Subtotal gastrectomy with horizontal gastrojejunostomy in the anterior half of the colon

Most of the stomach and duodenal ulcers can be cured by non-surgical treatment combined with traditional Chinese and Western medicine. Only when the following various conditions occur, surgery should be considered: 1. A large number of ulcers or repeated bleeding. 2. Scarring pyloric obstruction. 3. Acute perforation, not suitable for non-surgical treatment, and generally can tolerate gastrectomy. 4. Stomach ulcers and malignant changes. 5. Refractory ulcers, invalid treatment by internal medicine. Treatment of diseases: gastric teratoma, benign tumors of the stomach Indication Most of the stomach and duodenal ulcers can be cured by non-surgical treatment combined with traditional Chinese and Western medicine. Surgical treatment is only considered when the following conditions occur: 1. A large number of ulcers or repeated bleeding. 2. Scarring pyloric obstruction. 3. Acute perforation, not suitable for non-surgical treatment, and generally can tolerate gastrectomy. 4. Stomach ulcers and malignant changes. 5. Refractory ulcers, invalid treatment by internal medicine. Preoperative preparation 1. When there is no pyloric obstruction, change to liquid diet 1 day before surgery; when there is mild pyloric obstruction, change to liquid diet 2 to 3 days before surgery, fasting after noon on the 1st day before surgery; severe pyloric obstruction, Fasting should be done 2 to 3 days before surgery, but a small amount of water can be consumed. 2. Severe pyloric obstruction, the contents of the stomach have retention, 2 to 3 days before surgery, the stomach tube is placed every night to absorb the gastric retention, and the stomach should be washed with warm saline on the evening of 1st. 3. Patients with frequent pyloric obstruction and vomiting should check the binding of potassium, sodium, chlorine and carbon dioxide. If it is not normal, it should be corrected first. 4. Patients who are fasting before surgery should be supplied with heat by intravenous infusion to correct dehydration and electrolyte imbalance. 5. Enema with soapy water on the evening of the 1st day of surgery. 6. In the morning of the operation, the stomach tube is removed, and the gastric juice is taken out and left in the stomach. Surgical procedure 1. Position: supine position. 2. Incision: the median incision in the upper abdomen, the left superior transabdominal rectus muscle or the left median midline incision, about 12 to 14 cm long. 3. Exploring the abdominal cavity: dissection of the abdominal wall, exploration and confirmation of diagnosis, suitable for partial resection of the stomach, the stomach can be separated. 4. Separate the stomach from the big bend: the assistant lifts the stomach, and selects the avascular region on the gastric collateral ligament at the lower edge of the vascular arch of the middle part of the stomach. Here, there is generally no adhesion between the gastric collateral ligament and the transverse mesenteric membrane. Use a hemostat to separate the gastric ligament into a hole, extend into the finger to lift the gastric collateral ligament, and then along the large curved side of the lower retina of the vascular arch, to the left side of the ligament between the two clamps of the hemostat Cut and ligature with silk. After separation to the junction of the left and right arteries of the gastric retina (such as semi-gastrectomy, separation can be done), and then continue to separate close to the stomach wall until the left segment of the left gastric artery is cut into 2 to 3 branches. The cut blood vessels are double-ligated with a silk thread. In the opposite direction, it is separated to the right along the big curve of the stomach. On the right side of the lower edge of the big curve, the gastric collateral ligament and the posterior wall of the stomach and the transverse mesenteric and pancreatic head capsules are often close to or even stuck together. It should not be cut as a large piece of clamp on the left side. Appetizing the anterior layer of the colonic ligament, extending into the finger or using a small gauze ball, separating the anterior layer of the gastric colon ligament from the posterior layer. Care is taken to identify and protect the middle cerebral artery and push it back together with the posterior layer. In the vicinity of the pylorus, the proximal segment of the right ventricle of the gastric retina should be separated from the stomach wall, cut and ligated (the proximal stump should be double ligated or sutured). Then, continue to adhere to the lower edge of the stomach and duodenum, 1 cm below the pylorus, and cut off small branches from the superior pancreaticoduodenal artery. 5. Separation of gastric small curvature: In the small curvature of the stomach, choose the small omentum (liver and stomach ligament) avascular zone, first wear a hole, separate the right gastric artery from the upper edge of the pylorus, cut and ligature. Continue to separate the small omentum to the left along the small bend, and cut the left gastric artery distally in the second branch of the left gastric artery, and perform ligation and suture. 