用于胃良性病变：典型的胃大部切除术，变异：胃窦切除（图文演示）

10. Mobilization/curvature

[点击按纽展开更多->收起->回放]

The aim of this operative step is to free the posterior aspect of the stomach, key to a successful distal gastrectomy.
The stomach is retracted cephalad using either 1 or 2 Babcock clamps or a gauze pad to prevent the organ from slipping.
The transverse colon is lifted up slightly, to expose the vessels between itself and the stomach.

[点击按纽展开更多->收起->回放]

The vessels are all ligated either using ligatures, clips, or an automatic device that divides vessels after applying 2 staples. The dissection begins between the gastric wall and the gastroepiploic vessels. It extends from the middle part of the stomach up to the end of the gastroepiploic arch. The left gastroepiploic artery running along the stomach is ligated at this point.
The posterior adhesions between the stomach to the pancreas are dissected to the right down to the pylorus using an electrocautery device.

[点击按纽展开更多->收起->回放]

In case of an antrectomy:
To perform an antrectomy (without vagotomy), the dissection only extends up to the middle part of the gastroepiploic arch.
In this case, the vascular arch - supplied by the left gastroepiploic artery - must be preserved since it will be supplying the remainder of the body of the stomach.

11. Mobilization/transection

[点击按纽展开更多->收起->回放]

The vasculature of the duodenum must be preserved when dissecting the organ.
The posterior adhesions of the pylorus are preferably transected using an Argon electrical device since it guaranties hemostasis and thus obviates having to perform numerous ligatures of the fine venous networks.
The right gastroepiploic vein that joins the gastrocolic trunk is ligated.
Care must be taken to preserve the right gastroepiploic artery.

[点击按纽展开更多->收起->回放]

The stomach is retracted caudally to expose the lesser omentum.
The pars flaccida of the lesser omentum is incised down to the pylorus. This allows passage of the left hand behind the pylorus for better exposure. It allows:
- the dissection and ligature of the right gastric artery that runs along the pylorus thus presented (pyloric artery),
- the preservation of the hepatic artery, posteriorly.
The ligature or electrocauterization of 1 or 2 small supraduodenal vessels completes the dissection of the mobile duodenum.
The gastroduodenal artery constitutes the lateral landmark for the dissection of the duodenal bulb.

[点击按纽展开更多->收起->回放]

The duodenal transection is carried out just to the left of the gastroduodenal artery. From 2 to 4 cm of duodenum are resected during this maneuver. About 1 cm of mobile duodenum must be preserved to ensure adequate surgical management of the stump.

[点击按纽展开更多->收起->回放]

The gastric tube must be removed from the stomach to prevent it from coming in the way of the transection line. Surgical management of the stump depends on the type of anastomosis intended. Both the gastrojejunal and gastroduodenal anastomoses are described in this chapter.

12. Gastrojejunal anastomosis

[点击按纽展开更多->收起->回放]

a. In the gastrojejunal anastomosis, the duodenal stump must be closed immediately since this anastomosis is achieved under the condition that the stump be closed.
b. In the gastroduodenal anastomosis, the duodenal stump must be preserved.
In certain cases, the duodenal stump cannot be utilized for an anastomosis, nor can it be adequately closed.
If a gastrojejunal anastomosis is intended, the duodenal stump is closed.

[点击按纽展开更多->收起->回放]

The use of a transecting linear stapler (55 mm, blue cartridge) is simple, quick and secure.
The stapler achieves hemostasis, water-tightness and duodenal transection, and avoids contamination of the operative field since the organ is not opened.

[点击按纽展开更多->收起->回放]

With the use of a non-transecting linear stapler (55 mm, blue cartridge), closure of the duodenal stump is performed in a single operative step. An extra running suture is not necessary since this stapler applies 3 rows of staples. The stapler is fired and a clamp is placed at stomach level.

[点击按纽展开更多->收起->回放]

The transection and suture of the duodenum may both be performed manually.
Two rigid right-angled clamps are applied on both sides of the transection line. An interrupted or extra-mucosal running suture is performed to close the stump.
Most authors further bury the suture line by applying a second row of interrupted sutures or fashioning a purse-string closure. In this case, the duodenal wall must be at least 2.5 cm long (which is more than that required for the use of a stapling device).

