Gastric resection technique. Gastric resection according to Billroth-II modified by Hoffmeister-Finsterer The most physiological method of gastric resection is considered

Gastric resection is an operation that results in the removal of a significant part of the organ with subsequent restoration of the digestive system. Today, there are many methods of resection. This article will discuss resection using the Balfour method. In addition, important topics such as prescriptions and methods of rehabilitation after surgery will be covered.

Gastric resection according to Balfour, a diagram of which is available in the Great Medical Encyclopedia, including in 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 conducting and efferent intestinal loops. This made it possible to break the vicious circle that existed before 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. Before the invention of the Balfour method, most patients died within a few years of surgery.

Instructions for Balfour resection

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

Stage 1 gastric cancer is the most easily removable tumor. Balfour resection allows you to eliminate all tumor tissue in order to eliminate metastases. Most often, the ways in which stomach cancer spreads are as follows:

• • 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.

From a surgical point of view, Balfour resection can help in the first three cases, while approximately 75% of the stomach is removed.

Balfour resection for ulcers has two main goals:

• • firstly, the painful, dangerous area – the ulcer – is removed;
  • secondly, it prevents relapse, which can rapidly develop on the healthy wall of the gastrointestinal tract.

It should be noted that modern medicine has 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 percentage of relapses is minimal.

The essence of the operation

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

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

Rehabilitation

The rehabilitation process after resection is quite complex. Its timing is primarily determined by the individual characteristics of the body and the complete success of the surgical intervention.

The first seven days after resection using the Balfour method, the patient is prescribed bed rest. In the absence of side effects, after a week, the patient can sit down for a short time. On day 10, you are allowed to rise to your feet.

Throughout the entire rehabilitation period, the patient must wear a special elastic bandage. Any physical activity is excluded. To speed up the rehabilitation process, the patient can be sent to a health resort.

Diet after surgery

The key to successful recovery is following a strict diet. The first days after surgery, food intake is completely prohibited. Nutrients are administered parenterally, through installed catheters or through an IV, intravenously.

The most important condition of 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, warm. Additionally, to speed up the healing of stitches, you can consume milk, sea buckthorn and olive oil.

The diet prescribed after Balfour resection excludes the consumption of a number of foods, which primarily include:

• • salt;
  • alcohol-containing 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 thoroughly so as not to create additional stress 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 your life.

Possible complications

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

Like any other operation, Balfour gastrectomy 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;
  • deficiency of substances necessary for full life;
  • inability to take the amount of food necessary for full work.

The most common complication is dumping syndrome. Its reason is the accelerated evacuation of the food bolus into the intestines, which entails a decrease in blood glucose levels. It can be either early or late. The first occurs approximately 15 minutes after eating. The second one is in 2-4 hours.

Its symptoms are:

• • severe weakness;
  • cutting pain;
  • flatulence;
  • diarrhea.

It should be noted that dumping syndrome can be treated conservatively, but therapy must be comprehensive. Its basis is a diet that involves split meals, 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 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 cancer and ulcers, but also for obesity. Of course, resection for obesity is an extreme, undesirable method.

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

Gastrectomy from an oncological perspective- 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 damage to the distal and middle, middle and upper third of the stomach;
3. total damage to 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 gastroepiploic, splenic, left gastric and pancreatic lymph nodes;
6.tumors of the upper third of the stomach with metastases in the right gastric, gastroepiploic, pyloric, pancreatic and upper pancreaticoduodenal lymph nodes;
7. undifferentiated tumors.
Indications for combined access: stomach cancer with spread to the esophagus. Laparotomy and lateral thoracotomy on the left, performed in the sixth intercostal space, or the Garlock approach are used.

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

Gastrectomy. The operation is usually performed from the superomedian transperitoneal approach. Maximum operating convenience is achieved by correct positioning of the patient. The axis of the table raised during surgery 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 a combined approach, the patient is placed on the right side for a left anterolateral thoracotomy. The right arm is extended forward, and the left arm 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, slightly tilted back. The operating table roller should be positioned opposite the point of intersection of the midmuscular line with the line of the intended incision along the intercostal space.

When a stomach tumor spreads to the lower thoracic esophagus, the operation begins with either an upper-median laparotomy or an oblique laparotomy, and after revision, the issue of a combined approach is decided using the Garlock approach - supplementing the oblique laparotomy with a thoracotomy in the sixth intercostal space on the left with 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.

Initial stage of the operation- inspection of the abdominal organs in order to determine the spread of the tumor process and the possibility of performing a gastrectomy.

Mobilization of the greater omentum and its separation from the transverse colon begins with dissection of the gastrocolic ligament approximately in the region of the midcolon. The stomach is grabbed and brought into the wound cranially, the transverse colon is taken to the opposite side. The surgeon takes the greater omentum with his left hand and brings it into the wound. The gastrocolic ligament is stretched and divided layer by layer in the avascular zone. The greater omentum is mobilized to the hepatic angle of the colon. By dissecting 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 transected. With the intersection of the gastrocolic and pyloric-pancreatic ligaments, the block of lymph nodes (pyloric, right gastroepiploic, upper pancreaticoduodenal) goes to the part of the stomach that is being removed.

Then the left half of the greater omentum is mobilized to the gastrosplenic ligament and the short gastric vessels passing through it. When mobilizing the stomach along the greater curvature, the short gastric vessels are ligated directly near the spleen in the gastrosplenic ligament. Mobilization of the stomach along the greater curvature is completed by dissecting the diaphragmatic-gastric ligament to the left of the esophagus, which fixes the fundus of the stomach to the diaphragm.

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

Next stage- ligation of the left gastric artery and vein. All lymph nodes with fiber are mobilized and moved towards 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. It is stupidly circled with a finger and a rubber holder is passed around it. Both vagus nerves are divided with scissors.

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

Using the UO-40 device, the duodenum is sutured at a distance of 2 cm from the pylorus, and the stomach is cut off from it. The esophagus is sutured over the cardia using the UO-40 device and crossed. The stomach with omentums and lymph nodes is removed.

Thus, in one block with the stomach, lesser and greater omentums 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.

