home→Ulcer→ Distal resection of the stomach according to Billroth 1. Stages and technique of resection of the stomach according to Billroth II (gastrojejunostomy)

Distal resection of the stomach according to Billroth 1. Stages and technique of resection of the stomach according to Billroth II (gastrojejunostomy)

Resection of the stomach is an operation, the result of which is the removal of a significant part of the organ, followed by the restoration of the digestive system. Today, there are many methods of resection. This article will focus on Balfour resection. In addition, important topics such as instructions for conducting and methods of rehabilitation after surgery will be touched upon.

Balfour gastric resection, the scheme of which is available in the Great Medical Encyclopedia, including the electronic version on the Internet, is an improved Krenlein method proposed at the Berlin Conference of Surgeons in 1906. The addition of the method lies in the fact that Balfour proposed to supplement the technique with an anastomosis between the conductive and efferent intestinal loops. This made it possible to break the vicious circle that existed until 1927, the meaning of which was the development of peptic ulcers after resection.

It should be noted that the proposal was a kind of breakthrough in the field of resection of the main digestive organ. Prior to the invention of the Balfour method, most patients died within a few years of the operation.

Instructions for Balfour resection

Most often, resection performed in this way is used in the fight against two dangerous diseases: cancer and peptic ulcer. The goals of the ongoing surgical intervention in the fight against the above ailments should be discussed in more detail.

Stage 1 stomach cancer is the most easily removed tumor. Balfour resection allows you to remove all tumor tissue in order to eliminate metastases. The most common ways stomach cancer spreads are:

- within the wall of the main digestive organ;
- transition to an organ adjacent to the stomach;
- lymphogenous and hematogenous metastases;
- carcinomatous implantation of the abdominal cavity.

In terms of operative intervention, Balfour resection can help in the first three cases, while approximately 75% of the stomach is removed.

Balfour resection for ulcers has two main purposes:

- firstly, a painful, dangerous area is removed - an ulcer;
- secondly, a relapse is prevented, which can rapidly develop on a healthy wall of the gastrointestinal tract.

It should be noted that modern medicine reached incredible heights in the field of surgical intervention, in particular gastric resection. Therefore, most operations on the main digestive organ according to Balfour are carried out with a positive outcome. The recurrence rate is minimal.

The essence of the operation

Distal Balfour resection involves the removal of 66 to 75% of the main digestive organ. Next is the restoration of the gastrointestinal tract. After completing a course of rehabilitation, a person is able to live a full life.

Resection and the method of its implementation in most cases is appointed by a council of surgeons. For the most part, this is a forced step, designed to prevent complications or even save the life of the patient. The average duration of the operation (Balfour resection) is 2-4 hours.

Rehabilitation

The rehabilitation process after resection is quite complicated. Its timing is primarily due to the individual characteristics of the body and the completeness of the success of surgical intervention.

The first seven days after the Balfour resection, the patient is prescribed bed rest. With absence side effects, after a week, the patient may sit down for a short time. On the 10th day, rise to the feet is allowed.

Throughout the rehabilitation period, the patient must wear a special elastic bandage. Any physical exercise excluded. To speed up the rehabilitation process, the patient can be sent to a health-improving sanatorium.

Diet after surgery

The key to a successful recovery is a strict diet. The first days after surgery, eating is completely prohibited. Nutrients administered parenterally, through established catheters or through a dropper, intravenously.

The most important condition for the diet after resection of the main digestive organ is the consumption of a balanced amount of mineral salts, proteins and carbohydrates. All dishes, without exception, must be steamed. They should be consumed in small quantities, in a warm state. Additionally, for the speedy healing of stitches, you can eat milk, sea buckthorn and olive oil.

The diet prescribed after the Balfour resection excludes the consumption of a number of products, these should primarily include:

- salt;
- alcoholic and carbonated drinks;
- highly sweet confectionery products such as cakes;
- smoked and fried foods;
- overly rich broths;
- canned foods.

Food should be taken at least 6 times a day, but in small portions. You need to chew carefully so as not to create an additional burden on the diseased organ. It should be understood that resection is the removal of a significant part of the stomach, therefore, for a full life, such a diet should be followed not only during the rehabilitation period, but throughout life.

Possible Complications

The operation is a violation of the integrity of the body. No surgery goes unnoticed. That is why doctors resort to such methods only as a last resort.

Like any other operation, Balfour gastric resection can lead to a number of complications:

- intracavitary bleeding;
- thrombosis;
- infection with various infections;
- temporary anemia;
- damage to blood vessels located in organs adjacent to the stomach;
- skipping malignant foci;
- lack of substances necessary for a full life;
- inability to take the amount of food necessary for full-fledged work.

The most common complication is dumping syndrome. Its cause is the accelerated evacuation of the food bolus into the intestine, which entails a decrease in blood glucose levels. It can be both early and late. The first occurs about 15 minutes after eating. The second in 2-4 hours.

Its symptoms are:

- severe weakness;
- cutting pains;
- flatulence;
- diarrhea.

It should be noted that the dumping syndrome can be cured by a conservative method, but the therapy should be complex. Its basis is a diet that involves fractional nutrition, eating foods rich in vitamins and limiting the intake of liquids and carbohydrates.

Dumping syndrome can occur in both mild and severe forms. In the first case, as it was said, conservative treatment helps, in the second, surgical intervention is required.

It should be noted that resection of the main digestive organ according to Balfour can be carried out not only to combat oncological diseases and ulcers, but also in obesity. Of course, resection for obesity is an extreme, undesirable method.

Indication for surgical treatment of stomach cancer are the diagnosis of resectable gastric cancer and the absence of general contraindications to surgery.

Gastrectomy from oncological positions- complete removal of the stomach and all areas of regional metastasis - in the absence of tumor cells along the lines of intersection of the esophagus and duodenum(histologically). Gastrectomy is performed from the abdominal or combined access.

Indications for abdominal access:

1.localization of a tumor with exophytic or mixed type of growth in the middle third of the stomach;
2.simultaneous lesion of the distal and middle, middle and upper third of the stomach;
3.total lesion of the stomach;
4. infiltrative type of tumor growth;
5. tumors in the distal third of the stomach with metastases in the cardiac, right and left gastro-omental, splenic, left gastric and pancreatic lymph nodes;
6. tumors of the upper third of the stomach with metastases in the right gastric, gastro-omental, pyloric, pancreatic and upper pancreatoduodenal lymph nodes;
7. undifferentiated tumors.
Indications for combined access: gastric cancer with spread to the esophagus. Laparotomy and lateral thoracotomy on the left, performed in the sixth intercostal space, or Garlock access are used.

Subtotal distal resection of the stomach is indicated for exophytic or mixed type of tumor growth of the distal third of the stomach of I, II and III stages (T1-4 N0-2 M0).

Gastrectomy. The operation is usually performed from the upper median transperitoneal access. The maximum convenience of operation is achieved by correct laying of the patient. The axis of the table raised during the operation should be located 3-4 cm above the angle formed by the costal arches, at the level of the border between the body and the xiphoid process of the sternum.

With combined access, the patient is placed on the right side for left-sided anterolateral thoracotomy. right hand pulled forward, and the left is thrown back behind the head and fixed to the stand. The right leg is bent at the knee and hip joints, and the left leg is extended. The patient lies on his side somewhat leaning back. The roller of the operating table should be located opposite the point of intersection of the mid-muscular line with the line of the proposed incision along the intercostal space.

When the tumor of the stomach spreads to the lower thoracic esophagus, the operation is started either with an upper median laparotomy or with an oblique laparotomy, and after revision, the issue of a combined access using the Garlock access is decided - the addition of an oblique laparotomy with a thoracotomy in the sixth intercostal space on the left with the intersection of the costal arch; or thoracotomy on the left in the sixth or seventh intercostal space and the formation of an anastomosis in the left pleural cavity.

The initial stage of the operation- revision of the abdominal organs in order to establish the spread of the tumor process and the possibility of performing gastrectomy.

Mobilization of the greater omentum and its separation from the transverse colon begins with the dissection of the gastrocolic ligament approximately in the region of the middle part of the colon. The stomach is captured and brought into the wound cranially, the transverse colon is taken away in the opposite direction. The surgeon with his left hand takes a large omentum and brings it into the wound. The gastrocolic ligament is stretched, and it is cut in layers in the avascular zone. The greater omentum is mobilized to the hepatic angle of the large intestine. Cutting through the tissue of the greater omentum between the clamps, they reach the wall of the duodenum. Directly at the pancreatic tissue itself, the right gastroepiploic vessels are ligated and crossed. With the intersection of the gastrocolic and pyloric-pancreatic ligaments, the block of lymph nodes (pyloric, right gastroepiploic, upper pancreatoduodenal) moves to the removed part of the stomach.