• Dangers and variations

[点击按纽展开更多->收起->回放]

The transecting linear stapler only applies 2 rows of staples. An extra running suture must be performed to bury the staples applied on the stump.
Although the rate of postoperative fistulas is low (about 4.5% according to Kyzer et al. 1997), extreme care must be taken to prevent this grave type of surgical complication.

• Variation
Fibrin glue:
Fibrin glue can be used to reinforce suturing.
No study has demonstrated so far that the rate of postoperative fistulas significantly decreases when fibrin glue is used.

13. Gastroduodenal anastomosis

[点击按纽展开更多->收起->回放]

If a gastroduodenal anastomosis is intended, the duodenal stump is preserved.
A healthy duodenal stump must be preserved.
Anastomosis of the gastric and duodenal segments must be tension-free.
Posterior adhesions of both the duodenum and pancreas must be detached before performing the anastomosis (Kocher maneuver) in order to gain a few millimeters.
An automatic linear stapler can be placed 1cm above the transection area. The stapled fragment is transected a second time just before proceeding to the anastomosis.

• Variations

[点击按纽展开更多->收起->回放]

Circular stapler:
A circular stapler can be used for the gastroduodenal anastomosis to help fashion a purse-string type closure. The duodenal stump is transected and the anvil of the circular stapler set in place (see Billroth I anastomosis, step 17).

[点击按纽展开更多->收起->回放]

Anastomosis with preservation of the pylorus :
Preservation of the pylorus and vagal nerve in the anastomosis is thought to reduce the functional sequelae caused by gastrectomy. Yet this type of surgery is rarely practiced (Yunfu et al., 1998).

14. Difficult duodenums

[点击按纽展开更多->收起->回放]

Surgical management of duodenal stumps with advanced peptic ulcer growth is possible, yet it remains difficult to perform the transection of these duodenums.
Peptic ulcer development posterior to the duodenum affects the pancreas, the common bile duct and the accessory pancreatic duct. The sclerosis provoked by the ulceration process results in the destruction of the plane of dissection between the duodenum and the common bile duct. Transection of the duodenum may therefore injure the biliary tract.

[点击按纽展开更多->收起->回放]

We feel that it is preferable to leave ulcerated tissues untouched and to perform a protected duodenal closure.
When the duodenum is unhealthy and/or the duodenal segment is too short, it may be impossible to utilize a linear stapler to transect both walls of the duodenum. In such cases, transverse interrupted sutures may be applied to close the duodenum.
When it is impossible to dissect the posterior aspect of the duodenum, interrupted sutures are applied longitudinally.

When it is impossible to apply secure sutures to the duodenum, a duodenostomy must be performed with the use of a probe. Three to four centimetres of a multi-perforated or “Pezzer” rubber catheter are introduced into the lumen of the duodenal stump. The stump is closed around the catheter with a running suture line or a purse-string closure. A lamina is also placed with the catheter that comes out of the patient’s right flank. The duodenostomy will retrieve 300 to 600mL of liquid per day, be maintained for 8 to 15 days, and then be progressively removed (in most cases, the opening will close by itself).

15. Freeing of the curvature

[点击按纽展开更多->收起->回放]

The left lobe of the liver is retracted cephalad and to the right using a valve retractor.

[点击按纽展开更多->收起->回放]

The distal part of the stomach is retracted cephalad and to the left to expose the origin of the left gastric artery.

[点击按纽展开更多->收起->回放]

The left gastric artery is first ligated at its point of entry over the lesser curvature. Its anterior and posterior branches are then successively ligated.
This ligature allows preservation of:
- a collateral branch of the celiac trunk that heads to the liver;
- the left accessory hepatic artery (or hepatic artery);
- and the “cardio-fundic” branch of the left gastric artery that supplies the cardia of the stomach.

16. Transection of the stomach

[点击按纽展开更多->收起->回放]

The dual lumen gastric tube is retracted to lie at the junction between the abdominal esophagus and the cardia.

[点击按纽展开更多->收起->回放]

In performing a two-thirds gastrectomy, the left side of the transection line starts on the greater curvature where the first short gastric vessels appear.