6. Cutting off the duodenum: The separation of the large and small curved omentum must be more than 1 cm away from the pylorus. Two duodenal forceps were placed side by side in the near and far side of the pylorus, and gauze pads were placed behind the pylorus to avoid contamination. Cut the duodenum between the two forceps. The duodenal stump is temporarily not treated, covered with gauze, and anastomosis is performed after the stomach is cut. The duodenum can also be cut off after ligation of the right gastric artery, the duodenal stump is protected with gauze, and the gastric stump is turned up, the left gastric artery is separated, and the left branch is ligated after the second branch. Add stitching. 7. Excision of the corpus: a stomach forceps (payr) is placed 2 cm away from the tangential line of the stomach, and then the corpus callosum is placed horizontally with a duodenal forceps on the large curved side of the proximal end of the gastric forceps. Half of the width was cut parallel to the forceps at 0.5 cm distal to the duodenal forceps to cut the large curved side of the corpus. In order to completely remove the sinus and small curved side tongue-like protrusion, the small curved side incision should be oblique to the cardia. In the second branch of the left gastric artery, a large curved forceps is placed far away, and the distal end of the forceps is cut off to remove the distal segment of the stomach. 8. Close the duodenal stump: After cutting the duodenum, first treat the duodenal stump. After suturing the hemostasis with No. 0 gut for continuous suturing, remove the hemostatic forceps, tighten the ends of the suture, and do not knot and cut for the time being. Continue to use the ends of the same suture to make half of the purse in the upper and lower corners. Embedding the two corners, and then making a continuous varus suture in the middle of the sarcolemma. The two ends are knotted after meeting in the middle. Finally, a row of sarcoplasmic muscle layers were sutured intermittently. 9. Select the upper part of the jejunum and close the mesenteric space: the first assistant lifts the transverse colon and stretches the mesangium. The operator slides the transverse mesenteric to the root with the right and second fingers, and finds the left side of the first lumbar vertebrae. The duodenal suspensory ligament below, which is confirmed to be the beginning of the jejunum, selects a jejunum downward, and marks a traction line at two points from the duodenal suspensory ligament 15 and 25 cm. For each gastrointestinal anastomosis. If colonic jejunal anastomosis is performed, the mesenteric mesenteric and the selected spare jejunal mesenteric suture should be closed with a 1-0 silk suture 3 to 5 needles to prevent the passage of the small intestine after surgery to form internal hemorrhoids. When the initial segment of the jejunum is normal, it is necessary to use the proximal end of the jejunum to anastomosed the large curvature of the stomach to close the mesenteric space. 10. Stitching the posterior wall of the anastomosis: the pre-selected jejunal segment is lifted around the front of the transverse colon, close to the stomach stump, and ready for anastomosis. Roll up the stomach stump straight tongs upwards, expose the posterior wall, and suture the wall of the stomach at 0.5cm proximal to the jejunum wall for a row of pulp muscle layers, and remove the traction line as a marker. 11. Incision of the stomach wall and the jejunal wall: 0.5 cm on both sides of the suture of the muscle layer (seal of the posterior wall), the muscle wall of the posterior wall of the stomach is first cut, and the proximal end of the submucosal blood vessel of the stomach wall is sutured. . Each needle is placed next to the blood vessel, penetrates from the submucosal layer, crosses the blood vessel, and penetrates at the edge of the proximal muscle layer of the stomach. This way through a little muscle layer tissue, you can avoid excessive valgus of the mucosa after cutting off the clamped stump. The submucosal blood vessels of the anterior wall of the stomach were sutured by the same method. Then, the jejunal muscle layer was cut, and the submucosal blood vessels were sutured on both sides of the margin. Finally, the clamped stomach wall margin is cut off, and the jejunal mucosa is cut open to absorb the contents of the stomach and jejunum. 12. Complete the gastrojejunostomy: start with the 0 or 1 gut from the small corner of the stomach, enter the needle from the intestine, pass through the whole layer of the posterior wall of the stomach and intestine, and then return to the stomach cavity. Needle to the ileum intestine cavity, knotted in the cavity fixed, the thread is not cut temporarily. The same intestine was used for full-layer suture stitching on the posterior wall of the gastric jejunal anastomosis. The margin was 0.5cm, the needle spacing was 0.8cm, and it was directly to the side of the large curvature of the stomach, and the large curved side angle of the stomach was inverted. Then, the large curved side angle is wound around the front wall of the anastomosis, and the whole layer of the front wall is continuously inverted and sutured to the small curved side angle, and knotted with the retained gut line. Finally, the suture was sutured in the anterior wall with a silk thread. At this point, the subtotal gastroenterostomy before the colon is completed. Check the anastomosis is smooth, no bleeding and residuals in the abdominal cavity, suture the abdominal wall incision layer by layer.

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