Then, the left half of the greater omentum is mobilized to the gastrosplenic ligament and the short gastric vessels passing through it. Short gastric vessels, when the stomach is mobilized along the greater curvature, are tied up directly at the spleen in the gastrosplenic ligament. Mobilization of the stomach along the greater curvature is completed by dissection to the left of the esophagus of the diaphragmatic-gastric ligament, which fixes the fundus of the stomach to the diaphragm.

Mobilization of the lesser omentum. The omentum is separated in parts from the liver with clamps and crossed. At the pylorus, the right gastric artery (a branch of the common hepatic artery) is directly ligated. Produce lymph node dissection starting from the hepatic vessels.

Next stage- ligation of the left gastric artery and vein. All lymph nodes with fiber are mobilized and shifted to the stomach. In the proximal part of the lesser omentum, the ascending branch of the left gastric artery is ligated, and then the phrenic-gastric ligament and the anterior semicircle of the esophageal-phrenic ligament are crossed to the right of the esophagus, after which the abdominal esophagus becomes available for final mobilization. He is stupidly circled with a finger and a rubber holder is held around him. Both vagus nerves are cut with scissors.

For more complete mobilization of the esophagus and the convenience of creating an esophageal-intestinal anastomosis in the mediastinum, a sagittal diaphragmotomy according to Savinykh is performed. On the clamps cross lig. gastrodiafragmatica and stitch the lower diaphragmatic vessels.

Apparatus UO-40 at a distance of 2 cm from the pylorus pierce the duodenum, cut off from her stomach. The esophagus is stitched over the cardia with the UO-40 device and crossed. The stomach with omentums and lymph nodes is removed.

Thus, in the same block with the stomach, lesser and greater omentum, there are groups of lymph nodes located along the hepatic vessels, left, right, short gastric arteries, left and right gastroepiploic arteries. The duodenum is additionally sutured according to Rusanov.

The second stage of the operation- formation of esophagojejunostomy.

There are several dozens of ways to restore the continuity of the digestive tract after removal of the stomach, but they are all based on two basic principles: esophagoduodenostomy and esophagojejunostomy.

Direct esophagoduodenostomy, first successfully performed by Brigham in 1898, although it seems to be a “physiological” operation, is technically feasible in a very limited number of patients, therefore it has not received wide distribution.
End-to-side esophagojejunostomy with Brown intestinal anastomosis is the most common reconstruction technique after gastrectomy. In this form, the operation was first performed by SchlofTer in 1917.
End-to-side esophagojejunostomy with Roux-en-Y inter-intestinal anastomosis has been used since 1947 at the suggestion of Orr. With this method of reconstruction, there is less possibility of regurgitation of digestive juices into the esophagus.
The main types of esophagojejunostomy. Depending on what position is given to the intestine in relation to the diameter of the esophagus, horizontal and vertical esophagojejunal anastomoses are distinguished:

Horizontal end-to-side esophagojejunostomy.
Vertical end-to-side esophagojejunostomy using an adductor loop to cover the anastomotic sutures (Hilarowitz, 1931).
Vertical end-to-side esophagojejunostomy with fixation of the esophagus located along it to the intestine with special sutures (K.P. Sapozhkov, 1946).
Invaginated esophago-intestinal anastomosis according to Davydov: 2 serous-muscular sutures are placed at a distance of 30-40 cm from the Treitz ligament at the mesenteric edge of the jejunum. 3 serous-muscular sutures are placed on the antimesenteric edge and the posterior wall of the esophagus. Open the intestinal lumen. An inner row of anastomosis sutures is formed. Two rocker serous-muscular sutures invaginate the inner row of sutures into the discharge section of the intestine. The invagination is completed with the last suture, covering the anterior wall of the anastomosis with an afferent loop.

Subtotal distal resection of the stomach. In oncological practice, subtotal distal resection of the stomach using the Billroth-II method is the most common operation. The revision and initial mobilization of the stomach is performed in the same way as in gastrectomy performed from the abdominal access.

Mobilization and cutting off the greater omentum from the transverse colon is performed to the right to the hepatic angle with ligation of the right gastroepiploic arteries and veins, and to the left - to the short gastric vessels.

Mobilization of the stomach along the lesser curvature, the lesser omentum is cut off directly from the liver. The initial section of the duodenum at a distance of 1-1.5 cm below the pylorus is mobilized so that all the fiber with the lymph nodes goes to the removed part of the stomach. The right gastric artery is ligated and transected directly at the origin of the common hepatic artery. The lesser omentum is mobilized to the esophagus, ligated, and the esophageal branch of the left gastric artery is transected.

Ligation of the left gastric artery and vein. All lymph nodes with fiber are shifted to the wall of the stomach. The left gastric artery is ligated and crossed in the area of its origin from the celiac trunk.

Next, the line of resection of the stomach is outlined. On the lesser curvature, it should begin below the cardia. Along the greater curvature, the resection border is located at the level of the distal short vessels of the stomach. Thus, with subtotal distal resection of the stomach, it will be oncologically correct to remove all the lesser and greater omentums (up to the level of the short gastric arteries) with those located here lymph nodes and vessels.

Using the UO-40 device, at a distance of 1.5-2 cm from the pylorus, the duodenum is sutured, cut off, and additionally sutured according to Rusanov. Along the line of resection of the stomach, the stomach is sutured from the side of the lesser and greater curvature using UO-40 devices, the drug is cut off and removed. Additional serous-muscular sutures are applied to the lesser curvature of the stomach up to the proposed anastomosis zone.

Next stage- formation of an anastomosis between the remaining part of the stomach and a loop of the jejunum, passed through the window in the mesentery of the colon. It is placed isoperistaltically and sutured to the back wall of the stomach stump with the first row of serous-muscular sutures, then a continuous suture is applied to the posterior and anterior semicircles of the anastomosis and the second row of serous-muscular sutures to the anterior wall of the anastomosis. The stomach stump is strengthened with separate sutures in the window of the mesentery of the transverse colon so that the anastomosis is located below the mesentery.

Anastomotic modifications. After resection of the distal part of the stomach, the continuity of the digestive tract is restored in one of two ways: the stomach stump is connected directly to the duodenal stump or to the initial part of the jejunum.

The method of Billroth-I (1881) - the continuity of the digestive tract is restored by connecting the stumps of the stomach and duodenum with an end-to-end anastomosis.

Method Billroth-II (1885) - the stump of the stomach and the stump of the duodenum are closed with sutures tightly, and the continuity of the digestive tract is restored by imposing an anastomosis between the stump of the stomach and the initial section of the jejunum. In this case, food, bypassing the duodenum, enters directly into the lean.

Currently, various modifications of this method are used:

1. The Reichel-Polya method (1908, 1911) - the duodenal stump is sutured, and the stomach stump is not sutured and the entire width of the lumen is anastomosed with the initial loop of the jejunum, passed through the hole in the mesentery of the colon.
2. Roux's method (1893) - the duodenal stump is sutured tightly, and the stomach stump is anastomosed with the outlet end of the transected jejunum, the leading end of which is U-shapedly connected by an anastomosis to the outlet end of the intestine 15-20 cm below the gastrointestinal anastomosis.
3. Balfour's method (1917) - a gastrointestinal anastomosis is applied to a long loop of the jejunum, adding an inter-intestinal anastomosis according to Brown.
4. The Hofmeister-Finsterer method (1896), or Spasokukotsky-Finsterer (1914), or Spasokukotsky-Wilms, is now used most often. The duodenum is closed tightly. The stomach stump is closed only partially from the side of the lesser curvature and anastomosed with a short loop of the jejunum, passed through the hole in the mesentery of the transverse colon. The part of the intestine leading to the anastomosis is sutured to the stomach stump from the side of the lesser curvature. This strengthens the least durable place of the anastomosis sutures - at their junction with the sutures of the stomach stump, and, in addition, a kind of valve is created that prevents the contents of the stomach from entering the duodenum.

Operation in modification according to Billroth-I. Long-term experience of surgeons has shown that:

1.resection by the Billroth-I method is more dangerous;
2. in cancer it is less radical;
3. the condition of patients who underwent this intervention is no better than after resection performed by the Billroth-II method.
The operation of choice should be considered subtotal distal resection according to Billroth-P, since this method is not technically complicated, is associated with the lowest risk, and always makes it possible to perform the most radical operation.

