Operative Surgery and Topographic Anatomy - 2016

Content Module No. 3. Topographic Anatomy and Operative Surgery of Regions and Organs of the Abdominal Cavity

Topic 17. Stomach surgery. Incision, suturing. Gastric fistula, gastrointestinal anastomoses. Principles of gastric resection, organ-sparing surgeries (vagotomy), drainage procedures

1. Relevance of the topic: conditions such as Burns, inoperable tumors of the Esophagus and the Cytology/practical/109.html">Pyloric part of The Stomach, foreign bodies, etc., require Surgical Treatment. Various types of vagotomy are widely used. True gastric ulcers and gastric tumors require gastric resection. A thorough understanding by the surgeon of the TOPOGRAPHIC AND ANATOMICAL Features of the stomach Structure and mastering the technique of surgical interventions significantly affect the treatment outcomes of the aforementioned pathologies.

2. Specific objectives:

1. Explain the methodology of gastrostomy, gastrotomy, gastric resection, and organ-sparing surgeries.

2. Explain how to perform such surgeries as gastrostomy, gastrotomy, gastric resection, and organ-sparing surgeries.

3. Tasks for independent work during preparation for the Class.

3.1. List of basic terms, parameters, and characteristics that the student must master when preparing for the class:

3.2. Theoretical questions for the class:

1. What are the anatomical rationales for the transrectal approach to the stomach during gastrostomy?

2. How to justify the necessity of suturing the stomach wall to the parietal Peritoneum during gastrostomy?

3. What techniques are used to locate the jejunum?

4. Why is the intestinal loop sutured in an isoperistaltic direction with the afferent end of the intestine positioned above the efferent one?

5. Why is the anastomosis fixed in the opening of the transverse mesocolon?

6. What are the indications for gastric resection? What Methods of resection do you know?

7. What is The Essence of gastric resection according to Billroth I and Billroth II modified by Hofmeister-Finsterer?

8. What are the main disadvantages of Billroth II gastric resection in various modifications?

9. Will a normal postoperative period be ensured if the surgeon has not fixed the gastric stump to the opening in the transverse mesocolon?

10. What vagotomies and drainage Procedures do you know?

3.3. Practical skills mastered during the class:

1. Layer-by-layer incision of the stomach during gastrotomy.

2. Creation of a stoma using Witzel's method, performing gastropexy.

3. Placement of intestinal sutures when closing the duodenum (Billroth I method), and between the stomach and the jejunum (Billroth II method in the Hofmeister-Finsterer modification).

4. Performance of vagotomy and drainage procedures.

4. Topic Outline

Creation of a Gastric Fistula (Gastrostomy)

Terminology and indications for surgery. Surgical approaches for gastrostomy, advantages of left-sided paramedian and transrectal incisions.

Creation of a tube gastrostomy using Witzel's technique.

The anterior wall of the stomach is pulled out into the wound and packed with surgical Sponges. The tube is placed obliquely so that its end, which will be inserted into the stomach, lies closer to the cardia (directed toward the gastric air bubble). When creating the channel, interrupted sutures should be placed so that the channel wall tightly grips the tube. Prior to invaginating the tube, a purse-string (or semi-purse-string) suture is applied, and the tip of the tube must be inserted into the stomach by at least 3-5 cm. It is important to place a second row of sutures around the opening. During gastropexy, the gastric wall should be anchored to the parietal peritoneum and aponeurosis to ensure a permanently oblique position of the channel and sealing of the Abdominal cavity. The posterior wall of the rectus abdominis sheath is closed with interrupted silk sutures, with 1-2 sutures placed above and below the tube to anchor the gastric wall. The wound is closed in layers.

Gastrostomy according to Stamm-Senn-Kader and Toprover (Fig. 56).

Fig. 56. Toprover gastrostomy: a - formation of a cone from the anterior gastric wall and placement of three purse-string sutures; b - general view of the cone after the sutures are tied and a rubber tube is inserted into the gastric lumen; c - fixation of the cone to the parietal peritoneum.