Second stage of the operation- formation of esophagojejunostomy.

There are several dozen methods for restoring the continuity of the digestive tract after removal of the stomach, but all of them are 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, and therefore has not become widespread.
End-to-side esophagojejunostomy with Brown interintestinal anastomosis is the most common method of reconstruction after gastrectomy. The operation was first performed in this form by SchlofTer in 1917.
End-to-side esophagojejunostomy with Roux-en-Y interintestinal anastomosis began to be used in 1947 at the suggestion of Orr. With this method of reconstruction, there is less possibility of regurgitation of digestive juices into the esophagus.
Main types of esophagojejunostomy. Depending on the position given to the intestine in relation to the diameter of the esophagus, horizontal and vertical esophagojejunostomoses are distinguished:

Horizontal end-to-side esophagojejunostomy.
Vertical end-to-side esophagojejunostomy using an adductor loop to cover the anastomotic sutures (Hilarowitz, 1931).
Vertical esophagojejunostomy “end to side” with fixation of the esophagus located along it to the intestine with special sutures (K.P. Sapozhkov, 1946).
Invagination esophageal-small intestinal anastomosis according to Davydov: 2 seromuscular sutures are placed at a distance of 30-40 cm from the ligament of Treitz at the mesenteric edge of the jejunum. 3 seromuscular sutures are placed on the antimesenteric edge and the posterior wall of the esophagus. The intestinal lumen is opened. An internal row of anastomotic sutures is formed. Two side-by-side seromuscular sutures invaginate the inner row of sutures into the efferent section of the intestine. The last suture completes the intussusception, covering the anterior wall of the anastomosis with an adducting loop.

Subtotal distal gastrectomy. In oncological practice, subtotal distal gastrectomy using the Billroth II method is the most common operation. Inspection and initial mobilization of the stomach are performed in the same way as during gastrectomy performed through the abdominal approach.

Mobilization and cutting of the greater omentum from the transverse colon is carried out 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 part of the duodenum at a distance of 1-1.5 cm below the pylorus is mobilized so that all the tissue with the lymph nodes moves to the part of the stomach that is being removed. The right gastric artery is ligated and divided directly at its origin from the common hepatic artery. The lesser omentum is mobilized to the esophagus, ligated and the esophageal branch of the left gastric artery is divided.

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 where it originates from the celiac trunk.

Next, the line for gastric resection is outlined. According to 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, the oncologically correct removal of the entire small and large omentum (to the level of the short gastric arteries) with the lymph nodes and vessels located here.

Using the UO-40 device, the duodenum is sutured at a distance of 1.5-2 cm from the pylorus, cut off, and additionally sutured according to Rusanov. Along the gastric resection line, the stomach is sutured from the lesser and greater curvature using UO-40 devices, the preparation is cut off and removed. Additional seromuscular sutures are placed on the lesser curvature of the stomach up to the intended anastomosis area.

Next stage- formation of an anastomosis between the remaining part of the stomach and a loop of jejunum passed through a window in the mesentery of the colon. It is positioned isoperistaltically and sutured to the posterior wall of the gastric stump with the first row of seromuscular sutures, then a continuous suture is applied to the posterior and anterior semicircles of the anastomosis and a second row of seromuscular sutures is applied to the anterior wall of the anastomosis. The gastric 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.

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

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

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

Currently, various modifications of this method are used:

1. Reichel-Poly method (1908, 1911) - the duodenal stump is sutured, but the stomach stump is not sutured and is anastomosed across the entire width of the lumen with the initial loop of the jejunum passed through the hole in the mesentery of the colon.
2. Roux method (1893) - the duodenal stump is sutured tightly, and the gastric stump is anastomosed with the efferent end of the transected jejunum, the adducting end of which is Y-shaped connected by an anastomosis with the efferent end of the intestine 15-20 cm below the gastrointestinal anastomosis.
3. Balfour method (1917) - gastrointestinal anastomosis is performed on a long loop of jejunum, adding an interintestinal anastomosis according to Brown.
4. The method of Hofmeister-Finsterer (1896), or Spasokukotsky-Finsterer (1914), or Spasokukotsky-Wilms, is now used most often. The duodenum is closed tightly. The gastric stump is closed only partially from the lesser curvature and anastomosed with a short loop of jejunum passed through an opening in the mesentery of the transverse colon. The part of the intestine leading to the anastomosis is sutured to the gastric stump from the lesser curvature. This strengthens the least durable place of the anastomosis sutures - at their junction with the sutures of the gastric stump and, in addition, creates a kind of valve that prevents the flow of stomach contents into the duodenum.

Operation modified according to Billroth-I. Many years of experience of surgeons have shown that:

1. resection using the Billroth-I method is more dangerous;
2. for cancer it is less radical;
3. the condition of patients who underwent this intervention is no better than after resection performed using 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 least risk and always allows the operation to be performed most radically.

Requirements for anastomosis: The most common is gastric resection with anastomosis by suturing the stomach stump into the side of the jejunum using the Billroth-II method.

The anastomosis must 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 should flow freely into the stomach through the afferent loop. The most complete response to these requirements is a retrocolic anastomosis on a short loop of the jejunum with the formation of a kind of valve by suturing the wall of the afferent loop above the anastomosis to the lesser curvature of the stomach (according to Hoffmeister-Finsterer).

This anastomosis design has a number of advantages:

1.duodenal contents enter the stomach through the afferent loop;
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 of the duodenal stump are more favorable than with anastomosis on a long loop).

Technique of gastric resections. An upper-middle incision is used to open the abdominal cavity and examine the stomach and duodenum. Sometimes, to detect an ulcer, the omental bursa is opened, dissecting the gastrocolic ligament (GC), and even a gastrostomy is performed, followed by suturing the stomach wound. The volume of the resected part of the stomach is determined, after which the stomach and transverse OC are removed into the wound. The avascular area with a stretched VJS is dissected. The ZhOS are taken in parts onto the clamps and crossed. In the corner between the head of the pancreas and the duodenum, the gastroepiploic artery is found and, together with the gastrointestinal tract, it is crossed between two clamps and ligated.

