a completion vagotomy
- Transabdominal suprahepatic approach
- Reaching the trunks above the hiatus
- Transthoracic approach
- Finishing the thoracic operation
- Branching of the vagus nerves above the diaphragm
Drainage procedures
Preserving the pylorus but bypassing or disabling it
- Options for draining the denervated stomach
- Purpose of a drainage procedure
- Dilating the pylorus
- Is formal drainage always needed
- Pyloromyotomy and omental patch
- Technical points in pyloromyotomy
- Heineke-Mikulicz pyloroplasty: incision and vertical closure
- When Heineke-Mikulicz pyloroplasty is used
- The Kocher manoeuvre
- The Gambee stitch and the finished pyloroplasty
- How the Gambee stitch is placed
- When the Finney pyloroplasty is chosen
- Finney pyloroplasty: alignment and the inverted U incision
- Setting up the Finney pyloroplasty
- The inverted U incision
- Finney pyloroplasty: posterior septum and anterior tiers
- Closing the Finney pyloroplasty
Gastric resections and wedge excision
Principles of resection, and taking a lesion with a rim of wall
- What safe gastric resection requires
- Three groups of gastric resection
- Extent of stomach removed at each level
- Exposure and the limits of a wedge
- Handling the omentum and vessels
- Wedge excision of a small gastric tumour
- Closing the wedge and the minimally invasive option
- Lesions on the lesser curvature
- Billroth I gastroduodenostomy and its named variants
Vagotomy and antrectomy
Removing the gastrin-producing antrum
- Extent and landmarks of antrectomy
- Dissection of the lesser curvature
- Dissection along the greater curvature
- How far past the pylorus to go
- Dividing the stomach beyond the incisura
- Separating the duodenum from the pancreas
- Protecting the stump and proving the antrum is gone
Billroth I reconstruction
Joining the gastric remnant straight to the duodenum
- When Billroth I is preferred
- Preparing the gastric staple line
- End-to-end gastroduodenostomy in two layers
- The angle of sorrow
- Purse string on the duodenum and the anterior gastrotomy
- Firing the circular stapler for a stapled gastroduodenostomy
- Firing and checking the circular stapler
- Checking the doughnuts
Billroth II reconstruction
Four decisions before the first stitch
- Decisions in a Billroth II reconstruction
- When Billroth II is indicated
- Bancroft procedure: freeing the mucosa from the muscle
- How the Bancroft stripping is done
- Bancroft procedure: closing over the pyloric purse string
- Closing a duodenum scarred by a penetrating ulcer
- Antecolic or retrocolic
- Making and closing the mesocolic window
- Length of the afferent limb
- Billroth II gastrojejunostomy and its modifications
- Excising the distal resection line
- Bringing the jejunal limb through the window
- Two-layer gastrojejunal anastomosis
- Closing the retrocolic mesenteric window
- Stapled Billroth II gastrojejunostomy
- Closing the common opening with a transverse stapler
Subtotal and total gastrectomy
Extending the resection, and clearing the nodes for cancer
- Subtotal resection: indications and reconstruction
- Indications for total and near-total resection
- Technical points in subtotal resection
- Extent of lymph node dissection
- Goals of total gastrectomy for carcinoma
- Arterial anatomy relevant to resection for gastric carcinoma
- Choice of incision
- Thoracoabdominal incision
- Retraction and the diaphragm
- Detaching the omentum from the transverse colon
- Assessing and starting the distal dissection
- Dividing the duodenum beyond the pylorus
- Taking the tissue overlying the pancreas
- Exposure of the left gastric artery
- Should the spleen come out
- Transecting the oesophagus
Reconstruction after total gastrectomy
Roux-en-Y, and the jejunal pouch alternative
- Building the Roux-en-Y
- Dividing the jejunum to build the Roux limb
- Two-layer enteroenterostomy of the Roux-en-Y
- Oesophagojejunal anastomosis: placing and tying the posterior sutures
- Oesophagojejunal anastomosis: the anterior layer and the finished join
- Completed Roux-en-Y reconstruction
- Jejunal pouch reconstruction
- Positioning the circular stapler through the enterotomies
- Completed pouch and oesophagojejunal anastomosis
Laparoscopic approaches
Keyhole vagotomy, resection and sentinel node navigation
- Why laparoscopy reopened the argument
- Workarounds that evolved
- Theatre setup for laparoscopically assisted vagotomy
- Preparing the stomach and gaining access
- The five ports
- Laparoscopic view of the hiatus
- Entering the lesser sac laparoscopically
- Retracting the crus to expose the anterior trunk
- Dissecting the gastrohepatic ligament laparoscopically
- Clipping and dividing the posterior vagal trunk
- Laparoscopic view of the anterior vagus nerve
- Clipping and dividing the anterior vagus
- The hardest part laparoscopically
- Laparoscopic dissection of the anterior leaf
- Performing the anterior leaf dissection
- Layers divided in an anterior seromyotomy
- The idea behind seromyotomy, and marking it out
- Cutting through the layers
- Controlling bleeding safely
- Testing and closing the seromyotomy
- Port placement for laparoscopic gastrectomy
- Laparoscopic wedge resection
- When laparoscopic drainage is added
- Mobilising and dividing the stomach laparoscopically
- Laparoscopic Billroth II reconstruction
- Stapled oesophagojejunal join in laparoscopic total gastrectomy
- The question sentinel node mapping answers
- Double-tracer sentinel node mapping
- How the double-tracer method works
- What sentinel node mapping might change
- Takeaways: vagotomy
- Takeaways: resection and reconstruction
- References
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- References (continued)
- Maingot's Abdominal Operations, 12th Edition