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HOW I DO IT / HOW I DID IT SURGICAL PROCEDURES |
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GASTRECTOMY--SUBTOTAL
OPERATIVE TECHNIQUE § Patient lying supine IN supine position § Asepsis, antisepsis § Sterile drapes placed § High midline incision done § Intraoperative findings noted § Penrose drain inserted as the right hand passed through an avascular portion of the gastrohepatic ligament above the pylorus through the avascular space along the greater curvature—use as traction § Stomach retracted upward § Left hand inserted behind the stomach § Spreading the fingers along the gastrocolic ligament to identify individual vessels § Epiploic vessels clamp, cut and ligated § Left gastroepiploic artery and short gastric arteries identified clamp, cut and ligated § At mid point between the esophagogastric junction and the pylorus insert a large hemostat § Left gastric vessels idenfied clamp, cut and doubly ligated § Two allen clamps applied for a distance of 3-4 cm at an angle of 900 to the greater curvature (the amount of stomach in the allen’s clamp must approximate the size of anastomosis) § Another two Allen’s clamp applied at a cephalad angle to close the remaining stomach § Close by layer § First, use 3-0 PG with straight intestinal needle, pass the needle back and forth from the lesser curvature to the base of the Allen’s creating a basting suture § Trim excess gastric tissue then remove the Allen’s clamp § Return same suture to its origin as a continuous interlocking suture § Invert mucosa using silk 4-0 lembert sutures DUODENAL DISSECTION § Right gastric artery identify, clamp, cut and ligated § Apply anterior traction to exposed the posterior portion of the duodenum and the anterior surface of the pancreas § Small vessels identify, clamp, cut and ligated § 1.5 cm of the posterior duodenum freed from the pancreas § Apply an Allen clamp immediately distal to the pylorus § Cut the duodenum distal to the clamp § Check the distal end of the specimen to make sure no antral mucosa left behind § Insert a finger into the duodenal stump and palpate for the ampulla of Vater CLOSURE OF DUODENAL STUMP § Put a half purse string at the right lateral margin of the duodenum § Continue suturing up to midline using Connell suture of 4-0 PG § Initiate another suture at the left margin continue upto middle of the stump § Tie the two strands § By using interrupted 4-0 silk Lembert suture done as second layer
BILLROTH II (Gastrojejunal Anastomosis) Schoemaker-Hoffmeister Type § Get the jejunum 12-15 cm from the Ligament of Treitz § Major portion of the transverse colon and omentum be brought to the right side fro antecolonic anastomosis § Attach jejunum to gastric pouch with interrupted 4-0 silk seromuscular Lembert sutures about 5 mm apart § The first and last stitch left long serves as stay suture § Remove excess gastric tissue from the Allen’s clamp § Incision along the antimesenteric aspect of the jejunum done; shorter than the diameter of the gastric opening § Allen clamps removed § Bleeding points over the jejunum and gastric edges controlled by electrocautery § Mucosa of the posterior layer approximated by using 3-0 PG continuous running sutures from midline towards the periphery(full-thickness) § Anterior mucosal layer closed by Connell continuous running suture using the same 3-0 PG double arm from lateral to midpoint § As second layer do a interrupted 4-0 silk seromuscular Lembert sutures § At the “angle of sorrow” do a crown suture
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