1887

The stomach

image of The stomach
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Abstract

The stomach serves as a reservoir for food and initiates digestion. This chapter explores anatomy and different techniques. Practical tips are highlighted throughout. Gastronomy; Gastric biopsy; Partial gastrectomy of the gastric fundus; Transverse pyloroplasty (Heineke-Mikulicz procedures); Y-U antral advancement flap; Pyloromyotomy (Fredet-Ramstedt procedure); Pylorectomy and gastroduodenostomy (Billroth I procedure); Oesophageal hiatal hernia repair.

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Figures

Image of 5.1
5.1 (a) Anatomical regions of the stomach. The stomach is divided into a greater and a lesser curvature with five distinct regions: the cardia, the fundus, the body (or corpus), the antrum and the pylorus. The pyloric ‘sphincter’ has a thicker inner circular muscle. (b) Blood supply to the stomach. Major arterial blood vessels to the stomach arise from the coeliac (C) artery, which gives rise to the hepatic (H), splenic (S), gastric (G) and gastroepiploic (GE) vessels. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
Image of 5.2
5.2 Gastrotomy for removal of a hairball in a cat. (a) Stay sutures are used to elevate the stomach out of the abdomen, and the stomach is packed off using laparotomy swabs. Allis tissue forceps are used to retrieve the foreign body. (b) The hairball assumes the shape of the gastric lining.
Image of 5.3
5.3 (a) Intraoperative view of a 4-year-old Chinese Shar Pei who underwent gastric decompression for gastric dilatation and volvulus 12 hours earlier. Note the circular area of gastric necrosis protruding from the gastric fundus. (b) A partial gastrectomy was performed and the excised tissue is shown.
Image of 5.4
5.4 Endoscopic view of gastric mucosal hyperplasia in the area of a dog’s pylorus.
Image of 5.5
5.5 Incising the hepatogastric ligament with Metzenbaum scissors increases mobility of the pylorus prior to performing any of the pyloric procedures. Care should be taken to avoid the common bile duct when incising the ligament.
Image of 5.6
5.6 (a) A 3 mm longitudinal incision has been made into the lumen of the pylorus. (b) The transverse closure has been completed.
Image of 5.7
5.7 (a) The hyperplastic mucosa is incised, undermined and resected using Metzenbaum scissors. (b) The open bed is closed by re-opposing mucosa and submucosa with a simple continuous or Cushing pattern. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
Image of 5.8
5.8 Intraoperative photograph of a resected hypertrophic mucosal lesion removed during pyloroplasty.
Image of 5.9
5.9 (a) The pylorus has been scored with a surgical blade, showing the tail of the Y towards the duodenum and the arms towards the stomach. (b) Finished U-shaped configuration, which widens the pyloric outflow tract. (Courtesy of R M Bright)
Image of 5.10
5.10 (a) The pylorus is incised through the outer longitudinal and (b) inner circular musculature to allow protrusion of the submucosa.
Image of 5.11
5.11 Contrast study of a 13-year-old Beagle with a golf ball-sized filling defect located at the pylorus (arrowed). This was caused by a leiomyoma, which was successfully removed surgically.
Image of 5.12
5.12 Hiatal hernias. (a) Normal gastro-oesophageal junction. (b) Axial or sliding hiatal hernia; the junction slides into the thorax. (c) Paraoesophageal or rolling hiatal hernia; the junction remains fixed at the diaphragm but the cardia rolls into the thorax. C = cardia; D = diaphragm; F = fundus; J = gastro-oesophageal junction; Lig = phrenico-oesophageal ligament; O = oesophagus. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
Image of 5.13
5.13 (a) Lateral and (b) ventrodorsal radiographs of a 9-month-old Shar Pei with a paraoesophageal hiatal hernia. Note the large soft tissue opacity cranial to the diaphragm and dorsal to the vena cava.
Image of Stab incision.
Stab incision. Stab incision.
Image of Extending the incision.
Extending the incision. Extending the incision.
Image of Stay sutures to open the lumen.
Stay sutures to open the lumen. Stay sutures to open the lumen.
Image of Closure of the first layer with a continuous Cushing pattern (inset).
Closure of the first layer with a continuous Cushing pattern (inset). Closure of the first layer with a continuous Cushing pattern (inset).
