The patient is positioned supine, and an upper midline, short upper left paramedian, or left transverse incision is used. The choice of incision depends on the patient’s body habitus. If an old midline scar is present, a left transverse incision provides good access through a space that is often free of adhesions.

General anesthesia is preferred; however, in the cachectic, weakened patient, local anesthesia may be safer. If the procedure is to be performed using local anesthesia, use a midline incision because it requires minimal muscle manipulation. Infiltrate the skin and subcutaneous tissues with local anesthesia. As dissection progresses, inject additional local anesthesia just under the fascia to numb the peritoneum.

Identify the stomach with certainty by observing its thick muscular wall, absence of haustral folds and taeniae, and the vessels entering on the greater and lesser curvature. Grasp the stomach with a Babcock clamp and pull it into the wound. Choose a site well proximal to the pylorus, on a mobile, accessible part of the anterior wall.

Place two concentric pursestring sutures of 2-0 silk, leaving the needles on. Begin and end one pursestring suture at the cephalad end of the incision and the other suture at the caudad end.

Remember the disposition of major organs in the upper abdomen, their attachments, and how to distinguish one from the other. On a surface projection, the stomach is located in the left hypochondriac and epigastric regions, with the pylorus just to the right of the vertebral column. The lesser curvature and adjacent part of the stomach lie deep to the left lobe of the liver. The body of the stomach lies just deep to the parietal peritoneum of the anterior body wall. The free edge of the left lobe of the liver typically lies about halfway between the umbilicus and the xiphoid in the midline and then angles upward and to the left to pass behind the eighth costal cartilage. The greater omentum is attached to the greater curvature of the stomach. It normally is draped over the transverse colon and the numerous loops of small intestine.

The transverse colon is attached to the greater curvature of the stomach by the gastrocolic ligament (developmentally, the anterior “root” of the great omentum) and to the posterior body wall by the transverse mesocolon. It can lie anywhere in the upper abdomen, depending on the degree of redundancy of this organ and the lengths of its peritoneal attachments. Although it is classically described to be immediately inferior to the stomach and superior to the small intestine, it may be interposed between stomach and body wall, or conversely, it may sag inferiorly into the pelvis. To visualize small bowel, the greater omentum and often the transverse colon and transverse mesocolon must be reflected cranially.

Through the porthole of this small laparotomy incision, large bowel can be differentiated from other viscera by the
presence of haustra, taenia coli, and fatty epiploic appendages. Small bowel can be differentiated from stomach by its narrow diameter and from large bowel by the lack of the characteristics of large bowel just mentioned.

Unlike the colon, stomach lacks haustra and taeniae. Although the stomach is highly distensible and somewhat mobile, it should be remembered that it is attached along its lesser curvature to the liver by the hepatogastric ligament, along its greater curvature to the transverse colon by the gastrocolic ligament, to the esophagus proximally, and to the retroperitoneal duodenum distally. Because there are neurovascular structures in the ligaments and visceral continuity proximally and distally, care should be taken when delivering the anterior wall of the stomach into the wound to ensure that it is just the distensible anterior wall and that undue traction is not placed on the viscus wall or on accompanying neurovascular structures.