Anastomosis requirements: the most common resection of the stomach with the imposition of an anastomosis by suturing the stomach stump to the side of the jejunum using the Billroth-II method.

The anastomosis should be formed in such a way as to ensure unimpeded emptying of the stomach through the efferent loop of the jejunum and prevent the possibility of gastric contents entering the afferent loop. The contents of the duodenum must freely enter the stomach through the afferent loop. The retrocolic anastomosis on a short loop of the jejunum most fully meets these requirements with the formation of a kind of valve by suturing the wall of the adductor loop above the anastomosis to the lesser curvature of the stomach (according to Hofmeister-Finsterer).

This design of the anastomosis has several advantages:

1.duodenal contents enter through the afferent loop into the stomach;
2. less possibility of evacuation disorders;
3. with a short loop, evacuation from the duodenum occurs freely and there is no stagnation of the contents (the conditions for healing the duodenal stump are more favorable than with an anastomosis on a long loop).

Technique of resections of the stomach. The upper median incision opens the abdominal cavity and examines the stomach and duodenum. Sometimes, to detect an ulcer, the omental sac is opened, dissecting the gastrocolic ligament (GCL), and even a gastrostomy is performed, followed by suturing of the gastric wound. The volume of the resected part of the stomach is determined, after which the stomach and transverse OK are brought into the wound. The avascular area with stretched ACL is dissected. YOS is taken in parts on clamps and crossed. In the corner between the head of the pancreas and the duodenum, the gastroepiploic artery is found and, together with the LSG, it is crossed between two clamps and tied up.

Under the control of a finger passed through the lesser omentum, they are grasped with clamps, crossed and tied off the right gastric artery. The lesser omentum is dissected to the cardial part of the stomach. It should be noted that often there are vessels from the left gastric artery to the liver. Consider it necessary to check whether there is a hepatic artery among them. Ligation of the main trunk of the hepatic artery, abnormally extending from the left gastric artery (LVA), threatens with liver necrosis. Above the place of division of the LV, an incision is made in the serous membrane at the lesser curvature of the stomach. A clamp is made into the incision along the wall of the stomach towards the finger drawn to the posterior surface of the stomach at the lesser curvature.

Clamps are applied to the LV separated from the stomach, crossed and bandaged. The boundaries of gastric resection are finally determined and, if necessary, their expansion is additionally mobilized for greater curvature. The duodenum is grasped with a clamp closer to the pylorus, the second clamp is applied to the stomach at the pylorus. Between the clamps, the stomach is cut along the duodenum. In cases where the ulcer is located in the duodenum, the latter is crossed below the ulcer, if mobilization of the intestine allows, since on its posteromedial wall, at a distance of 2-8 cm from the pylorus, there is a BDS. The further course of the operation depends on the method of restoring the patency of the gastrointestinal tract. In accordance with this, several types of gastric resection are distinguished: according to Billroth-I, according to Billroth-II, gastrojejunoplasty.

Resection of the stomach according to Billroth-I. In this operation, the stomach stump is directly connected to the duodenum. The indication for resection of the stomach according to Billroth-I is the patient's predisposition to dumping syndrome. There are many modifications of this method. The most common is the classical technique according to Billroth-I. After the mobilization of the stomach, clamps (soft) are applied to its remote part or it is stitched using the UKL-60 apparatus, and the mobilized part of the stomach is cut off. On the greater curvature, a section of the stomach stump is left unsutured, the diameter of which is equal to the lumen of the duodenum. The rest of the stomach stump is sutured with a continuous catgut blanket overlap or dip suture, furrier suture or Connel suture. Impose the second row of nodal gray-serous sutures.

When using UKL-60, the tantalum suture is peritonized with gray-serous sutures, except for the area near the greater curvature, which, after excision of the suture with tantalum staples, is anastomosed with the duodenum. The unsewn part of the stump of the stomach and duodenum is brought together. Departing 0.5 cm from the edge of the incision, nodal gray-serous sutures are applied to the posterior lips. The posterior lip of the anastomosis is sutured with a continuous catgut overlapping suture, and the anterior lip with a dip Connell suture. Gray-serous sutures are applied to the anterior lip of the anastomosis, reinforcing the corners with U-shaped gray-serous sutures. The greater omentum, and in its absence, the mesentery of the transverse OK is sutured to the stomach and duodenum in the area of the entrance to the stuffing bag, eliminating the entrance to the latter.

To avoid divergence of the anastomosis sutures at the junction, a 90° rotation of the gastric stump is used, followed by its connection with the duodenum or TC (Kirschner, 1932). Thus, the suture of the newly formed lesser curvature is located on the posterior lip of the anastomosis.

With highly located ulcers of the lesser curvature of the stomach, the latter is lengthened (Shosmaker, 1957; P.M. Shorluyan, 1962). When a large part of the stomach is removed and there is no area of great curvature convenient for creating a tube, HEA is applied, i.e. the operation is completed according to Billroth-II.

A number of authors (Flym and Longmire, I9S9; Kilcer and Symbas, 1962; B.C. Pomslov et al., 1999) recommend that the pylorus be preserved during resection of the stomach according to Billroth-I. At the same time, they completely remove the SM of the gastric area preserved above the pylorus, connecting the SM of the duodenum with the SM of the gastric stump and then covering the suture line with a serous-muscular flap. A.A. Shalimov (1963) and T. Mayu (1967) proposed to cut out a 1.5–2 cm long suprapyloric segment, while maintaining the gastric mucosa, which greatly simplifies the technique and improves the results.

If it is impossible to complete the operation by applying a direct GDA, an end-to-side anastomosis is applied. The terminolateral GDA according to Gaberer-Finney-Finsterer has received the greatest distribution. In this case, the stomach stump is sutured from the side of the lesser curvature, leaving a section along the greater curvature for anastomosis with a vertically dissected anterior wall of the duodenum (Andreotu, 1961; Tomoda, 1961; and others).

Considering the advantages of the Billroth-I method as the most physiological, preventing or significantly reducing the severity of the dumping syndrome, A.A. Shalimov (1962) developed a technique for resection of the stomach, in which, in the case of leaving at least a small part of the fundus of the stomach, the stomach stump is connected without tension of the sutures with the duodenum.

Resection of the stomach according to Billroth-II is by far the most technically developed operation. This explains its availability and prevalence. Various modifications of the Billroth-II method are classified as follows (A.L. Shalimov, V.F. Saenko, 1987).

I. GEA by side-to-side type:
1) anterior anterior colonic anastomosis (Bilroth, 1985); Y-anastomosis (Schiassi, 1913);
2) anterior anterior colonic anastomosis with EEA (Braun, 1987);
3) anterior retrocolic anastomosis (Dubourg, 1998);
4) posterior anterior colonic anastomosis (Eiselberg, 1899);
5) posterior retrocolic anastomosis (Braun, 1894; Hacker, 1894).

II. Side-to-end HEA - posterior retrocolic U-anastomosis (Roux, 1893).

III. Gea by type end in horses:
1) retrocolic U-anastomosis (Moskowicr, 1908);
2) anterior-colic Y-anastomosis (Rydygier, 1904; Eoresi, 1921).

IV. GEA end-to-side:
1) anterior colonic total U-anastomosis (Klonlein, 1897);
2) anterior colonic total anastomosis with a Brown fistula (Balfour, 1927);
3) anterior colonic total antiperistaltic anastomosis (Moynihan-II, 1923);
4) anterior-colon inferior anastomosis (Hacker, 1885; Eiselsberg, 1988), Y-anastomosis (Cuneo, 1909);
5) anterior colonic total anastomosis (Reichel, 1908; Rolya, 1911);
6) Y-anastomosis (Moynihon-I, 1919);
7) retrocolic upper anastomosis (Mayo, 1919);
8) retrocolic middle anastomosis (Wilms, 1911; Waes, 1947);
9) retrocolic inferior anastomosis (Hofmeister, 1911; Finsterer, 1914);
10) retrocolic lower horizontal anastomosis (Neuber, 1927);
11) retrocolic lower U-anastomosis (A.A. Opokin, 1938; IL. Ageenko, 1953);
12) retrocolic inferior anastomosis with transverse dissection of the TC (M.A. Mazuruk, 1968; Moise and Harvey, 1925).