Various types of anastomoses. Anterior (antecolic) or posterior (retrocolic) gastroenteroanastomosis.

Sequence and technique of suture placement: seromuscular, continuous locking (Schmieden's) suture; during The formation of the gastroenterostomy, the length of the anastomosis is 7-8 cm, and the width of the posterior lip is 7-8 cm. Next, the anastomosis is fixed within the incision of the transverse mesocolon (in posterior gastroenteroanastomosis) by suturing the edge of the mesocolic incision to the gastric wall around the anastomosis with a row of interrupted silk sutures. In anterior anastomosis using a long loop, an additional enteroanastomosis (Braun) is created between the afferent and efferent loops of the jejunum at a distance of 10-12 cm from the gastroenteroanastomosis.

Potential Errors and Complications (spur formation, vicious circle). Preventive measures against vicious circle formation (suturing the intestinal loop in an isoperistaltic direction, positioning the afferent limb of the anastomosis higher than the efferent limb, closer to the lesser curvature, and correct sizing of the anastomotic lumen).

Gastric Resection

Principles of gastric resection methods — Billroth-I and Billroth-II as modified by Hofmeister-Finsterer (Fig. 57). Possible resection volumes in various types of organ pathology. Mobilization of the stomach.

Fig. 57. Gastric resection:

I - resection boundaries: A - one-third; B - two-thirds; C - subtotal; II - diagram of Billroth I resection; III - diagram of Billroth II resection; IV - diagram of Billroth II resection as modified by Hofmeister-Finsterer.

Technical details of handling gastric ligaments and major individual Arteries (left gastric, right gastric, etc.). Different levels of vascular ligation (organ mobilization) in PEPTIC ULCER DISEASE and gastric neoplasms.

Transection of the stomach from the duodenum.

In Billroth-I gastric resection, an end-to-end anastomosis is performed with mobilization of the duodenum using Kocher's maneuver.

In Billroth-II gastric resection as modified by Hofmeister-Finsterer, special attention is paid to closing the duodenal stump. The critical nature of this surgical step is emphasized due to the risk of duodenal fistula and Peritonitis development, which pose severe hazards to the patient.

Main techniques for closing the duodenal stump. Standard closure according to Moynihan, and other methods.

Closure of the gastric stump with a short jejunal loop (end-to-side anastomosis) resembling a posterior gastroenteroanastomosis. Upon completion of the anastomosis, its patency is tested. Finally, the gastric walls are anchored to the edges of the transverse mesocolon incision through which the jejunal loop was brought up.

Less traumatic types of organ-sparing surgeries: truncal and selective vagotomy combined with pyloroplasty or antrectomy, highly selective vagotomy (HSV).

Heineke-Mikulicz pyloroplasty, Finney pyloroplasty, and Jaboulay gastroduodenostomy.

The Heineke-Mikulicz procedure involves longitudinal incision of the pylorus followed by transverse closure of the enterotomy. The Finney procedure involves incision of the muscular layer of the pylorus without opening the mucosa.

5. Self-Assessment Materials

A. Self-Assessment Tasks

Test No. 1

A surgeon performed a gastric resection and proceeded to create a gastrojejunostomy. For the outer lip of the anastomosis, the surgeon decided to place a continuous full-thickness suture. To do this, the margins of the anastomosis were successively sutured from the mucosal side, causing them to invert into the lumen of the anastomosis when the suture was tightened. What type of suture did the surgeon use?

a. Pirogov

b. Schmieden

c. Lembert

d. Albert

e. Czerny

Test No. 2

A surgeon performed a Witzel gastrostomy. What type of fistula was thus formed?

a. Natural

b. Tubular

c. Temporary

d. Permanent

e. Gastrointestinal

Test No. 3

A surgeon performed a Toprover gastrostomy. What sutures were used to form a tube from the gastric wall?

a. Purse-string

b. Simple interrupted and purse-string

c. U-shaped

d. Purse-string and Z-shaped

e. Simple continuous and U-shaped

Test No. 4

The surgeon performed a physiological gastric resection. Which part of the stomach was removed?

a. 1/4

в. 1/3

c. 1/2

d. 2/3

e. 3/4

Test No. 5

A patient with bleeding peptic ulcer underwent gastric resection using the Billroth I method. The passage of the gastrointestinal tract was restored by creating which type of anastomosis?