[点击按纽展开更多->收起->回放]

The automatic stapler is considered the most simple, quickest and efficient method for transection and closure of the stomach.
A 90 mm linear stapler using 2.5 mm green staples is applied to the stomach and fired.
An extra cartridge can be used to finish the entire transection line in order to perform the gastric transection in one operative step.

[点击按纽展开更多->收起->回放]

A right clamp is placed below the staple line. The stomach is transected as close as possible to the clamp.
An extra running suture is performed along the staple line to ensure hemostasis.

• Variation

[点击按纽展开更多->收起->回放]

In performing an antrectomy, the gastric transection line ends on the greater curvature at the terminal end of the right gastroepiploic artery.

• Manual transection
Manual transection may be performed using either a scalpel or an electrocautery device.
The serous and muscular planes are gradually incised to expose the submucosal plane with its rich vasculature. A thin 3.0 or 4.0 absorbable suture is used to ligate the submucosal vessels.
The transection line is closed in two planes using interrupted or running absorbable sutures.

17. Restoration/continuity
▶
Two major modalities exist for restoring gastrointestinal tract continuity after partial gastrectomy:
- the gastroduodenal anastomosis (Billroth I);
- the gastrojejunal anastomosis (Billroth II).
These procedures, first described in 1881 (Lau & Leow, 1997; Trias et al., 1996), both allow for restoring digestive tract continuity following gastric resection.

They are performed in comparable overall operative times (Kyzer et al., 1997). In the surgical literature, neither technique has been reported as giving better results (as far as secondary complications are concerned).
Secondary complications:
- late occurrence of gastric stump cancer;
- calcium and hormone metabolism alterations;
- hemorrhage;
- reflux;
- cholecystokinin secretion (Kyzer et al., 1997; Oka et al., 1995).

18. Billroth I anastomosis

[点击按纽展开更多->收起->回放]

▶
Billroth I anastomosis is an end-to-end gastroduodenal anastomosis between the distal part of the stomach remnant and duodenal stump. This simple, quick, and easy-to-perform anastomosis restores the physiologic continuity of the digestive tract.
However, this anastomosis may lead to fistula formation which is particularly serious in this area, since it may prevent the patient from resuming normal dietary habits.

[点击按纽展开更多->收起->回放]

▶
The duodenum must be healthy and well vascularized.
The suture line must be tension-free.
Gastrointestinal tract restoration using the Billroth I anastomosis should only be performed after an antrectomy.
The remaining stomach and duodenum are anastomosed manually, starting from the posterior wall, using absorbable sutures.
Danger: Because of the risk of secreting cells remaining in the stomach remnant, the Billroth I anastomosis must be performed in conjunction with a truncal vagotomy.

[点击按纽展开更多->收起->回放]

▶
Among the many variants of the Billroth I gastroduodenal anastomosis are:
a. the end-to-side gastroduodenal anastomosis (Von Haberer technique, Patel-Lataste-Noack anastomosis);
b. the anastomosis starting from the right aspect of the stomach;
c. the anastomosis starting from the posterior aspect of the gastric stump using a circular stapler.
A purse-string suture line is fashioned and the duodenal stump is resected. The anvil of the circular stapler is placed into the duodenal lumen and the purse-string tightened. One corner of the staple line resulting from the gastric resection is excised and opened to introduce the circular stapler into the gastric lumen. The posterior aspect of the stomach is perforated by the center of the circular stapler. The anvil is closed and the stapler fired to perform the anastomosis. The orifice created for entry of the circular stapler is closed using a linear stapler.
It is possible to perform the anastomosis with the circular stapler before transecting the stomach. The antrum is preserved. The circular stapler is introduced into the pylorus. The posterior aspect of the stomach is perforated by the center of the circular stapler. The stomach and duodenum are then anastomosed using an automatic stapler before proceeding to the gastric resection (Oka et al., 1995).