There are the following modifications of resection of the stomach but Billroth-II.
The most responsible and difficult stage of any modification of the Billroth-II method is the closure of the duodenal stump. Failure of the duodenal stump is one of the main causes of unfavorable outcomes of resections, ranging from 0.2% (I.K. Pipia, 1954) to 4.2% (G.I. Shumakov, 1966), depending on the nature of the ulcer.

All methods of processing the duodenal stump are divided into four groups (A.L. Shalimov, V.F. Saenko, 1987): 1) used with unchanged duodenum; 2) with a penetrating ulcer; 3) with a low-lying intractable ulcer and 4) with an internal fistula.

With unchanged duodenum, the methods of Doyen-Beer, Moynigen-Toprover, suturing using the UKL-60 apparatus, the Rusanov method, etc., are most widely used.

With the Doyen-Beer method the stump of the duodenum is stitched in the middle through both walls and tied. A purse-string suture is applied below and the stump is tightened with immersion in it. For the reliability of the seam, the duodenum is sutured to the capsule of the pancreas.

With the Moynigen-Toprover method the duodenum is stitched with a continuous catgut suture, capturing both clamps in the stitch. By pulling the threads (at first alternately) the intestinal stump is hermetically sutured. A purse-string suture is placed at the base of the suture. The catgut threads are tied and the stump is immersed in a purse-string suture, as in the Doyen-Bier method. For tightness, another purse-string serous-muscular suture is sometimes applied.

With the Rusanov method The duodenum is crossed between the clamps applied to the stomach and the remaining part of the intestinal stump, the stump of the duodenum is sutured below the sphincter with a twisting suture, and the sphincter is removed. The thread is pulled and tied. An 8-shaped purse-string suture is applied, the threads are lifted up, tightened and tied. If the length of the duodenal stump allows, then a second similar 8-shaped suture is applied.

With low-lying penetrating ulcers, the most commonly used methods are Nissen (1933), Znamensky (1947), Sapozhkov (1950), Yudin (1950), Rozanov (1950), Shalimov (1968), Krivosheev (1953).

With the Nissen method The duodenum is transversely crossed at the level of the ulcer penetrating into the pancreas. On the distal edge of the ulcer and the anterior wall of the duodenum, interrupted sutures are applied through all layers. The anterior wall of the duodenal stump is sutured with serous-muscular interrupted sutures to the proximal edge of the penetrating ulcer with the capture of the pancreatic capsule. In this case, the ulcer turns out to be tamponed by the anterior wall of the duodenal stump.

Znamensky's method is a modification of the Nissen method. With this method, the duodenum is transversely crossed over an ulcer penetrating into the pancreas. The anterior wall of the duodenum is sutured with Pribram sutures to the distal edge of the ulcer. The second row of Pribram's interrupted sutures is used to suture the anterior wall of the duodenum to the proximal edge of the penetrating ulcer. Interrupted sutures are applied to the corners of the intestinal stump through all layers of the wall. The stump of the duodenum is peritonized by applying gray-serous interrupted sutures to the capsule of the pancreas and the stump of the duodenum.

When applied the "cuff" method (according to Sapozhkov) after mobilization of the stomach, the wall of the duodenum is dissected along the edge of the ulcer penetrating into the pancreas and transversely crossed. in a sharp way the SO of the duodenum is separated from the edge for 2-3 cm. The “cuff” formed from the serous-muscular layers of the intestine is unscrewed, a purse-string suture is applied to the SO, tightened and tied. The edges of the "cuff" are sewn with interrupted sutures. The duodenal stump is sutured with serous-muscular sutures to the edges of the penetrating ulcer to the pancreatic capsule.

With the "snail" method (according to Yudin) the mobilized duodenum is crossed obliquely at the level of the ulcer, leaving most of the anterior intestinal wall. On the duodenal stump, starting from the lower corner, a continuous turning furrier suture is applied and tied at the upper corner of the stump. From the side of the superimposed seam through the entire thickness of the stump, a second seam is carried out, forming the last turn of the "snail". The suture forming the "cochlea" is tightened, the "cochlea" is immersed into the penetrating ulcer, after which the suture is passed through the proximal edge of the ulcer, where it is tied. The adjacent edge of the "cochlea" is fixed to the proximal edge of the ulcer with interrupted serous-muscular sutures.

B.S. Rozanov simplified the imposition of the "snail" by reducing the number of turns, thereby helping to reduce the possibility of circulatory disorders in it. After crossing in an oblique direction, the duodenum leaves most of the anterior wall. On the stump of the duodenum (from the lower corner) impose a continuous screwing suture and tie at the upper corner of the stump. The second floor of nodal sutures is applied to the sutured stump. The upper corner of the duodenum is pulled down and fixed with interrupted sutures of the second floor. A marginal semi-purse-string suture is applied to the upper corner of the duodenal stump, the ends of which are passed through the proximal edge of the penetrating ulcer and tied. Interrupted serous-muscular sutures are applied to the stump of the duodenum and to the "capsule" of the pancreas.

At Krivosheev's method ("submersible hood" method) after cutting out the tongue-shaped flap from the wall of the duodenum and suturing it, a “hood” is formed, which is invaginated into the intestinal lumen with a purse-string suture superimposed on its base. The second purse-string suture, capturing the edges of the ulcer, plugs the bottom of this intestine.

With the method of A.A. Shalimova after mobilization of the stomach, the wall of the duodenum is released from the crater of the ulcer (when it penetrates into the pancreas) to its lower edge. The intestine is crossed obliquely, refreshing the ulcerative edges and leaving most of the anterior wall. The wall of the duodenum is separated from the distal edge of the ulcerative crater to a depth of 0.5-0.8 cm in an acute way. covered with a serous membrane.

The scar tissue between the intestinal wall and the ulcer is captured in the suture, and the thread is again inserted into the intestinal lumen. From the inside out, the thread is passed through the serous membrane-covered wall at its separated front edge. It turns out a “semi-pouch”, when tightened and tied, the weakest part of the duodenal stump is hermetically sutured, where the edges of the SO, concave into the lumen, come into contact. Sewing up the rest of the duodenal stump, they form a “snail”, which is covered with furrier sutures.

The lateral surfaces of the "cochlea" are sutured with gray-serous sutures, and a semi-purse-string suture is applied to the top of the "cochlea", with which it is sutured to the distal edge of the ulcer crater. To create hermeticism with interrupted U-shaped sutures, the duodenal stump is sutured to the proximal edge of the ulcerative crater and to the pancreatic capsule.

For choledochoduodenal fistulas, exclusion resection is performed in combination with choledochostomy, cholecystoduodenostomy, and choledochoduodenoanastomosis (CDA). In some cases, it is considered possible to cut off the fistula with sewing it into the duodenum or TC.

In some cases, in the presence of a dense infiltrate around the duodenum, if it is impossible to securely suture its stump, then as a last resort it is considered possible (permissible) to use external duodenostomy. A catheter is inserted into the stump of the duodenum, around which the stump is sutured with fixation of the latter. The catheter is covered with an omentum and, together with the drainage, is removed through a separate incision in the right hypochondrium and fixed to the skin. Produce aspiration. On the 8-9th day, the catheter is clamped, and on the 10-12th day it is removed.

Among HEAs, the method developed by Hofmeister (1911) and Finsterer (1914) is the most widely used.

For low-lying unremovable ulcers most often used resection of the stomach to turn off. The technique for processing the duodenal stump was developed by Finsterer (1918), Wilmans (1926), B.V. Kekalo (1961) and other authors. The currently used methods of resection of the stomach to turn off provide for the complete removal of CO from the antrum of the stomach, which produces gastrin. There are various ways of resection of the stomach to turn off the ulcer.

Finsterer's method. When the stomach is mobilized, food is maintained in the upper part of the duodenum and the antrum of the stomach 2-3 cm above the pylorus. The stomach is transected 3-4 cm above the last one. The stomach stump is sutured through all layers with continuous catgut suturing or submerged or furrier suture. The second row of seams - gray-serous nodal.

Wilmans method. The antral part of the stomach at a distance of 4-5 cm from the pylorus is intercepted with a clamp. The seromuscular membrane is dissected below the clamp to CO. A clamp is applied to the CO of the stump and the seroeno-muscular layer of the stump is separated from the CO to the pylorus, where the CO is bandaged with a legature and cut off above the latter. Above the stump, the antral serous-muscular tube is sutured tightly with U-shaped sutures.

