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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