Under the control of a finger passed through the lesser omentum, the right gastric artery is grasped with clamps, crossed and ligated. The lesser omentum is dissected to the cardiac part of the stomach. It should be noted that vessels often pass here from the left gastric artery to the liver. It is considered necessary to check whether there is a hepatic artery among them. Ligation of the main trunk of the hepatic artery that abnormally arises from the left gastric artery (LVA) threatens liver necrosis. An incision is made in the serous membrane at the lesser curvature of the stomach above the division site of the left ventricle. A clamp is inserted into the incision along the wall of the stomach towards the finger held to the posterior surface of the stomach at the lesser curvature.

Clamps are applied to the LVAD separated from the stomach, crossed and ligated. The boundaries of gastric resection are finally determined and, if it is necessary to expand them, the greater curvature is additionally mobilized. The duodenum is grabbed with a clamp closer to the pylorus, the second clamp is placed on the stomach at the pylorus. Between the clamps, the stomach is cut off 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 the BDS is located on its posteromedial wall, at a distance of 2-8 cm from the pylorus. 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.

Gastric resection according to Billroth-I. In this operation, the gastric stump is directly connected to the duodenum. The indication for gastric resection according to Billroth-I is the patient's predisposition to dumping syndrome. There are a large number of modifications of this method. The most common is the classical Billroth I method. After mobilization of the stomach, clamps (soft) are applied to its removed part or it is stitched using the UKL-60 device, 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 remaining portion of the gastric stump is sutured with a continuous catgut overlapping or immersed suture, furrier suture or Connell suture. A second row of interrupted gray-serous sutures is applied.

When using UKL-60, the tantalum suture is peritoneized with gray-serous sutures, except for the area at the greater curvature, which, after excision of the suture with tantalum staples, is anastomosed with the duodenum. The unsutured part of the stump of the stomach and duodenum is brought together. At a distance of 0.5 cm from the edge of the incision, interrupted gray-serous sutures are placed on the posterior lips. The posterior lip of the anastomosis is sutured with a continuous catgut overlapping suture, and the anterior lip with a submerged Connell suture. Gray-serous sutures are placed on the anterior lip of the anastomosis, strengthening 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 omental bursa, eliminating the entrance to the latter.

To avoid divergence of the anastomotic sutures at the junction, the gastric stump is rotated 90° and then connected to the duodenum or TC (Kirschner, 1932). Thus, the suture of the newly formed lesser curvature is located on the posterior lip of the anastomosis.

For 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 section of the greater curvature convenient for creating a tube, a GEA 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 preserving the pylorus during Billroth-I gastrectomy. At the same time, they completely remove the mucosa from the area of ​​the stomach preserved above the pylorus, connecting the mucous membrane of the duodenum to the mucosa of the stomach stump and then covering the suture line with a seromuscular flap. A.A. Shalimov (1963) and T. Mayu (1967) proposed cutting out the suprapyloric segment 1.5-2 cm long, while preserving 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 performed. The most widespread is the terminolateral GDA according to Haberer-Finney-Finsterer. In this case, the gastric stump is sutured from the side of the lesser curvature, leaving a section along the greater curvature for anastomosis with the vertically dissected anterior wall of the duodenum (Andreotu, 1961; Tomoda, 1961; etc.).

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

Gastric resection according to Billroth-II to date is the most technically developed operation. This explains its accessibility and prevalence. Various modifications of the Billroth-II method are classified as follows (A.L. Shalimov, V.F. Saenko, 1987).

I. Side-to-side GEA:
1) anterior anterior colic anastomosis (Bilroth, 1985); Y-anastomosis (Schiassi, 1913);
2) anterior anterior colic 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 GEA - posterior retrocolic U-anastomosis (Roux, 1893).

III. GEA type end in horses:
1) retrocolic U-anastomosis (Moskovicr, 1908);
2) anterior colonic U-anastomosis (Rydygier, 1904; Eoresi, 1921).

IV. End-to-side GEA:
1) anterior colonic total Y-anastomosis (Klonlein, 1897);
2) anterior colonic total anastomosis with Brown's anastomosis (Balfour, 1927);
3) anterior colonic total antiperistaltic anastomosis (Moynihan-II, 1923);
4) anterior-colic lower anastomosis (Hacker, 1885; Eiselsberg, 1988), U-anastomosis (Cuneo, 1909);
5) anterior-colic total anastomosis (Reichel, 1908; Rolya, 1911);
6) U-anastomosis (Moynihon-I, 1919);
7) retrocolic superior anastomosis (Mayo, 1919);
8) retrocolic middle anastomosis (Wilms, 1911; Waes, 1947);
9) retrocolic lower 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 lower anastomosis with transverse dissection of the TC (M.A. Mazuruk, 1968; Moise and Harvey, 1925).

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

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

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

With the Doyen-Beer method the duodenal stump is stitched in the middle through both walls and tied. A purse-string suture is placed below and tightened, immersing the stump into it. To ensure reliability of the suture, the duodenum is sutured to the pancreas capsule.

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

With Rusanov's method The duodenum is crossed between clamps placed on the stomach and the remaining part of the intestinal stump, the duodenal stump is sutured below the sphincter with a wrapping suture, and the sphincter is removed. The thread is tightened 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.

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

With the Nissen method The duodenum is transected at the level of the ulcer penetrating into the pancreas. Interrupted sutures are placed on the distal edge of the ulcer and the anterior wall of the duodenum 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, capturing the pancreatic capsule. In this case, the ulcer turns out to be plugged by the anterior wall of the duodenal stump.

Znamensky method is a modification of the Nissen method. With this method, the duodenum is cut transversely over an ulcer that penetrates 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 interrupted Pribram sutures is used to suture the anterior wall of the duodenum to the proximal edge of the penetrating ulcer. Interrupted sutures are placed at the corners of the intestinal stump through all layers of the wall. The duodenal stump is peritonized by placing gray-serous interrupted sutures on the pancreatic capsule and the duodenal stump.