Kekalo method. It is a modification of the Wilmans technique, differs in the way the seromuscular tube is closed. After removal of CO, the seromuscular cone is dissected along both curvatures and the anterior flap is shortened by half. Above the SO stump, interrupted serous-muscular sutures are applied and covered. The second row of sutures fixes the edge of the anterior flap to the posterior one. Then the posterior flap is folded to the right, covering the second row of sutures, and sutured to the serosa of the anterior flap.

Chamberlain-Finsterer operation technique. After mobilization of the stomach according to the method described above, it is clamped with a firm clamp at the pylorus, the duodenum is transected and sutured using one of the described methods. If the UKL-60 device is used to suture the duodenal stump and the stomach, the duodenal stump is immersed in a purse-string suture, and the stomach stump is sutured with gray-serous sutures from the lesser curvature to the start of the planned anastomosis. The transverse OK is pulled up. At the level of the left edge of the spine, a loop of lean skin is found at the duodenal-lean bend. Departing 10 cm from it, through the intervascular section of the mesentery, a loop of the jejunum is taken on a thread-holder.

The mesentery of the transverse OK is dissected in an avascular place and a loop of the jejunum taken on a holder is passed through the incision. A loop of the jejunum at a distance of 4-10 cm from the duodenal-lean bend is sutured to the posterior wall of the stomach from the lesser curvature towards the greater curvature and downwards for 8 cm with gray-serous interrupted sutures leading to the lesser curvature, diverting to the greater. The bowel loop is sutured in such a way that it is slightly rotated around the long axis. The first suture from the side of the lesser curvature of the stomach passes through the middle of the distance between the free and mesenteric edges of the intestine. Subsequent sutures gradually move to the free edge of the intestine. This suture should coincide with the middle of the anastomosis. Subsequent sutures pass to the opposite side of the intestine.

The last suture is located in the middle of the intestine. At a distance of 0.5-0.8 cm from the applied gray-serous sutures, the stomach is cut off, and if the stomach was resected using the UKL-60 apparatus, the suture with tantalum staples is cut off, and the protruding CO is cut off. Departing 0.5-0.6 cm from the gray-serous sutures, the lateral wall of the jejunum is dissected for 7 cm. A continuous overlapping suture is applied to the posterior lip of the anastomosis through all layers of the common walls.

The anterior lip of the anastomosis is sutured with a catgut thread punctured from the inside to the outside after the last twisting suture of the posterior lip, a continuous dip suture of Connell, or a furrier suture. The initial and final catgut threads of the anastomosis are tied. Interrupted gray-serous sutures are applied to the anterior lip of the anastomosis, and a semi-purse-string suture is placed in the corner of the upper part of the stomach and intestine, capturing the wall of the stomach and intestine from the side of the adductor knee. In this case, the part of the stomach stump, located above the anastomosis, is invaginated inside.

This is the so-called Hofmeister suture. Finsterer (1918) instead of this suture imposed two or three interrupted sutures, capturing the anterior and posterior walls of the stomach and the intestine with two stitches, and thus covered the junction of the anastomosis suture and the lesser curvature. In addition to this, Kapeller (1919) proposed suspension sutures. At the same time, the afferent loop of the jejunum is sutured to the stump with several semi-purse-string gray-serous sutures towards the lesser curvature, creating a spur and reducing the lumen of the afferent colon.

Due to the formation of a spur and the narrowing of the afferent loop, favorable conditions are created for the movement of chyme into the afferent knee. Two or three reinforcing U-shaped sutures are additionally applied at the gastrointestinal angle of the efferent loop. The stomach stump is fixed to the edges of the incision of the mesentery of the transverse OK around the HEA, departing from the last 1-1.5 cm, with gray-serous interrupted sutures at a distance of 2 cm from one another.

With the Reichel-Polya method connect the entire lumen of the stomach with the lumen of the TC. Anastomosis is applied behind the colon on a short loop. Wilms (1911) made an anastomosis with the lower, non-sutured part of the stomach stump, similarly to the Hacker-Eiselsberg technique, but conducted the intestine behind the colon and fixed it in the window of the mesentery of the transverse OK. After the imposition of an anastomosis between the jejunum and the lower third of the stump, the latter departs to the left and upwards. With the Wilms method, this creates an inflection of the intestine with the development of stagnation in the afferent loop.

With the Kronlein method in the same way as with the Reichel-Polna method, HEA is applied to the entire lumen of the stomach, but the intestine is passed in front of the transverse OK. To improve the evacuation of the contents of the duodenum, Balfour (1927) supplemented the Kronlein technique with the imposition of a Brownian anastomosis between the afferent and efferent loops.

S.I. Spasokukotsky(1925) suggested fixing the free upper part of the gastric suture with several interrupted sutures to the remnants of the lesser omentum and to the pancreatic capsule. To reduce the throwing of the contents of the stomach stump into the afferent loop, it is sutured at the lesser curvature, and the outlet loop - at the large one.

A. V. Melnikov(1941) in addition to Reichel-Polna resection performed invagination of the lesser curvature, which is partially narrowed by HEA, applied with the entire lumen of the stomach. With this technique, the junction of the four seams becomes more secure. Moynihon (1923) proposed to impose an antiperistaltic anastomosis in front of the colon. In this case, the stomach is crossed perpendicular to the longitudinal axis and its entire lumen is anastomosed.

Roux(1909) proposed to impose a U-shaped anastomosis. The intestinal loop is transected and connected to the stomach, and the proximal part of the intestine is sutured into the side of the efferent colon. Subsequently, it was proposed various options Y-anastomosis, which differ in the way the stomach and intestines are connected.

Neuter(1927) proposed to impose a horizontally located isoperistaltic HEA along the greater curvature. Moise and Harvey (1925) suggested that when anastomosis is applied, the intestine should be transversely cut into half of its circumference.

Resection of the cardial part of the stomach. Usually performed in the presence of an ulcer in it. The main stages of resection: 1) mobilization of the greater curvature of the stomach; 2) mobilization of the lesser curvature of the stomach with ligation of the left gastric artery; 3) mobilization of the duodenum according to Kocher; 4) resection of the proximal half of the stomach; 5) the imposition of the pancreas.

During this operation, the left lobe of the liver is mobilized by dissecting the triangular ligament, and then pushing it to the right. The mobilization of the stomach begins with the intersection of the AJ in the avascular area at the level of the confluence of the right gastroepiploic artery and continues from the bottom up, from the body of the stomach to the esophagus. Clamps are placed on the LOS, and then on the gastro-splenic ligament with short gastric vessels and cross them.

In conclusion, the esophageal-phrenic ligament is dissected, and then the lesser omentum. From the gastro-pancreatic ligament, the left gastric artery and vein are isolated, ligated and crossed. Fedorov's clamps are applied to the esophagus and the proximal half of the stomach is resected. A second row of serous interrupted sutures is applied, leaving the area near the greater curvature unsutured for anastomosis. The stump of the stomach is brought under the esophagus. The pancreas is applied from the side of the greater curvature according to one of the methods that ensure, if possible, the restoration of the closing function of the cardial part of the stomach.

The lost closing function of the cardial part of the stomach is replaced by the creation of a valve mechanism in the pancreas, the use of a small-colonic insert, and plastic transformation of the stomach (G.P. Shorokh et al., 2000).

To prevent reflux, the abdominal part of the esophagus is placed in the submucosal layer of the posterior wall of the stomach stump. The wall of the stomach is sutured over the esophagus.

Intestinal plasty during resection of the stomach. In order to prevent dumping syndrome that occurs after resection of the stomach according to Billroth-II, various options for small and large intestinal plastics have been proposed, which are aimed at including the duodenum in digestion, slowing down the emptying of the stomach stump and increasing the capacity of the latter. Plastic replacement of the removed distal part of the stomach with a segment of the TC was first proposed and developed in the experiment by P.A. Kupriyanov (1924).

In clinical conditions, this operation was first performed by E.I. Zakharov (1938). Its technique is as follows. After mobilization of the stomach, the avascular part of the mesentery of the transverse OK is dissected, the initial loop of the jejunum 20 cm long is inserted into the hole and placed isoperistaltically with respect to the stomach. According to the line planned for resection, the stomach is crossed between the terminals, the part to be removed is turned to the right. The upper half of the lumen of the stomach stump from the side of the lesser curvature is sutured with a two-row suture.