Image of Closure of the second layer with a continuous Cushing or continuous approximating pattern.
Closure of the second layer with a continuous Cushing or continuous approximating pattern. Closure of the second layer with a continuous Cushing or continuous approximating pattern.
Image of A gastric biopsy is performed by tenting the stomach wall with a stay suture. An elliptical sample 10 mm long by 5 mm wide is taken.
A gastric biopsy is performed by tenting the stomach wall with a stay suture. An elliptical sample 10 mm long by 5 mm wide is taken. A gastric biopsy is performed by tenting the stomach wall with a stay suture. An elliptical sample 10 mm long by 5 mm wide is taken.
Image of The gastric wall is closed with three simple interrupted sutures that engage the submucosa, the muscularis and the serosa.
The gastric wall is closed with three simple interrupted sutures that engage the submucosa, the muscularis and the serosa. The gastric wall is closed with three simple interrupted sutures that engage the submucosa, the muscularis and the serosa.
Image of Identification of necrotic area.
Identification of necrotic area. Identification of necrotic area.
Image of A TA90 stapling device is used to resect the necrotic portion of the stomach.
A TA90 stapling device is used to resect the necrotic portion of the stomach. A TA90 stapling device is used to resect the necrotic portion of the stomach.
Image of Resected portion of the stomach.
Resected portion of the stomach. Resected portion of the stomach.
Image of Closure.
Closure. Closure.
Image of A 3–4 cm incision is centered over the pylorus and made into the lumen.
A 3–4 cm incision is centered over the pylorus and made into the lumen. A 3–4 cm incision is centered over the pylorus and made into the lumen.
Image of The wound edges are closed transversely using a simple interrupted pattern.
The wound edges are closed transversely using a simple interrupted pattern. The wound edges are closed transversely using a simple interrupted pattern.
Image of Eversion is prevented by using Gambee sutures as necessary.
Eversion is prevented by using Gambee sutures as necessary. Eversion is prevented by using Gambee sutures as necessary.
Image of Final closure.
Final closure. Final closure.
Image of A Y-shaped full-thickness incision is centred over the pylorus with the tail of the Y towards the duodenum and the arms towards the antrum.
A Y-shaped full-thickness incision is centred over the pylorus with the tail of the Y towards the duodenum and the arms towards the antrum. A Y-shaped full-thickness incision is centred over the pylorus with the tail of the Y towards the duodenum and the arms towards the antrum.
Image of The point of the Y is trimmed to round it and the resultant flap is advanced distally and sutured to the end of the Y with a simple interrupted or modified Gambee suture pattern.
The point of the Y is trimmed to round it and the resultant flap is advanced distally and sutured to the end of the Y with a simple interrupted or modified Gambee suture pattern. The point of the Y is trimmed to round it and the resultant flap is advanced distally and sutured to the end of the Y with a simple interrupted or modified Gambee suture pattern.
Image of The two sides of the antral flap are sutured to the sides of the duodenum, resulting in a U-shaped closure.
The two sides of the antral flap are sutured to the sides of the duodenum, resulting in a U-shaped closure. The two sides of the antral flap are sutured to the sides of the duodenum, resulting in a U-shaped closure.
Image of Intraoperative photograph of a completed Y–U antral advancement flap.
Intraoperative photograph of a completed Y–U antral advancement flap. Intraoperative photograph of a completed Y–U antral advancement flap.
Image of The pyloromyotomy procedure involves a 3–4 cm incision through the serosa and pyloric muscle.
The pyloromyotomy procedure involves a 3–4 cm incision through the serosa and pyloric muscle. The pyloromyotomy procedure involves a 3–4 cm incision through the serosa and pyloric muscle.
Image of Care is taken not to enter the lumen of the stomach.
Care is taken not to enter the lumen of the stomach. Care is taken not to enter the lumen of the stomach.