When using “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 transected. The duodenal mucous membrane is sharply 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 placed on the duodenal mucosa, tightened and tied. The edges of the “cuff” are sewn together with interrupted sutures. The duodenal stump is sutured with seromuscular 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 wall of the intestine. A continuous screw-in furrier's suture is applied to the duodenal stump, starting from the lower corner, and tied at the upper corner of the stump. From the side of the applied suture, a second suture is passed through the entire thickness of the stump, forming the last turn of the “snail”. The suture forming the “snail” is tightened, the “snail” is immersed in 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 “snail” is fixed to the proximal edge of the ulcer with interrupted seromuscular sutures.

B.S. Rozanov simplified the application of the “snail” by reducing the number of turns, thereby helping to reduce the possibility of circulatory disorders in it. After crossing the duodenum in an oblique direction, most of the anterior wall is left. A continuous screw-in furrier's suture is applied to the duodenal stump (from the lower corner) and tied at the upper corner of the stump. A second floor of interrupted sutures is applied to the sutured stump. The upper corner of the WPC is pulled down and fixed with interrupted seams 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 seromuscular sutures are placed on the duodenal stump and on the “capsule” of the pancreas.

At Krivosheev method ("submersible hood" method) after cutting out a 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 placed at its base. The bottom of the intestine is tamponed with a second purse-string suture, capturing the edges of the ulcer.

With the method of A.A. Shalimova after mobilization of the stomach, the wall of the duodenum is freed from the crater of the ulcer (when it penetrates into the pancreas) to its lower edge. The intestine is cut obliquely, refreshing the ulcerative edges and leaving most of the anterior wall. The wall of the duodenum is sharply separated from the distal edge of the ulcer crater to a depth of 0.5-0.8 cm. A kettut thread is passed from the outside inward through the wall covered with the serous membrane at the separated posterior edge of the duodenum, and from the inside out the thread is passed through the part of the intestine separated from the ulcer, not covered with a serous membrane.

The suture captures the scar tissue between the intestinal wall and the ulcer, and the thread is again passed into the intestinal lumen. From the inside to the outside, a thread is passed through the wall covered with the serous membrane at its separated anterior edge. It turns out to be a “half-pouch”, when tightened and tied, the weakest part of the duodenal stump is hermetically sutured, where the edges of the duodenum, concave into the lumen, touch. By suturing the rest of the duodenal stump, a “snail” is formed, which is covered with furrier’s sutures.

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

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

In some cases, in the presence of a dense infiltrate around the duodenum, if it is impossible to reliably sutured its stump, then as a last resort it is considered possible (acceptable) to use external duodenostomy. A catheter is inserted into the duodenal stump, 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. Perform aspiration. On the 8-9th day the catheter is clamped, and on the 10-12th day it is removed.

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

For low-lying, unremovable ulcers gastric resection is most often used to switch off. The method for processing the duodenal stump was developed by Finsterer (1918), Wilmans (1926), B.V. Kekalo (1961) and other authors. Currently used gastric resection methods for exclusion provide for the complete removal of CO from the antral part of the stomach, which produces gastrin. There are various methods of gastric resection to eliminate the ulcer.

Finsterer's method. When mobilizing the stomach, nutrition is maintained in the upper part of the duodenum and the antrum of the stomach 2-3 cm above the pylorus. The stomach is crossed 3-4 cm above the latter. The gastric stump is sutured through all layers using continuous catgut suturing or a submersible or furrier's suture. The second row of sutures is gray-serous interrupted.

Wilmans method. The antrum 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 the CO. A clamp is applied to the SB of the stump and the sereno-muscular layer of the stump is separated from the SB to the pylorus, where the SB is bandaged with a bandage and cut off above the latter. The antral seromuscular tube is tightly sutured over the stump with U-shaped sutures.

Kekalo method. It is a modification of the Wilmans technique, differing in the method of suturing the seromuscular tube. After removing the CO, the seromuscular cone is dissected along both curvatures and the anterior flap is shortened by half. Interrupted seromuscular sutures are placed above the stump of the joint and covered. The second row of sutures secures the edge of the anterior flap to the posterior one. Then the posterior flap is turned to the right, covering the second row of sutures, and sutured to the serosa of the anterior flap.

Technique of the Hoffmeister-Finsterer operation. After mobilizing the stomach using the method described above, it is clamped with a hard clamp at the pylorus, the duodenum is transected and sutured using one of the described methods. If the UKL-60 device is used for suturing the duodenal stump and stomach, the duodenal stump is immersed in a purse-string suture, and the gastric stump is sutured with gray-serous sutures from the lesser curvature to the beginning of the intended anastomosis. The transverse OK is pulled up. At the level of the left edge of the spine, a loop of the jejunum is found at the duodenojejunal flexure. At a distance of 10 cm from it, through the intervascular section of the mesentery, a loop of the jejunum is taken onto a thread holder.

The mesentery of the transverse OK is dissected in an avascular place and a loop of jejunum taken on a holder is passed through the incision. A loop of jejunum at a distance of 4-10 cm from the duodenum-jejunal flexure 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 and abducting to the greater. The intestinal loop is sutured so that it is slightly rotated around its long axis. The first suture from 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 go 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 device, the suture with tantalum staples is cut off, and the bulging SB is cut off. At a distance of 0.5-0.6 cm from the gray-serous sutures, the side 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 out after the last wrapping suture of the posterior lip, with a continuous immersed Connell suture or a furrier's suture. The initial and final catgut threads of the anastomosis are tied. Interrupted gray-serous sutures are placed on the anterior lip of the anastomosis, and in the corner of the upper part of the stomach and intestines - a semi-purse-string suture, grasping the wall of the stomach and intestines from the side of the adductor knee. In this case, part of the gastric stump located above the anastomosis is invaginated inward.

This is the so-called Hofmeister penetration seam. Finsterer (1918) instead of this suture placed 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 anastomotic suture and the lesser curvature. In addition to this, Kapeller (1919) proposed the use of suspension sutures. In this case, 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 intestine.