The mesentery of the intestinal loop intended for insertion is dissected towards the root and mobilized so that it is possible to bring the initial part of the graft to the stomach stump without tension. The intestinal loop is cut in the transverse direction. The initial end of the formed graft is sutured, immersed in a purse-string suture and sutured to the upper part of the stomach stump. An end-to-side anastomosis is applied with double-row sutures between the unsewn part of the stomach stump and the gut. Cross the duodenum and remove part of the stomach. Then the outlet loop of the jejunum is crossed and the outlet end of the graft is sutured into the duodenal stump in an end-to-end fashion.

Intestinal patency is restored by stitching the jejunum end-to-end. The sewn loop of the jejunum is moved through the gap into the mesentery of the transverse OK into the free abdominal cavity. The mesentery of the graft on the right and left is sutured with the remnants of the LSG and fixed to the edges of the incision of the mesentery of the transverse OK. There are many options for gastrojejunoplasty after gastrectomy. In all these variants of gastrojejunoplasty, the graft is located isoperistaltically. To slow down the emptying of the gastric stump and create conditions for its portionwise emptying, an antiperistaltic small bowel plasty has been proposed.

Table of contents of the subject "Stomach Operations. Liver Operations.":

Resection, or partial removal of the stomach, perform with ulcers, extensive wounds and tumors of the organ. Among the many modifications stomach resections the most widely used operations Billroth(options I and II), and an improved version of the operation Billroth II Chamberlain - Finsterer.

At the first resection of the stomach(Billroth I) after removal of a part of the stomach, the proximal stump, which has a significant lumen, is partially sutured from the side of the lesser curvature, but the area on the side of the greater curvature, corresponding in size to the diameter of the duodenum, is left unsewn. Between the stump of the stomach and the duodenum, an end-to-end anastomosis is applied. The method is physiological, as it creates conditions for the normal movement of food, and the gastric mucosa is connected to the duodenal mucosa, as is normal. The latter circumstance excludes the formation of peptic ulcers of the anastomosis. However, it is not always possible to bring the stump of the stomach to the duodenum. The tension of the ends during the creation of the anastomosis is unacceptable, as it leads to eruption of the sutures and failure of the anastomosis.

At the second resection of the stomach(Billroth II) the duodenal and stomach stumps are sutured tightly, and then a side-to-side gastro-jejunal anastomosis is created. A loop of the jejunum is brought to the stomach stump behind the transverse colon through an opening in the mesocolon transversum.

Modification of this method Chamberlain - Finsterer consists in the fact that gastroenteroanastomosis is applied end-to-side (the end of the stomach stump is sutured with a lateral opening in the small intestine) in the isoperistaltic direction. The width of the lumen is 5-6 cm. The leading end of the intestine is sutured with 2-3 sutures to the stomach closer to the lesser curvature. The edges of the mesocolon incision are sutured to the stomach with interrupted sutures around the created anastomosis.

This technique eliminates disadvantages of the billroth method I mentioned above, but there is a unilateral exclusion from the function of the gastrointestinal tract of the duodenum, which is not physiological. In addition, food through the leading end of the intestine can enter the duodenum, where it stagnates and rots. To avoid this, Brown proposed to impose an enteroenteroanastomosis between the afferent and outlet ends. small intestine.

The same goal is pursued by Roux operation.

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Methods of surgical treatment of gastric ulcer (according to A.A. Shalimov. V.F. Saenko):
1 - resection of the stomach according to Billroth-1; 2 - resection of the stomach according to Billroth-II; 3 - resection of the cardial part of the stomach; 4 - ladder resection of the stomach (by Schoemaker, Schmieden, Pauchet); 5 - resection of the stomach according to Kelling-Madlener; 6 - resection of the stomach with a small intestine insert according to Zakharov; 7 - Nissan operation; 8 - vagotomy with pyloroplasty (according to Farris, Smith); 9 - resection of the stomach with preservation of the pylorus (according to A.A. Shalimov); 10 - vagotomy, wedge resection of the ulcer, pyloroplasty (according to Zollinger); 11 - Nissan operation; 12 - selective vagotomy, antrumectomy with preservation of the pylorus (according to A.A. Shalimov); 13 - resection of the cardial part of the stomach, selective vagotomy, gastroduodenostomy (according to A.A. Shalimov); 14 - selective proximal vagotomy, wedge resection of the ulcer, pyloroplasty (according to Holle)

Mobilization of the stomach for ulcers:
a-c — ligation of the right gastroepiploic artery and vessels of the posterior surface of the duodenum; d — LV ligation

Dimensions of the removed part of the stomach:
1 - subtotal resection; 2 - resection of 2/3 of the stomach; 3 - antrumectomy

Modifications of stomach resection according to Billroth-I (according to A.A. Shalimov, V.F. Saenko):
1 Pean, Billroth; 2—Rydygler, Billroth; 3 - Kocher; 4 - Schoemaker, Schmieden, Pauchet; 5, 6 - Haberer; 7 - Goepel, Babcocr; 8 - Finsterer; 9 - Kutscha-Usserg, Pototschnig; 10 - Ito Soyesima; 11 - Horsley; 12 - Leriche; 13 - Lundblad; 14 - Winkelbauer; 15 - Oliani; 16 - Kirschner; 17 - Mirizzi; 18 - Rechtenmacher; 19 - A. I. Lubbock; 20 - Shoemaker; 21 - Corriego and Bayer, 22 - Vician; 23 - Clemens; 24 - A.A. Shalimov; 25 - Tomoda; 26 - G.P. Zaitsev; 27 - A.A. Shalimov; 28 - Andreoiu; 29.30 - AA Shalimov; 31.32 - G.A. Khai; 33 - Orr; 34.35 - G.S. Topprover; 36 - Zacho, Amdrup

II. Side-to-end HEA - posterior retrocolic U-anastomosis (Roux, 1893).

III. Gea by type end in horses:
1) retrocolic U-anastomosis (Moskowicr, 1908);
2) anterior-colic Y-anastomosis (Rydygier, 1904; Eoresi, 1921).

Resection of the stomach according to Billroth-I. Method A.A. Shalimov:
a - suturing of the lesser curvature; b - the imposition of the first row of sutures between the stump of the stomach and duodenum; c — formation of gastroduodenal anastomosis; d — final view after surgery

Modifications of stomach resection according to Billroth-II (according to A.A. Shalimov, V.F. Saenko):
1 - Billroth; 2- Hacker; 3 - Kronlein; 4 Roux; 5.6 - Braun; 7 - Dubourg; 8 - Elselsberg; 9 - Rydygier; 10 - Moskowicz; 11 - Reichel, Polya; 12 - Cuneo; 13—Wilms; 14 - Hofmeister, Finsterer; 15 -Schiassi; 16 - Mayo; 17-Moynlnan; 18 - Goetze; 19 - Moynihan; 20 - Moise, Harvey; 21 - Balfour; 22 - Neuber; 23 - AL. Opokina, I.A. Ageenko; 24 - Maingot

With unchanged duodenum, the Doyen-Beer, Moynigen-Topraver methods, suturing with the UKL-60 apparatus, the Rusanov method, etc., are most widely used.

When applied "cuff" method (according to Sapozhkov) after mobilization of the stomach, the wall of the duodenum is dissected along the edge of the ulcer penetrating into the pancreas and transversely crossed. In a sharp way, the SD of the duodenum is separated from the edge for 2-3 cm. The “cuff” formed from the serous-muscular layers of the intestine is unscrewed, a purse-string suture is applied to the SD, tightened and tied. The edges of the "cuff" are sewn with interrupted sutures. The duodenal stump is sutured with serous-muscular sutures to the edges of the penetrating ulcer to the pancreatic capsule.

Suturing the duodenal stump according to Rusanov

Suturing the duodenal stump according to Znamensky

Sapozhkov's "cuff" method

Yudin's "snail" method

Suturing the duodenal stump according to Rozanov

Among HEAs, the method developed by Hofmeister (1911) and Finsterer (1914) is the most widely used.

Resection for exclusion according to Kekalo

The mesentery of the transverse OK is dissected in an avascular place and a loop of the jejunum taken on a holder is passed through the incision. A loop of the jejunum at a distance of 4-10 cm from the duodenal-jejunum bend is sutured to the back wall of the stomach from the lesser curvature towards the greater curvature and downwards for 8 cm with gray-serous interrupted sutures leading to the lesser curvature, diverting to the greater. The bowel loop is sutured in such a way that it is slightly rotated around the long axis. The first suture from the side of the lesser curvature of the stomach passes through the middle of the distance between the free and mesenteric edges of the intestine. Subsequent sutures gradually move to the free edge of the intestine. This suture should coincide with the middle of the anastomosis. Subsequent sutures pass to the opposite side of the intestine.