а. End-to-end gastroduodenostomy

в. End-to-side gastroduodenostomy

c. Side-to-side gastroduodenostomy

d. End-to-side gastrojejunostomy

e. Side-to-side gastrojejunostomy

B. Self-Assessment Tasks

Task 1. A 65-year-old patient is diagnosed with stage IV Cancer of the lower third of the esophagus, with metastatic Lymph Nodes identified on the left side of the neck. The patient is emaciated and dehydrated. Only Water can pass through the esophagus. What surgical procedure is indicated for this patient?

Task 2. On the fourth day after Witzel gastrostomy placement, the patient accidentally pulled out the rubber tube located in the gastric cavity. What surgical error was made during the gastrostomy placement, and what management strategy should be applied?

Task 3. A 60-year-old patient underwent surgery for cancer of the gastric antrum accompanied by symptoms of severe gastric outlet obstruction. Exploration revealed that the tumor invades the HEAD of the Pancreas. There are numerous metastatic lymph nodes along the Abdominal Aorta, in the lesser and greater omentum. The stomach is dilated and fixed. How will you conclude the operation?

Task 4. A month ago, a 47-year-old patient underwent a retrocolic posterior gastrojejunostomy for an unresectable tumor of the gastric antrum. However, as early as 5–6 days postoperatively, after

every meal, the patient experiences diarrhea. Undigested food particles are present in the stool. Coprological examination reveals a large amount of mucus and undigested food. What surgical error was made during the operation? What should be done?

Task 5. A 45-year-old patient underwent elective Billroth I gastric resection for a gastric ulcer. On the third postoperative day, the patient's condition sharply deteriorated. Acute pain developed in the epigastric region and gradually spread throughout the abdomen. The Tongue is dry, and the abdomen is distended, tender in the epigastric region, and rigid. Shchetkin-Blumberg sign is positive. Percussion dullness is present in the dependent areas of the abdominal cavity. What complications should be suspected? What is your management strategy for this patient?

Task 6. During surgery for Gastric Cancer, a patient is found to have an infiltrative tumor of the gastric antrum. No visible metastases are detected. What surgical procedure should be performed?

Task 7. In a patient at "high surgical risk" undergoing surgery for a duodenal ulcer, it is found that the ulcer is located low, severe periduodenitis is present, and the hepatoduodenal ligament is encased in adhesions. Your experience in gastric surgery is relatively limited. How will you proceed?

References

Basic

1. Operative Surgery and Topographic Anatomy; edited by M.S. Skrypnikov. — Kyiv: Vyshcha Shkola, 2000. — P. 312-332.

2. Operative Surgery and Topographic Anatomy; ed. by M.P. Kovalsky. — K.: Medytsyna, 2010. — P. 237-272.

Supplementary

1. Kovanov V.V. Operative Surgery and Topographic Anatomy / V.V. Kovanov. — M., 2001. — P. 334-364.

2. Operative Surgery and Topographic Anatomy; ed. by M.S. Skrypnykov. — Poltava, 2001. — P. 202-246.

3. Operative Surgery and Topographic Anatomy; ed. by K.I. Kulchytsky. — K., 1994. — P. 207-240.

4. Elizarovsky S.I. Operative Surgery and Topographic Anatomy / S.I. Elizarovsky, R.N. Kalashnikov. — M., 1979.

5. Matyushin I.F. Introduction to the Course of Operative Surgery and Topographic Anatomy / I.F. Matyushin. — Gorky, 1976.

6. Tomashuk I.P. Guide to Operative Technique for Beginning Surgeons / I.P. Tomashuk, I.I. Tomashuk. — K.: European University Publishing House, 2001. — 860 p.

7. Frautschi V.Kh. Course of Topographic Anatomy and Operative Surgery / V.Kh. Frautschi. — M., 1976.