Image of Note how the submucosa bulges out through the muscularis.
Note how the submucosa bulges out through the muscularis. Note how the submucosa bulges out through the muscularis.
Image of Branches of the right gastric and gastroepiploic arteries are ligated around the pylorus. Forceps are placed and the pylorus and antrum are resected between Doyen forceps to prevent spillage.
Branches of the right gastric and gastroepiploic arteries are ligated around the pylorus. Forceps are placed and the pylorus and antrum are resected between Doyen forceps to prevent spillage. Branches of the right gastric and gastroepiploic arteries are ligated around the pylorus. Forceps are placed and the pylorus and antrum are resected between Doyen forceps to prevent spillage.
Image of The submucosa and mucosa are inverted with an interrupted pattern and the seromuscular layer is approximated with a simple interrupted Lembert pattern.
The submucosa and mucosa are inverted with an interrupted pattern and the seromuscular layer is approximated with a simple interrupted Lembert pattern. The submucosa and mucosa are inverted with an interrupted pattern and the seromuscular layer is approximated with a simple interrupted Lembert pattern.
Image of Two similar lumens are established and the anastomosis is completed with simple interrupted or Gambee sutures.
Two similar lumens are established and the anastomosis is completed with simple interrupted or Gambee sutures. Two similar lumens are established and the anastomosis is completed with simple interrupted or Gambee sutures.
Image of Intraoperative view of the partially oversewn gastric stump with haemostats placed in the gastric stoma.
Intraoperative view of the partially oversewn gastric stump with haemostats placed in the gastric stoma. Intraoperative view of the partially oversewn gastric stump with haemostats placed in the gastric stoma.
Image of After incising the phrenico-oesophageal ligament, the diaphragm is apposed to reduce the oesophageal hiatus.
After incising the phrenico-oesophageal ligament, the diaphragm is apposed to reduce the oesophageal hiatus. After incising the phrenico-oesophageal ligament, the diaphragm is apposed to reduce the oesophageal hiatus.
Image of The phrenico-oesophageal ligament has been cut and is retracted with stay sutures, freeing the oesophagus (black arrow) from the diaphragm. A Penrose drain had been placed caudally around the distal oesophagus to retract it caudally into the abdomen. The dorsal branch of the vagus nerve can be seen (white arrow). (Courtesy of J. Niles)
The phrenico-oesophageal ligament has been cut and is retracted with stay sutures, freeing the oesophagus (black arrow) from the diaphragm. A Penrose drain had been placed caudally around the distal oesophagus to retract it caudally into the abdomen. The dorsal branch of the vagus nerve can be seen (white arrow). (Courtesy of J. Niles) The phrenico-oesophageal ligament has been cut and is retracted with stay sutures, freeing the oesophagus (black arrow) from the diaphragm. A Penrose drain had been placed caudally around the distal oesophagus to retract it caudally into the abdomen. The dorsal branch of the vagus nerve can be seen (white arrow). (Courtesy of J. Niles)
Image of The oesophagus and cardia can also be sutured to the diaphragm.
The oesophagus and cardia can also be sutured to the diaphragm. The oesophagus and cardia can also be sutured to the diaphragm.
Image of The diaphragm has been closed around a large orogastric tube to reduce the diameter of the hiatus (black arrow), and simple interrupted sutures have been placed to pexy the distal oesophagus and cardia to the margin of the diaphragmatic hiatus (white arrow). (Courtesy of J. Niles)
The diaphragm has been closed around a large orogastric tube to reduce the diameter of the hiatus (black arrow), and simple interrupted sutures have been placed to pexy the distal oesophagus and cardia to the margin of the diaphragmatic hiatus (white arrow). (Courtesy of J. Niles) The diaphragm has been closed around a large orogastric tube to reduce the diameter of the hiatus (black arrow), and simple interrupted sutures have been placed to pexy the distal oesophagus and cardia to the margin of the diaphragmatic hiatus (white arrow). (Courtesy of J. Niles)

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