The anterior lip of the anastomosis is sutured with a catgut thread punctured from the inside to the outside after the last twisting suture of the posterior lip, a continuous dip suture of Connell, or a furrier suture. The initial and final catgut threads of the anastomosis are tied. Interrupted gray-serous sutures are applied to the anterior lip of the anastomosis, and a semi-purse-string suture is placed in the corner of the upper part of the stomach and intestines, capturing the wall of the stomach and intestines from the side of the adductor knee. In this case, the part of the stomach stump, located above the anastomosis, is invaginated inside.

Resection of the stomach according to Billroth-II:
a — passage of the TC loop through the window in the mesentery of the transverse colon; b — the beginning of the formation of the posterior lip of the anastomosis; c — final formation of the anastomosis; g - the imposition of suspension sutures on the lesser curvature. Fixation of the stomach stump in the window of the mesentery of the transverse colon

Roux(1909) proposed to impose a U-shaped anastomosis. The intestinal loop is transected and connected to the stomach, and the proximal part of the intestine is sutured into the side of the efferent colon. Subsequently, various variants of the Y-anastomosis were proposed, differing in the way the stomach and intestine are connected.

To prevent reflux, the abdominal part of the esophagus is placed in the submucosal layer of the posterior wall of the stomach stump. The wall of the stomach is sutured over the esophagus.

Options for primary gastrojejunoplasty after gastric resection (according to A.A. Shalimov, V.F. Saenko):
1 - according to Kupriyanov; 2, 6 - according to Zakharov; 3 - according to Biebl, Henley; 4 - according to Moroney; 5 - Poth; 7, 9 - according to Rozanov; 8 - according to Kurikuca and Urbanovich; 10, 12 - after Poth and Cleveland; 11 - according to Rothkov

Grigoryan R.A.

(Method of the operation)

2. Revision of the abdominal organs. The sister gives the surgeon a napkin to fix the stomach, the assistant - the liver mirror. Large tampons are introduced into the abdominal cavity through the wound mirrors, the mirrors are moved from under the tampons on top of them and the surrounding tissues are removed by the mirrors.

3. Mobilization of the stomach. The purpose of this stage of the operation is to ensure the mobility of the stomach due to the intersection of the tissues fixing it. To separate the stomach along the greater curvature, the sister gives the surgeon a pointed clamp, with which two holes are made in the gastrocolic ligament. Then she gives hemostatic clamps: one to the surgeon and the other to the assistant, who apply these clamps to the formed strand of the ligament. . (See picture)

In this sequence, everyone works until the sister has 2-4 clamps left, about which she must warn the surgeon in a timely manner. After that, ligation begins. For ligation of the part of the gastrocolic ligament remaining in the body, the sister gives strong catgut threads No. 6. As a rule, the ligament contains adipose tissue, the threads slide when tied, so they must be of sufficient length (25-30 cm). Silk ligatures No. 6 are applied to the part leaving with the stomach. After the release of all clamps, the mobilization is continued in the same order as before. When manipulating near the duodenum and pancreas, the surgeon may need thin clips of the "Mosquito" type in the amount of 2-4 pieces. and strong thin No. 2 silk ligatures 20-25 cm long.

After releasing the entire greater curvature, the sister gives a long curved clamp, with which the surgeon makes a hole in the lesser omentum and passes a gauze ribbon or rubber tube, prepared in advance by the sister, around the stomach. The surgeon applies a clamp to the ends of this tube or ribbon and passes it to the second assistant to hold the stomach in an elevated position. The surgeon completes the mobilization in the area of the duodenum. The instruments are served in the same sequence: a clamp for separating tissues, two clamps for clamping the received portion, scissors for cutting it and two ligatures of the appropriate caliber (in each specific case, the surgeon usually calls what he needs).

Before crossing the duodenum, the nurse gives the surgeon two strong clamps, which he puts on the intestine. A crushing clamp (or small Payr's press) is applied closer to the pylorus. To isolate adjacent tissues, the sister gives two medium napkins, which the surgeon and an assistant place in the circumference of the compressed duodenum, prepares a scalpel, a stick with iodine and, at the request of the surgeon, gives him a scalpel, an assistant - a stick with iodine.

The surgeon crosses the duodenum between the clamps (see figure), the assistant turns the stomach up and closes the crossed surface first with the middle one, then wraps it around the clamp with a large napkin and finally fixes it all with a long silk No. 8 ligature. The operating nurse, without reminders, must quickly submit the materials needed to cover the dirty surface. The contaminated scalpel is laid aside on a special napkin: it will be needed to cut the stomach.

After that, the surgeon proceeds to the processing of the duodenal stump. In a typical case, catgut thread No. 4 should be applied to a round intestinal needle. The surgeon applies a continuous twist suture around the clamp. After applying this seam, the clamp is removed, the thread is tightened, tied and, without cutting off its ends, a second row of interrupted silk sutures No. 4 is applied on the same needle. Before applying the last stitches of the second row, the ends of the catgut thread are cut off. Sometimes the surgeon will deem it necessary to apply a third row of sutures - also nodal silk No. 2. After suturing the lumen of the duodenum, they wash their hands, change napkins and tools.

In technically difficult cases, the duodenal stump is sutured atypically, and the nurse follows the instructions of the surgeon. In any case, she must remember that the processing of the duodenal stump is one of the crucial moments of the operation, and carefully check the strength of the suture material and the serviceability of the instruments before submitting them to the surgeon.

5. Ligation of the left gastric artery. An equally important stage is the ligation of a large vessel that approaches the lesser curvature of the stomach from above and behind - the left gastric artery. If the ligature slips or the hemostat fails, there is a strong arterial bleeding which is extremely difficult to stop. The sister should be extremely attentive at this stage, have long hemostatic clamps and an electric pump at the ready.

Having mobilized the stomach along the lesser curvature, the surgeon cuts the anterior leaf of the lesser omentum with a scalpel, passes the clamp under the control of the finger through the entire thickness of the omentum and prepares to clamp the artery. At his direction, the sister gives two strong, sharply curved clamps - many successfully use Fedorov's clamps for the renal pedicle for this purpose. The left gastric artery, along with the surrounding tissue, is transected between clamps. The sister immediately gives another clamp, which is applied to the visible central end of the crossed vessel. For dressing, a long (30-40 cm) silk ligature No. 6 is used. After tying, its ends are cut off with scissors and the artery is tied up a second time under a clamp applied to the vessel. Silk #4 is used here. The part remaining on the stomach is ligated with No. 6 silk.

6. Preparation of a loop of the small intestine for anastomosis with the stomach.

7. Cut-off of the stomach, treatment of the lesser curvature. The surgeon applies sutures-holders, for which he is fed two long silk #2 threads on a round needle. The holders are taken to the clamps. After that, Payr's pulp and two strong Kocher's clamps are applied to the resection line. Isolation is made with napkins, the stomach is cut off with a scalpel along the upper edge of the Payra pulp (see figure ) and thrown away along with the instruments and scalpel placed on it.

The stump is treated with iodine and, from the side of the lesser curvature, at a distance equal to the width of the future anastomosis, a continuous catgut thread No. 4 is sutured on a round needle. Some surgeons prefer to suture not with a curved needle on the needle holder, but with a straight needle held by the fingers. After applying a continuous catgut suture, the ends of the tied thread are cut off, the Payra pulp is removed and the second row of interrupted silk sutures No. 2 is applied. The threads of three or four sutures closest to the site of the future anastomosis can be used to fix the adductor loop of the intestine, so they are not cut off, but taken on a clamp.

8. The first moment of this stage of the operation is the imposition of interrupted sutures made of silk No. 2 on the posterior lip of the anastomosis without opening the lumen of the stomach and intestines (see figure). After applying this series of sutures, fixing the posterior wall of the stomach stump to the site of the small intestine chosen for anastomosis, the nurse gives the surgeon scissors to cut off all threads, except for the extreme ones, and a scalpel to cut off the stomach stump between the line of sutures and the clamp remaining on the stump from the side of the greater curvature .

Parallel to the lines of sutures, the lumen of the small intestine is opened. On a round intestinal needle, the sister feeds a long (40-50 cm) thread from catgut No. 2 to apply a continuous suture, first to the back and then to the anterior wall of the anastomosis. To drain the suture line, the assistant is given anatomical tweezers and small balls. After tying and cutting off the ends of the catgut thread, gloves are processed, napkins and tools are changed. The surgeon proceeds to the second row of sutures on the anterior wall of the anastomosis (threads of silk No. 2, 16-20 cm long).