Due to the formation of a spur and narrowing of the afferent loop, favorable conditions are created for the advancement of chyme into the abductor limb. At the gastrointestinal corner of the outlet loop, two or three reinforcing U-shaped sutures are additionally applied. The stump of the stomach is fixed to the edges of the transverse mesentery incision around the GEA, at a distance of 1-1.5 cm from the last, 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 colon. The anastomosis is performed retrocolic on a short loop. Wilms (1911) performed an anastomosis with the lower, unsutured part of the gastric stump similar to the Hacker-Eiselsberg technique, but passed the intestine retrocolic and fixed it in the window of the mesentery of the transverse OK. After applying an anastomosis between the jejunum and the lower third of the stump, the latter moves to the left and upward. With the Wilms method, this creates a bend in 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, GEA is applied to the entire lumen of the stomach, but the intestine is passed in front of the transverse OC. To improve the evacuation of duodenal contents, Balfour (1927) supplemented the Kronlein technique by applying a Brownian anastomosis between the afferent and efferent loops.

S.I. Spasokukotsky(1925) proposed 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 gastric stump into the afferent loop, it is sutured at the lesser curvature, and the efferent loop at the greater curvature.

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

Roux(1909) proposed to apply a Y-shaped anastomosis. The loop of intestine is divided 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 U-anastomosis were proposed, differing in the method of connecting the stomach and intestines.

Neuter(1927) proposed to apply a horizontally located isoperistaltic GEA along the greater curvature. Moise and Harvey (1925) proposed transversely dissecting the intestine to half its circumference when performing an anastomosis.

Resection of the cardiac part of the stomach. Usually performed when there is an ulcer. 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) application of PVA.

In this operation, the left lobe of the liver is mobilized by cutting the triangular ligament and then pushed to the right. Mobilization of the stomach begins with the intersection of the GJ 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 applied to the VS, and then to the gastrosplenic ligament with short gastric vessels and crossed.

Finally, the esophageal-diaphragmatic ligament is dissected, and then the lesser omentum. The left gastric artery and vein are isolated from the gastropancreatic ligament, ligated and transected. Fedorov 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 stomach stump is placed under the esophagus. The pancreas is applied from the side of the greater curvature according to one of the methods that ensures, if possible, restoration of the closure function of the cardiac part of the stomach.

The lost closing function of the cardiac part of the stomach is replaced by the creation of a valve mechanism in the pancreas, the use of a small-colic 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 gastric stump. The stomach wall is sutured over the esophagus.

Intestinal plastic surgery during gastric resection. In order to prevent dumping syndrome that occurs after gastric resection according to Billroth II, various options for small and large intestinal plastic surgery have been proposed, which are aimed at including the duodenum in digestion, slowing down the emptying of the gastric 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 experimentally developed by P.A. Kupriyanov (1924).

In a clinical setting, 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 transverse mesentery is dissected, an initial loop of jejunum 20 cm long is inserted into the hole and placed isoperistaltically in relation to the stomach. Along the line marked for resection, the stomach is crossed between the terminals, and the part to be removed is turned to the right. The upper half of the lumen of the gastric stump from the lesser curvature side is sutured with a double-row suture.

The mesentery of the intestinal loop intended for insertion is dissected towards the root and mobilized so that the initial part of the graft can be brought to the gastric stump without tension. The intestinal loop is dissected in the transverse direction. The initial end of the graft being formed is sutured, immersed in a purse-string suture and sutured to the upper part of the gastric stump. An end-to-side anastomosis is performed between the unsutured part of the stomach stump and the supplied intestine with double-row sutures. The duodenum is divided and part of the stomach is removed. Then the efferent loop of the jejunum is crossed and the efferent end of the graft is sutured into the duodenal stump in an end-to-end fashion.

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

The abdominal cavity is opened with an upper midline incision. The first stage is mobilization of the stomach by freeing the part to be removed from the ligaments (lig.gastrocolicum, lig.hepatogastricum) with simultaneous ligation of the vessels. The stomach and large intestine are brought into the wound, the assistant separates them so as to stretch the lig.gastrocolicum. The ligament is dissected in an avascular place and mobilization of the removed part of the stomach begins along the greater curvature (Fig. 12-14).

Rice. 12. Scheme of gastric resection for switching off

a - area of ​​stomach resection, b - final type of resection. (From: Voilvnko V.N., Medelyan A.I., Omelchenko V.M. Atlas of operations on the abdominal wall and abdominal organs. - M., 1965.)

Rice. 13. Scheme of classical gastrectomy with Billroth type II anastomosis

Rice. 14. Scheme of gastric resection according to Hofmeister-Finsterer

(From: Mayat V.S., Pantsyrev Yu.M. Gastric resection and gastrectomy. - M., 1975.)

To do this, through the hole formed in the ligament, fingers push back or peel off the mesocolon transversum located behind it, so as not to damage the a. Colica media. Lig.gastrocolicum is sequentially dissected between Kocher forceps, applying ligatures to the crossed areas. In this way, the greater curvature of the stomach is isolated along the required length: to the left - to the intended boundaries of resection (as a rule, to the low-vascular field of the greater curvature at the junction of the right and left gastroepiploic arteries), to the right - to the initial part of the duodenum.

To mobilize the lesser curvature, the index finger is passed along the posterior wall of the stomach to the lesser omentum and, having bluntly made a hole in it at the level of the antrum of the stomach, the stomach is pulled to the left and down. The avascular part of the lesser omentum (lig.hepatogastricum) is dissected; put on a. gastrica dextra, and then on a.gastrica sinistra two strong ligatures and the vessels are crossed between them. The application of a ligature to the central segment of the left gastric artery is the most crucial moment in the process of mobilization of the stomach (a double ligature is applied) and can be performed at the following stages of the operation.

The second stage is cutting off the stomach along the right border of the resection and processing the duodenal stump. Before cutting off the right end of the stomach, the initial loop of the jejunum is found and through a hole made in the mesocolon, it is brought to the upper floor, into the bursa omentalis, where it is held by means of an elastic sphincter applied to it or a thick silk thread passed through its mesentery.

