Stomach, Duodenum, and Esophagus



Stomach, Duodenum, and Esophagus






VAGUS NERVES (TRUNCAL AND HIGHLY SELECTIVE VAGOTOMY)


INCISION

Access to the chest and abdomen will facilitate this procedure (Figs. 3.2 and 5.1). If the chest has been dissected, remove the lungs and identify the thoracic esophagus.



CLINICAL HIGHLIGHTS



  • Transthoracic vagotomy is done in the distal thoracic esophagus near the esophageal hiatus. This procedure is utilized to salvage prior truncal vagotomy that was clinically incomplete (see Chapter 3).


  • The “criminal nerve of Grassi” is simply the most superior branch of the posterior vagus. This particular branch divides from the right vagus in the chest and descends separately from the posterior trunk into the abdomen. Be aware that small branches of the vagus may descend through the esophageal hiatus separate from the main trunks. It is particularly important to remember to transect the criminal nerve during vagotomy to treat peptic ulcer disease (Fig. 3.31A, B).


  • Highly selective vagotomy, superselective vagotomy, proximal gastric vagotomy, and parietal cell vagotomy all refer to the same operation.


  • Damage to the crow’s foot during HSV may inhibit relaxation of the pylorus.


  • Nerves of Latarjet can have highly variable structure but will always have gastric branches that are the target of HSV.


  • Truncal vagotomy is always accompanied by a drainage procedure such as pyloroplasty. Otherwise, 40% of patients with truncal vagotomy will have pyloric spasm and will require reoperation for gastric drainage.


  • Remember that truncal vagotomy may involve more than a single vagal nerve trunk in either the anterior or posterior position.



  • Although transection of the nerve in truncal vagotomy should be sufficient, many surgeons remove a 1-cm segment of each nerve and send it to pathology for confirmation.


  • Clips placed on the vagal ends will show on future chest x-rays to show a vagotomy was performed.


  • To ensure complete transection of the vagal trunks, it is recommended to clear the distal esophagus superiorly for 5-6 cm of all investing tissues.


ESOPHAGEAL HIATUS (NISSEN FUNDOPLICATION)


INCISION

Access to the chest and abdomen will facilitate this procedure (Figs. 3.2 and 5.1). Reflect the anterior chest wall superiorly and the anterior abdominal wall inferiorly.



CLINICAL HIGHLIGHTS



  • The gastrohepatic ligament will contain aberrant hepatic arteries in ˜11% of patients (Fig. 6.5). Preservation should be attempted. The vessels can be divided if necessary without causing harmful ischemia to the left lobe of the liver.


  • Right and left crus of the esophageal hiatus both arise from the right crus of the diaphragm in most cases (Fig. 6.7).


  • Right and left pleural reflections are close to the mediastinal dissection of the esophagus and may be torn during surgery. After Nissen fundoplication, whether open or laparoscopic, remember to obtain a postop chest x-ray to rule out pneumothorax.


  • With the right index finger placed posterior to the esophagus to create the space for a Nissen wrap, note the transverse angle of the finger. Now, think about port placement for a laparoscopic Nissen. It is easy to see that the right medial subcostal port needs to be very close to the rib margin in order to have a Babcock clamp follow this transverse trajectory (Fig. 6.9).



  • Remember during Nissen fundoplication, use esophageal dilators of 50-60 French with or without the presence of a nasogastric tube when suturing the wrap to avoid postoperative dysphagia.


  • Esophageal perforation during Nissen fundoplication is most commonly associated with severe esophagitis. Preoperative endoscopy should be performed by the surgeon for anatomical considerations and for evaluation of the status of the esophagus. Esophagitis must be medically controlled preoperatively to avoid perforation at surgery.






    Figure 6.12 A, B: Muscular layers of the stomach emphasizing the circular lower esophageal sphincter, angle of His, and collar of Helvetius.


  • The Nissen fundoplication re-establishes the angle of His. An acute angle of His must be established for the collar of Helvetius (oblique muscle band) to act as an active part of the lower esophageal sphincter in concert with the inner circular muscle layer of the esophagus. Place an instrument in the newly established angle of His after your Nissen to demonstrate (Fig. 6.12A, B).



GREATER CURVATURE OF THE STOMACH AND SHORT GASTRIC VESSELS (MOBILIZATION FOR ESOPHAGECTOMY OR FUNDOPLICATION)


INCISION

Access to the chest and abdomen will facilitate this procedure (Figs. 3.2 and 5.1). Reflect the abdominal wall inferiorly and the anterior chest wall superiorly. Identify the stomach. Identify the right gastroepiploic artery on the greater curvature of the stomach and be certain to preserve it.



CLINICAL HIGHLIGHTS



  • The gastrosplenic ligament may have one or two welldefined folds. During mobilization of the greater curvature of the stomach, if present, the presplenic fold may be confusing to the surgeon who is unaware of this anatomic variable (Fig. 6.15).


  • Remember that short gastric vessels may come off the superior-most aspect of the spleen. These socalled supreme short gastric vessels may be identified only at the uppermost portion of the cardia of the stomach in the gastrophrenic ligament. Be aware that inferior phrenic vessels may also be found in this area arising from branches of the celiac axis and traversing posterior to the esophagus (Fig. 5.2).







    Figure 6.14 Entrance into the lesser sac; relationship of the greater omentum and transverse mesocolon.






    Figure 6.15 Presplenic fold; gastrosplenic ligament with short gastric arteries.



  • In the operating room, the short gastric vessels can be divided and ligated individually or transected with a vessel coagulation device. Depending on the body habitus, the supreme short gastric vessels can be difficult to identify and control. Appropriate retraction, visualization, and careful dissection in this area are key to prevent massive hemorrhage.


  • When taking down the short gastrics, the surgeon must exercise care in retraction of the stomach, as overzealous retraction can lead to avulsion of the short gastrics from the splenic hilum, necessitating splenectomy.


  • Note that a pancreatic pseudocyst in the lesser sac will likely be adjacent to the posterior wall of the stomach. On the body, re-evaluate this relationship. The surgeon can now see why a posterior wall gastrocystostomy is a convenient and anatomically sensible method of pseudocyst drainage for lesser sac pseudocysts.


  • Remember the critical nature of the right gastroepiploic artery when performing transhiatal esophagectomy. The right gastroepiploic artery, the right gastric artery, and the extremely rich interconnected nature of the gastric submucosal plexus allow complete mobilization of a viable stomach for an esophageal replacement conduit.






Figure 6.16 A: Dimensions and incision for Heller myotomy of the esophagus. B: Heller myotomy with bulging mucosa.

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Oct 16, 2018 | Posted by in ANATOMY | Comments Off on Stomach, Duodenum, and Esophagus
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