The anastomosis is completed by fixing the afferent loop of the small intestine above the anastomosis to 3-4 sutures previously applied to the stomach in order to suture the lesser curvature. The sister gives the surgeon a needle holder with an unloaded needle; the threads taken on the clamp are sequentially threaded into the needle and the intestine is sutured to the stomach stump.

9. The final stage of the operation. After applying the anastomosis, the surgeon fixes the stomach stump to the edges of the window in the mesentery of the transverse colon with three or four interrupted sutures of #2 silk. The sister carefully counts the tools and materials used. All holders are cut off, the condition of the duodenal stump is checked again (in this case, abdominal mirrors may be needed), tampons are removed from the abdominal cavity, hemostasis is checked and the abdominal cavity is drained.

10. Suturing the wound of the anterior abdominal wall.

Removal of a significant part of the stomach and restoration of the integrity of the esophageal tube is called resection. During surgery, an anastomosis is formed between the duodenum and the gastric stump. Resection of the stomach is prescribed for ulcers and oncology.

general information

This operation is considered quite traumatic and complicated. According to many doctors, the removal of part of the stomach is a necessary therapeutic measure.

Today, the technique of this intervention is well developed. The operation is performed in any department of general surgery. Resection saves even those patients who were considered inoperable.

The type of surgery depends on:

Locations of the pathological focus.
Damage area.
Histological diagnosis.

Relative readings

Surgery is almost always prescribed for:

Also, gastric resection is prescribed when there is no effect in the treatment of chronic ulcers for 30-90 days.

Absolute readings

The operation is always assigned when:

stomach cancer;
decompensated pyloric stenosis;
chronic peptic ulcer stomach.

What are the contraindications

Resection of the stomach is not prescribed for:

The doctor refuses to perform the operation even if the patient is in a very serious condition.

Features of surgery

For the first time this operation was carried out at the end of the 19th century by T. Billroth. He managed to bring to life 2 main methods of gastric resection with subsequent resuscitation of the digestive processes.

Since the beginning of the 2000s, methods of surgical intervention have been known that do not affect the fundamental anatomical functionality of the organ. One of these methods is a longitudinal resection of the stomach.

During the operation, the patient lies face up. Below the corners of the shoulder blades, a roller is placed on it. Most often, the surgeon resorts to distal resection of the stomach. The operation includes the following steps:

Mobilization.
Clipping.
Formation of gastroduodenoanastomosis.
Creating an anastomosis between the stump of the stomach and intestines.

The last step in gastric resection is suturing and draining the wound.

Key Interventions

The operation can be:

Total.
Subtotal.
Extensive.
economical.

With total surgery, more than 90% of the stomach is removed. With subtotal resection, 4/5 of the volume is cut off. With an extensive operation, 2/3 of the organ is removed. With an economical surgical intervention, from 1/3 to 1/2 of the stomach is cut off.

Today Billroth 2 is being resected. This involves suturing the stump of the duodenum and stomach. An end-to-side anastomosis is then formed with the small intestine.

Surgery for peptic ulcer

With this pathology, the surgeon resects 2/3-3/4 of the body of the organ. The pyloric and antral sections are removed. This contributes to the relief of relapses.

Today, as an alternative to this method, organ-preserving operations are often used. The surgeon often resorts to excision of the vagotomy that regulates the production of hydrochloric acid. This method is relevant for patients with high acidity.

Surgery for oncology

When diagnosed cancer tumor, the doctor resorts to volumetric resection. During the operation, parts of the lesser and greater omentum are removed. This helps to reduce the risk of relapse.

Cancer cells can be found in lymph nodes adjacent to the stomach. Therefore, in order to avoid metastasis, the doctor removes them too.

If a malignant neoplasm grows into neighboring organs, the surgeon resorts to a combined resection. The stomach is removed with part of some organs of the gastrointestinal tract.

What are the possible complications

In oncology, only part of the organ is often removed. The surgeon connects the stump to the jejunum. This contributes to the emergence of difficulties with the digestion of food. Chemically and mechanically, it is not processed. The result of this is dumping syndrome.

Features of the dumping syndrome

Within half an hour, unpleasant consequences of eating can appear. The duration of discomfort varies from 30 to 120 minutes.

The occurrence of dumping syndrome is due to the penetration of a large amount of unprepared food into the jejunum. The person's heart rate increases. Sweating increases, the patient complains of excruciating dizziness. Sometimes there is a loss of consciousness. Dumping syndrome is not life-threatening, but its quality is significantly reduced.

Other complications

More serious complications include anastomosis. It is an inflammation that develops at the junction of tissues during surgery. Against the background of this complication, edema appears at the resection site. This contributes to the complete obstruction of the gastrointestinal tract.

After about 3-7 days, the inflammatory process stops, the patency is restored. Symptoms of anastomosis disappear. In 8-12% of cases, this pathology becomes chronic. This refers to disability factors.

The main complication of sleeve resection of the stomach is a dysfunction of the lower esophageal sphincter. Against this background, the contents of the organ are thrown into the esophagus. This leads to the development of reflux esophagitis. The most specific sign of this complication is excruciating heartburn.

After a longitudinal resection, dyspeptic symptoms appear. Unpleasant symptoms occur after eating and finally disappear after about 4-6 months.

Sometimes there are complications of peptic ulcer disease. There are peptic ulcers. Most often this occurs after surgery according to Billroth-1.

After Billroth-2 surgery, afferent loop syndrome occurs. It is based on violations of the functional and anatomical relations of the digestive tract. An excruciating pain syndrome appears. It is localized with right side hypochondria. The patient often vomits bile, which relieves his condition a little.

Other common complications include:

recurrence of oncology;
a sharp decrease in weight;
development of iron deficiency anemia.

Against the background of insufficient production of the Castle factor in the stomach, B-12 deficiency anemia develops. This condition is less common.

Resection of the stomach affects the digestive system. Therefore, during the postoperative period, the patient undertakes to adhere to the diet prescribed by the doctor. Compliance with all the rules of nutrition contributes to the rapid restoration of all functions of the body.

The diet after surgery involves the exclusion of carbohydrates. The list of prohibited foods primarily includes potatoes and pastries. The diet of the patient should contain a large amount of fat and protein.

With very strong discomfort, it is allowed to take no more than two tablespoons of novocaine solution before meals. Food should be chewed as carefully as possible. The postoperative diet is divided into several stages. The first day after surgery, the patient is prescribed therapeutic fasting. Then the food is introduced to him with the help of droppers. In the next step, food is introduced through a probe.

third day

For 3-4 days, the patient is allowed to drink non-acid compotes, fruit drinks. They can be alternated with decoctions and green tea. The patient is allowed to eat mucous soups. On the second it is allowed to serve fish puree. Meat can be eaten, preference should be given to beef, rabbit or turkey.

Low-fat cottage cheese is allowed. You can also eat other easily digestible foods.

Fifth day

On the 5-6th day after resection, you can eat steam omelettes. Vegetables are allowed to bake and grind thoroughly. Porridges cooked on water bring great benefits to the body.

If the food intake is adequately tolerated by the body, the patient's menu can be diversified with foods with a high protein content.

What to eat in a week

7-10 days after gastric resection, the patient is prescribed a sparing diet. Fish and meat products with a high protein content are allowed. It is recommended to give preference to:

Non-sour fruits.
Groats.
Vegetables.
Grain.

The amount of light carbohydrates should be limited. It is desirable to reduce the amount of sugar, muffins and confectionery.

What to exclude from the diet

After surgery, the patient must refuse fatty and fried foods. You can not eat canned food, smoked products. It is not recommended to use marinades, pickles. This applies not only to store, but also to home products.

Alcohol intake is prohibited. You should also refrain from sugary carbonated drinks. It is important to exclude the use of refractory fats. First of all, this applies to lamb. It is necessary to abandon products that contain dyes and food additives.

Finally

Adaptation of the body to new conditions takes from six months to 8 months. After this time, the weight gradually returns to normal. To facilitate this period, in addition to diet, the patient should pay attention to physical activity. It is advisable to run more, swim, walk in the fresh air. But overexertion is not recommended.

After that, the person returns to normal life. Disability is usually not assigned. Many people remain functional even without part of the stomach.