A Payr's splint is applied to the mobilized upper part of the duodenum; a gauze pad is placed under the duodenum; After the operation, everything is fenced off with large gauze napkins. Immediately above the pylorus, a hard crushing sponge is applied to the removed part of the stomach. Then the duodenum is crossed between the sphincter below the pylorus and the incision is lubricated with iodine. The gastric stump is covered with a large gauze napkin and tilted to the left. They begin to close the duodenal stump.

For this purpose, a Moynigen suture or a through enveloping suture is used, which is immersed with a seromuscular-purse-string suture. To close the stump, the UKL-60 device is also used, and then the hardware suture line is immersed with interrupted serous-muscular ones. The suture of the duodenal stump is further strengthened by fixing the peritoneum and fascia (capsule) of the adjacent area of ​​the pancreas to it with 3-4 catgut sutures.

The third stage is the removal of the stomach and the application of a gastrointestinal anastomosis. The pulp placed on the right (pyloric) end of the stomach is temporarily removed, the contents of the stomach are removed with an electric suction, the pulp is applied again and the stump is wrapped in gauze. Accordingly, two Kocher clamps are applied in a direction transverse to the axis of the stomach along the line of the left border of the stomach. The clamps are applied from the lesser and greater curvature towards each other: the upper (from the lesser curvature) clamp captures 2/3 of the diameter of the stomach, the lower (from the greater curvature) - 1/3 of it. Distally (to the right) and parallel to these clamps, a Payra crushing press is applied to the removed part of the stomach over its entire width.

After careful isolation with gauze compresses, the removed part of the stomach is retracted to the left and upward and cut off with a scalpel along the crushing sphincter. Then they begin suturing the upper part of the gastric stump using a clamp applied from the lesser curvature. Suturing is carried out with a continuous through catgut suture through all layers around the clamp, the suture starts below from the point of contact of the clamp noses and leads upward, to the lesser curvature. Having removed the upper clamp, tighten the seam by its ends at the moment when it reaches the slight curvature. Then, using the same wraparound stitch, sew in the opposite direction to the greater curvature to the nose of the remaining lower clamp; here the end of this seam is connected to its beginning. You can also close the lumen with a hemostatic suture: sew with a continuous suture in the same direction to the lesser curvature, but all the time under a clamp, piercing the walls sequentially from the front and back surfaces, with each subsequent injection made behind the last puncture; having reached the lesser curvature, the clamp is removed; then with the same thread, already with a twisted seam, they return back to the beginning of the seam; The ends are tied without cutting them.

After finishing the deep through suture, they begin to apply seromuscular interrupted silk sutures. These sutures are used to gradually lower the angle formed by the edge of the gastric stump and the lesser curvature, while also suturing the area of ​​the left gastric artery that was deseroticized during ligation. The upper part of the lumen of the stomach can also be sutured using the UKZH-7 device (gastric stump suturing device) with tantalum staples. The device closes the stump lumen with a double-row suture; this speeds up the operation and ensures tightness.

Now the removed loop of jejunum is sutured to the posterior wall of the stomach stump in the area of ​​the lower, unsutured part with a series of serous-muscular sutures. First, the adducting and efferent ends of the loop are connected; the adducting end, taken at a distance of 8-10 cm from the flexura duodenojejunalis, is fixed with several seromuscular sutures to the lower part of the sutured stump, and then the abducting end of the loop is fixed with an interrupted suture at the greater curvature; thus, the adducting end of the loop will be facing upward, towards the lesser curvature of the stump, and the abductor end - downwards, towards the greater curvature. After this, a series of interrupted seromuscular sutures connect the walls of the intestinal loop facing each other and the posterior wall of the gastric stump. They must be connected so that the suture line on the intestine does not run strictly longitudinally along the axis of the intestine, but in a spiral. The threads of all seromuscular sutures are cut off, with the exception of the first and last. The surgical field is covered with gauze compresses and the jejunum is opened parallel to the line of sutures; then the lower section of the stump, captured by the Kocher clamp, is cut off and the contents of the stomach are removed with an electric suction. Pulling up the stomach and the intestine sutured to it by the left threads of the first and last sutures, they begin to apply a continuous catgut suture to the posterior lips of the anastomosis through all layers. Having finished suturing the posterior lips of the anastomosis, the suture is continued on the anterior lips of the anastomosis using a Schmiden screw-in suture. The anastomosis formed occupies the lower third of the lumen of the stomach. The isolating drapes are changed and a series of seromuscular interrupted silk sutures are placed to close the internal suture line of the anastomosis. The afferent loop of the small intestine is pulled to the previously sutured area of ​​the stump of the newly formed lesser curvature and fixed with 2-3 seromuscular sutures. Check the patency (width) of the anastomosis. The greater omentum with the transverse colon is folded upward, the anastomosis is brought out through the window in the mesocolon into the lower floor of the abdominal cavity and fixed with interrupted sutures to the edges of this opening. After toileting the abdominal cavity, the abdominal wall incision is closed in layers.

A) Indications for Billroth II gastrectomy (gastrojejunostomy):
- Relative indications: if the creation of gastroduodenostomy is impossible for anatomical reasons.
- Alternative operations: Billroth I, so-called combined resection, gastrectomy.

b) Preoperative preparation:
- Preoperative studies: transabdominal and endoscopic ultrasound, endoscopy with biopsy, radiography of the upper gastrointestinal tract, computed tomography.
- Patient preparation: nasogastric tube.

