Surgery of the Stomach

Chapter 68 Surgery of the Stomach

Ronald M. Bright

Retrieval of foreign bodies is the most common reason for surgery on the stomach. Surgery of the pylorus is most often indicated for some forms of gastric outflow obstruction. The most common sign related to surgical disease of the stomach is emesis. The stomach has an excellent blood supply and heals rapidly (10–14 days).

ANATOMY

Stomach

• The stomach is a musculoglandular organ capable of undergoing a great amount of distention.
• The stomach is a C-shaped, partially coiled, bulging tube.
• The stomach lies in a transverse plane. The larger part of the stomach (fundus) lies to the left of the midline.
• The esophageal entrance and duodenal exit are dorsal—the former lying to the left of the midline, the latter to the right.
• In the fasting dog, the stomach does not extend caudally beyond the costal arch and is rarely palpable.
• The stomach is divided into four regions: cardia, fundus, body (corpus), and pylorus.
• The stomach has four tunics: mucosa, submucosa, muscularis, and serosa. The submucosa and mucosa layers are easily separated from the overlying seromuscular layers.
• The blood supply to the distal stomach is from a branch of the hepatic artery, giving rise to the right gastric and gastroepiploic arteries.
• The splenic artery gives rise to the left gastroepiploic artery, which supplies the greater curvature.
• The left gastric artery supplies blood to the lesser curvature of the stomach and the distal esophagus.
• Veins are satellites to the arterial branches. Most blood drains from the left side of the stomach via the gastrosplenic vein and from the right side via the gastroduodenal vein. These veins ultimately drain into the portal vein.
• The major innervation is parasympathetic from the vagi and sympathetic from the celiac plexus.

Omentum

• The greater omentum extends caudally from the greater curvature of the stomach to the urinary bladder, forming a double-layered cover of the small intestine.
• A splenic portion of the omentum attaches to the greater curvature to the spleen and a smaller portion attaches to the pancreas.
• The lesser omentum extends from the lesser curvature of the stomach and attaches to the diaphragm, liver, and duodenum.
• The hepatoduodenal and hepatogastric ligaments are loose attachments between the respective components.

Pylorus

• The pylorus is composed of two segments, the antrum and the canal. The antrum is a narrow funnel-shaped chamber leading to the narrowed pyloric canal.
• The inner circular muscle layer is thickened in the pyloric region and functions as a powerful sphincter. An outer longitudinal muscle layer is also present.
• The pylorus has two major functions—to control the emptying of solid food once it becomes reduced to an appropriate size and to prevent excessive duodenogastric reflux.

GASTROTOMY

Preoperative Considerations

Key Point

Serious water and electrolyte abnormalities often accompany conditions that affect the stomach and require gastrotomy. Initiate fluid and electrolyte resuscitation before gastrotomy.

• The most common indication for gastrotomy is to retrieve foreign bodies.
• Endoscopic retrieval of gastric foreign bodies is preferred. When this approach fails, a gastrotomy is indicated.

Surgical Procedure

Objectives

• Access to and exposure of intraluminal contents.
• Collection of biopsy specimens.
• Avoidance of contamination of the peritoneal cavity.

Equipment

• General surgical pack
• Babcock forceps (optional)
• Abdominal self-retaining Balfour retractors
• Laparotomy pads

Technique

1. Make a cranial ventral midline abdominal approach, with the skin incision extending from the xiphoid to the umbilicus.
2. Exteriorize the stomach and isolate it from the other abdominal organs using moistened laparotomy pads.
3. Place two Babcock forceps or two stay sutures 10 to 15 cm apart on a hypovascular area of the stomach, halfway between the lesser and greater curvature.
4. Make a stab incision into the lumen with a #11 blade.
5. Use suction to remove liquids from the stomach.
6. Extend the stab incision with scissors.
7. Do a visual and tactile exploration of the entire stomach.

Closure

1. The first layer is a continuous inverting horizontal mattress (Connell) suture pattern involving only the submucosal and mucosal layers. A simple continuous suture pattern can be substituted. Synthetic 3-0 absorbable suture material is preferred. Use of chromic gut suture material is discouraged, because it breaks down too rapidly when coming in contact with the lumen of the stomach.
2. Close the second layer with a vertical (Lembert) or horizontal (Cushing) continuous inverting pattern.
3. If the gastrotomy closure is likely to incorporate diseased or devitalized tissue, suture a section of vascularized omentum or a serosal patch, employing a loop of jejunum over the wound for additional reinforcement.

Postoperative Care and Complications

Short Term

• Give no food for 24 hours; water is allowed ad libitum.
• Monitor the patient for leakage, especially if the gastrotomy closure involves diseased tissue (neoplasia).
• Emesis may be noted once or twice following gastric surgery and treatment is usually not required.
• Systemic antacids are indicated if ulcers or severe gastritis is observed during surgery (see Chapter 67).

Prognosis

• Good to excellent if the reason for surgery is related to a foreign body.

PARTIAL GASTRECTOMY RELATED TO GASTRIC DILATATION-VOLVULUS

Preoperative Considerations

• Gastrectomy in patients with dilatation-volvulus is a high-risk procedure.
• Initially, attempt to stabilize metabolic abnormalities but rapidly proceed with surgery because gastric rupture may occur.