19. Billroth II anastomosis

[点击按纽展开更多->收起->回放]

Billroth II anastomosis is a gastrojejunal anastomosis.
The main advantage of this type of anastomosis is that it can be performed regardless of the condition of the duodenum. This procedure is quick and offers good functional results.
Certain general rules should be followed:
- it is preferable to perform a mechanical anastomosis;
- the posterior aspect of the stomach and the first jejunal loop are anastomosed using a side-to-side anastomosis;
- the jejunal loop used for the anastomosis must be only 20 to 40 cm long to preserve the physiology of the digestive tract.
- the anastomosis is antiperistaltic -- the afferent loop is approximated to the lesser curvature of the stomach. The lesser curvature hence becomes the point of entry of the biliopancreatic secretions discharged into the stomach. The secretions clear the gastric pouch at the lowest point of the greater curvature.
- the anastomosis is performed below the mesocolon to prevent loop stricture at that level.

• Preparing the anastomosis

[点击按纽展开更多->收起->回放]

The transverse colon is lifted and exteriorized by the assistant. It is stretched and transilluminated to find an avascular zone in the mesocolon between its origin and Riolan's vascular arcade. A 5 to 7 cm opening is fashioned at the origin of the transverse mesocolon in this avascular zone.
The part of the jejunum chosen for the anastomosis is brought closer to the stomach by using Babcock clamps placed on the staple line under the mesocolic incision.

[点击按纽展开更多->收起->回放]

The posterior fold of the mesocolic opening is first sutured to the posterior aspect of the stomach about 4 cm from the staple line. Care must be taken to preserve enough tissue for the anastomosis.
The posterior fold must be fixed at this point of the operative step since access to this area is impossible once the small bowel is sutured to the stomach.

[点击按纽展开更多->收起->回放]

The gastric wall and small bowel are each incised for 1 cm. The jaws of the automatic mechanical stapler are inserted into these incisions to perform the side-to-side anastomosis.
The stapler is removed and its introduction site is closed with absorbable interrupted sutures or with a 55 mm linear stapler whose opening is triangulated to prevent the staple lines from being in approximation when the stapler is fired.
The anterior fold of the mesocolic opening is closed at stomach level, anterior to the anastomosis. The stomach can, therefore, still move cephalad and the anastomosis will remain in a submesocolic position.

• Manual anastomosis

[点击按纽展开更多->收起->回放]

The stomach is completely dissected free and the transection line defined but at this point, the stomach is not yet transected.
Once the mesocolic opening is fashioned and the posterior fold is sutured, the small bowel is approximated to the stomach. First, a posterior seromuscular running suture is placed to secure the small bowel to the stomach and then both the stomach and the small bowel are opened on either side of the posterior suture line. Next, a through and through, 3.0 absorbable running suture is placed across the stomach (from the lesser curvature to the greater curvature) prior to transection, as a hemostatic measure.

[点击按纽展开更多->收起->回放]

The stomach is completely transected. Another through-and-through suture is placed between the stomach and the anterior aspect of the small bowel. The suture line is completed by a second sero-serous anterior running suture.
The mesocolon is next sutured to the anterior aspect of the stomach so that the anastomosis always remains in submesocolic position.

• Dangers and variations
• Danger
Hemorrhage at the transection line of a mechanical stapler:
The transection line is inspected interiorly prior to closing the anstomosis, to make sure that the transection lines are not bleeding.

• Variations
Other types of gastrojejunal anastomosis:
1. The gastrojejunal anastomosis can be performed on the posterior aspect of the stomach. The stomach is transected using a 90 mm linear stapler and its posterior aspect approximated to the small bowel (as in an end-to-end anastomosis). The side-to-side anastomosis is performed in 4 ways:
2. Isoperistaltic anastomosis
3. Precolic anastomosis
4. Loop anastomosis forming a Y-shaped pattern
5. Anastomosis to the anterior aspect of the stomach (may impair the functional aspect of the stomach)

Finsterer anastomosis:
This type of anastomosis is also submesocolic.
The main difference between the Finsterer and Billroth II anastomoses concerns the length of the anastomosis. Billroth II anastomosis is an end-to-end anastomosis whereas the Finsterer anastomosis is an end-to-side anastomosis performed on the left part of the gastric transection line. The small bowel is sutured to the corner of the inferior gastric pouch. This creates an angle preventing biliary secretions from discharging into the stomach. It is fashioned by applying 3 to 4 stitches to the anterior and posterior aspects of the stomach and eventually the small bowel.