V) Specific risks, informed consent of the patient:
- Damage, splenectomy (0.5% of cases)
- Bleeding (2% of cases)
- Homologous blood transfusion
- Anastomotic failure (gastroenterostomy - in 1%, duodenal stump - in 2% of cases)
- Impaired passage of food (5-15% of cases; dumping syndrome, afferent loop syndrome)
- Damage to the common bile duct
- Damage to the middle colic artery
- Anastomotic ulcer
- Gastric stump cancer
- Pancreatitis (less than 2% of cases)

G) Anesthesia. General anesthesia (intubation).

d) Patient position. Lying on your back.

e) Access. Upper midline laparotomy.

and) Stages of gastric resection according to Billroth II:
- Gastrojejunostomy according to Billroth II: sutures of the posterior wall
- Gastrojejunostomy according to Billroth II: sutures of the anterior wall
- Billroth II: enteroenteroanastomosis according to Brown
- Billroth II with enteroenteroanastomosis according to Brown

h) Anatomical features, serious risks, surgical techniques:
- The fundus of the stomach and spleen (short gastric vessels), greater curvature and transverse colon/mesentery, distal lesser curvature and hepatoduodenal ligament, as well as the posterior wall of the stomach and pancreas are located close to each other.
- There are several important vascular connections: between the left gastric artery and the right gastric artery from the hepatic artery - along the lesser curvature; between the left gastroepiploic artery from the splenic artery and the right gastroepiploic artery from the gastroduodenal artery - along the greater curvature; between the short gastric arteries from the splenic artery - in the area of ​​the fundus of the stomach. An important venous trunk along the lesser curvature (gastric coronary vein) drains into the portal vein.
- Warning: rupture of blood vessels.
- In approximately 15% of cases, an additional left hepatic artery is found in the lesser omentum, coming from the left gastric artery.

And) Measures for specific complications:
- Bile duct injury: Place a primary suture with absorbable material (4-0 PDS) after insertion of the T-tube.
- Splenic injury: Attempt to preserve the spleen by electro/sapphire/argon plasma coagulation hemostasis and application of hemostatic material.
- Rupture of the duodenal stump: if repeated secure sutures are not possible, either provide a Roux-en-Y jejunal vent, or create a controlled duodenal fistula by inserting a thick, soft catheter (e.g., urinary) into the duodenal stump, covering the omentum with a strand, and removing the catheter through the abdominal wall.

To) Postoperative care after gastrectomy according to Billroth 2:
- Medical care: remove nasogastric tube on days 3-4, remove drains on days 5-7.
- Resumption of nutrition: small sips of clean liquid from 4-5 days, solid food - after the first independent stool.
- Bowel function: enema from the 2nd day, oral laxatives - from the 7th day.
- Activation: immediately.
- Physiotherapy: breathing exercises.
- Period of incapacity: 2-4 weeks.

1. Gastrojejunostomy according to Billroth II: sutures of the posterior wall. Restoring the continuity of the gastrointestinal tract after gastrectomy can be achieved by Billroth II gastrojejunostomy. To do this, the stomach is anastomosed with a loop of jejunum, which is carried anteriorly or retrocolicly. The anastomosis begins from the posterior wall, with separate sutures (3-0 PGA). The width of the anastomosis should be approximately twice the width of the duodenal lumen.

2. Gastrojejunostomy according to Billroth II: sutures of the anterior wall. Once the posterior suture line is completed, the anterior wall is created with separate sutures. Particular attention should be paid to the junction of the gastrointestinal anastomosis and the resected lesser curvature. Both corner flaps of the stomach and the edge of the anastomosis are closed with U-shaped sutures. Otherwise, anastomotic failure may occur in the so-called “sorrow angle.”

3. Billroth II: enteroenteroanastomosis according to Brown. With a long jejunal loop, an enteroenteroanastomosis according to Brown is required to connect the afferent and efferent loops. The anastomosis can be performed with a manual or hardware suture.

4. Billroth II with enteroenteroanastomosis according to Brown. Restoring the continuity of the gastrointestinal tract after gastrectomy using Billroth II anastomosis involves closing the duodenal stump and applying an enteroenteroanastomosis according to Brown in an anterior colon modification.

5. Video of gastric resection technique according to Billroth 2 .

2. Revision of the abdominal organs. The sister hands the surgeon a napkin to fix the stomach, and the assistant a liver speculum. Large tampons are inserted into the abdominal cavity using the installed mirrors, the mirrors are moved from under the tampons on top of them and the surrounding tissues are removed with the mirrors.

3. Mobilization of the stomach. The purpose of this stage of the operation is to ensure mobility of the stomach by intersecting the tissues that fix it. To separate the stomach along the greater curvature, the nurse gives the surgeon a pointed clamp, which makes two holes in the gastrocolic ligament. She then hands hemostatic clamps: one to the surgeon and one to the assistant, who apply these clamps to the resulting strand of ligament . (See picture)

In this sequence, everyone works until the nurse has 2-4 clamps left, which she must promptly warn the surgeon about. After this, ligation begins. To ligate the part of the gastrocolic ligament remaining in the body, the nurse applies 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 that leaves along with the stomach. After releasing all the clamps, mobilization continues in the same order as before. When manipulating near the duodenum and pancreas, the surgeon may need thin Mosquito clamps 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 nurse gives a long curved clamp, with which the surgeon makes a hole in the lesser omentum and passes a gauze strip or rubber tube, prepared in advance by the sister, around the stomach. The surgeon places a clamp on 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 mobilization in the duodenum area. The instruments are supplied in the same sequence: a clamp for separating tissue, two clamps for clamping the resulting portion, scissors for crossing it and two ligatures of the appropriate caliber (in each specific case, the surgeon usually names what he needs).

4. Transection of the duodenum performed in the same sequence as for resection according to. After wrapping the crossed surface of the stomach with napkins and retracting it to the upper corner of the wound, the surgeon does not suture the duodenal stump, but, leaving a clamp on it, also closes it with a napkin in order to return to this area after removing the resected part of the stomach and prepare the stump for anastomosis with the rest of the stomach.

5. Ligation of the left gastric artery. An equally important step 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 malfunctions, severe arterial bleeding occurs, which is extremely difficult to stop. The nurse should be extremely attentive at this stage, have long hemostatic clamps and an electric suction ready.

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

6. Cutting off the stomach, treating the lesser curvature. The surgeon applies stay sutures, for which he is given two long silk No. 2 threads on a round needle. The holders are held on clamps. After this, a Payr's press and two strong Kocher clamps are applied to the resection line. Isolation is carried out with napkins, the stomach is cut off with a scalpel along the upper edge of Payra's pulp (see figure ) and thrown away along with the instruments and scalpel placed on it.