Surgical Procedure

Objectives

• Resect non-viable gastric tissue and restore gastric continuity.
• Use a stapling technique, if possible, to expedite this high-risk procedure.

Equipment

• General pack
• LDS stapler (U.S. Surgical, Norwalk, CT) (optional)
• TA stapler (U.S. Surgical, Norwalk, CT) (optional)
• Abdominal self-retaining retractor
• Laparotomy pads
• Non-crushing straight Doyen intestinal clamps

Technique

1. The approach to the stomach is similar to that for a gastrotomy.
2. Non-viable tissue is recognized by its lack of bleeding on cut surfaces, bluish-black or greenish discoloration, and severe thinning of the stomach wall on palpation.
3. Ligate and divide the appropriate short gastric vessels. LDS stapler apparatus is optimal. This procedure may not be necessary because these vessels are frequently torn.
4. After placement of stay sutures, apply intestinal forceps 2 lateral to the junction of viable and non-viable tissue. The tips of the forceps meet at an approximately 45-degree angle.
5. Use a #10 scalpel blade to cut along the intestinal clamps, leaving a 1-cm margin of healthy tissue outside the intestinal clamps.

Key Point

Do not rely on the appearance of the mucosa alone to determine if full-thickness stomach wall necrosis has occurred.

Alternate Method of Resection

1. Place a TA stapler parallel to the junction of viable and non-viable tissue, leaving a 1-cm width of normal tissue.
2. After the stapler is engaged and the staples are placed in the tissue, cut the stomach wall next to the blade of the stapler and remove the necrotic tissue.

Closure

1. Without a stapler, the closure is similar to that for a gastrotomy incision.
2. With a stapler, perform the closure before cutting the non-viable tissue away from the TA stapler’s blade.
3. Close the abdomen routinely. If gastric rupture has occurred, the abdomen may be left partially open as in treating peritonitis (see Chapter 76).

Postoperative Care and Complications

Short Term

• Refer to the discussion of gastric dilatation-volvulus surgery for postoperative management of metabolic problems.
• Delay feeding for 24 hours.
• Monitor very closely for signs of gastric leakage (fever, vomiting, pneumoperitoneum, peritonitis), especially during the first 96 hours postoperatively.

Key Point

When a partial gastrectomy is performed during surgical therapy for gastric dilatation-volvulus complex, the mortality rate ranges from 30% to 60%.

PARTIAL GASTRECTOMY (DISTAL STOMACH)

Preoperative Considerations

Key Point

Attempts to define the extent and nature of the disease (benign polyp, malignancy, fungal disease, chronic gastric ulcer) by radiography and endoscopic biopsy are extremely important when planning surgical therapy.

Many animals with gastric neoplasia are old and debilitated and are at greater risk during surgery than others.

Surgical Procedure—Partial Gastrectomy and Gastroduodenostomy (Billroth I)

Objectives

• To remove diseased tissue that is benign or, if malignant, is limited to the antrum and/or body of the stomach.
• To correct failed pyloroplasty procedures.
• To maintain an adequate outflow lumen.

Equipment

• Same as that for partial gastrectomy associated with the gastric dilatation-volvulus complex
• GIA stapler (U.S. Surgical, Norwalk, CT)—recommended if a stapler technique is used
• Large straight intestinal clamps

Technique

1. Place the dog in dorsal recumbency with surgical preparation similar to that for gastrotomy.
2. Stapling devices (e.g., the GIA stapler) can be substituted for more traditional suturing techniques.
3. If the diseased tissue is limited to the pylorus, a modification of a Billroth I (von Haberer) technique can be done (Fig. 68-1).
4. If a partial gastrectomy is performed to control ulcer disease, resect the entire antrum.
5. More extensive resection of the pylorus or distal stomach can be done and reconstructed with the original Billroth I (Shoemaker) procedure (see Fig. 68-1).
6. After the line of resection is determined, ligate and divide the blood vessels supplying the lesser and greater curvature and attached omentum.
7. Mobilize the pylorus after incising the gastrohepatic ligament. Avoid cutting the common bile duct and hepatic arteries.
8. Isolate the area to be resected from the abdominal cavity with moistened laparotomy sponges.
9. Place large, straight non-crushing intestinal forceps above and below the proposed lines of incision.
image

Figure 68-1 Partial gastrectomy with a Billroth I (gastroduodenostomy) repair. Above, Lesser curvature of the stomach is closed until lumen disparity is corrected. Below, Closure with single interrupted sutures.

Closure

1. Use a single-layer interrupted appositional suture pattern to appose the stomach and duodenum. With unequal lumen sizes, first close the lesser curvature side of the stomach until the lumen disparity is corrected (see Fig. 68-1, top).
2. Appose the back (far) wall first, placing the knots into the lumen. Synthetic 3-0 absorbable suture (e.g., polydioxanone [PDS]) is recommended.
3. Then appose the near wall.

Surgical Procedure—Partial Gastrectomy and Gastrojejunostomy (Billroth II)

Objectives

• Resect a significant portion of the diseased stomach and all or part of the duodenum.

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Aug 27, 2016 | Posted by in SMALL ANIMAL | Comments Off on Surgery of the Stomach

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