The stump is treated with iodine and a suture is placed on a round needle with a continuous catgut thread No. 4 at a distance equal to the width of the future anastomosis at a distance equal to the width of the future anastomosis. Some surgeons prefer to sew not with a curved needle on a needle holder, but with a straight needle, holding it with their fingers. After applying a continuous catgut suture, the ends of the tied thread are cut off, the Payra pulp is removed and a 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 afferent loop of the intestine, so they are not cut off, but taken with a clamp.

7. Application of gastroduodenoanastomosis. Under a clamp applied to the duodenum, the surgeon uses a scalpel to incise the seromuscular membrane, stitches the vessels present here with thin catgut threads on an intestinal needle, ties the threads and cuts them off with scissors. The stomach stump is prepared in a similar way. After this, the surgeon sews together the posterior walls of the stomach and duodenum with interrupted sutures using silk No. 2; the ends of the threads are trimmed.

The edges of the duodenal stump and the gastric stump are cut off with scissors under clamps. At this stage of the operation, an electric suction may be needed. The nurse places a long catgut thread, No. 4, on an intestinal needle to apply a continuous suture first to the posterior and then to the anterior walls of the anastomosis. The assistant uses anatomical tweezers to dry the suture line with small balls. After tying, the ends of the thread are cut off with scissors. Change napkins and tools, treat gloves. Interrupted silk sutures are placed on the anterior wall of the anastomosis. Silk threads No. 2 should be 25-30 cm long.

8. The final stage of the operation. Remove napkins and instruments from the abdominal cavity and carefully count them. Toilet the abdominal cavity.

9. Layer-by-layer suturing of the wound of the anterior abdominal wall.

Gastric resection– removal of part of the stomach:

a) distal – 2/3 of the stomach is removed

b) proximal – 95% of the stomach is removed

Indications:

1. operable malignant tumor of the pyloric region

2. complicated forms of gastric and duodenal ulcers (perforated, bleeding, malignant, stenotic, penetrating, chronic callous, ulcer refractory to drug therapy)

Contraindications:

1. old age

3. pathological changes in the kidneys and liver

Gastric resection according to Billroth-1:

1. Access: upper median laparotomy

2. Within the resection, the stomach is mobilized along the greater and lesser curvature.

3. Clamps are applied to the stomach and duodenum. Between the clamps, the stomach is crossed, turned to the left and resected.

4. The upper part of the gastric stump is sutured with a double-row suture (continuous through catgut suture + pure Lambert seromuscular sutures). At the greater curvature, an area with a diameter of the duodenum is left unsutured to form a gastroduodenoanastomosis.

5. The unsutured part of the stomach is brought to the duodenum. The posterior walls of the stomach and duodenum are sutured with seromuscular sutures. Using a long catgut thread, a through continuous catgut suture is applied to the posterior lip of the anastomosis, starting from bottom to top; the same thread is passed to the anterior lip of the anastomosis and a Schmieden screw-in suture is applied.

6. After changing instruments and linen, a seromuscular suture is applied and the formation of the anastomosis is completed. The wound of the anterior abdominal wall is sutured in layers.

Advantages of the method: the most physiological, passage of food occurs through the duodenum, dumping syndrome is not expressed. Flaws: difficulty mobilizing the duodenum; discrepancy between the lumens of the stomach and duodenum.

Gastric resection according to Billroth-2. The bottom line: if the duodenum is immobile, we sutured both stumps tightly and performed a side-to-side gastroenteroanastomosis. Currently running in Hoffmeister-Finsterer modifications (end-to-side anastomosis):

1. Access: upper median laparotomy.

2. Mobilization of the stomach by freeing the part to be removed from the ligaments with simultaneous ligation of the vessels.

3. We find the initial loop of the jejunum and pass it through a hole made in the avascular zone of the mesentery of the transverse colon to the upper floor, where we hold it by applying an elastic sphincter to its mesentery.

4. We place a Payra sponge on the upper part of the duodenum, a sponge on the stomach below the pylorus and cross it between the sponges.

5. Close the duodenal stump:

a – placing a continuous suture on the stump around the clamp

b – tightening the thread

c – loading of the intestinal stump with a serous-serous purse-string suture

d – tightening the purse-string suture

6. Two straight gastric sphincters are placed on the stomach along the line of future intersection on the left: one from the side of the greater curvature, the second from the side of the lesser curvature so that they touch. Next to them, a Payra crushing press is applied to the removed part of the stomach. The stomach is cut off between two straight sphincters and Payra's sphincter.

7. The upper part of the gastric stump is sutured using a clamp applied from the lesser curvature.

8. We bring the prepared loop of jejunum to the stump of the stomach so that its adducting end corresponds to the lesser curvature, and the efferent end corresponds to the greater curvature of the stomach. The intestine is fixed to the posterior wall of the unsutured part of the gastric stump with holders so that the line of the future anastomosis falls on the antimesenteric edge of the intestine.

9. Posterior seromuscular sutures are placed between the holders at intervals of 0.5 cm. The surgical field is covered with napkins. The intestine is cut open.

10. A continuous wrapping Multanovsky catgut suture is applied to the posterior lip of the anastomosis, the same thread is passed to the anterior lip of the anastomosis and it is sutured with a continuous continuous screw-in Schmieden suture. A second row of seromuscular sutures is placed on top. Monitor the patency of the anastomosis.

11. To prevent the reflux of gastric contents into the afferent loop, it is sutured with several sutures above the anastomosis zone to the gastric stump.

Gastrectomy– complete removal of the stomach.

Indications: cancer of the cardia of the stomach or its upper half.

1. Upper midline laparotomy.

2. We mobilize the stomach by freeing the part to be removed from the ligaments with simultaneous ligation of the vessels.

3. The initial section of the duodenum is crossed between the clamps, and the duodenal stump is sutured.

4. We mobilize the esophagus, separating the esophagus from the peritoneum, ligating the vessels, dissecting the nerves.

5. We create an esophagojejunostomy of the “end to side” type (according to Gilyarovich, according to Lagay) with Brown’s anastomosis between the afferent and efferent loops of the intestine or of the “end to end” type (according to Laska-Tsatsanidi).