Surgical Procedure 4 Gastrostomy

4.  Gastrostomy

Objective

In case of:

•   Esophageal obstruction, e.g. carcinoma esophagus or cardiac to deliver nutrition.

•   Prolonged ileus or severe pancreatitis to provide gastric drainage (as an alternative to nasogastric intubation).

Position

Supine.

Anesthesia

General or local.

Procedure

•   Small midline incision.

•   Left arterior wall of stomach between two Babcock’s forceps midway between greater and lesser curvature.

•   Two purse string sutures at one and two cm radius from an imaginary center.

•   Incise the stomach at the centre and insert a 14 F Foley’s catheter and tie the two purse strings to produce an inkwell effect.

•   Bring out the tube through a stab in the anterior abdominal wall.

•   Anchor the stomach to peritoneum and rectus sheath using interrupted 20 silk sutures.

Instruments

•   Gastrointestinal set, 1

•   Foley’s catheter, 14 F.

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SURGICAL PROCEDURE 3 Pyloroplasty

3.  Pyloroplasty

Indications

•   In peptic ulcer to drain stomach after Truncal vagotomy.

•   In cancer esophagus after total esophagectomy.

Position

Supine.

Anesthesia

General.

Procedure

•   Locate pylorus.

•   Make a longitudinal incision, 3 to 5 cm on stomach side and 2.5 cm on duodenal side, cutting through the pylorus. Control all bleeding with ligatures.

•   Suture the longitudinal incision in a transverse direction using interrupted sutures.

Instruments

•   General set, 1

•   Gastrointestinal set, 1.

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SURGICAL PROCEDURE 2 Gastro-jejunostomy

2.  Gastrojejunostomy

Objective

In cases of obstruction of stomach outlet:

•   To establish alternative connection between stomach and small intestine.

•   To follow Vagotomy.

Position

Supine.

Anesthesia

General.

Procedure

•   Midline or Paramedian incision

•   Opening made in transverse mesocolon

•   Stomach antrum isolated tissue forceps at lesser and greater curvature

•   Jejunum also held in tissue forceps loop 10 to 20 cm form duodenojejunal junction

•   Non-crushing occlusion clamp applied

•   Two layers anastomosis 2/0 chromic

•   Outer continuous seromuscular

•   Inner continuous all layers

•   Anastomosis brought above the mesocolon tethered

•   Wound closed in layers.

Instruments

•   General set, 1

•           Gastrointestinal set, 1

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General Surgical Procedures 1 Truncal Vagotomy object position anaesthesia steps instruments

general surgical procedure

1.  Vagotomy

Objective

In case of peptic ulcer:

•   Division of Vagus Nerve below diaphragm

•   To reduce gastric acid secretion.

Position

Supine.

Anesthesia

General.

Procedure Steps

•   Incision Midline/Paramedian

•   Mobilize left lobe of liver

•   Liver colon and Small Intestines packed down and toward right

•   Mobilize lower esophagus

•   Sling round lower esophagus

•   Both nerves identified by palpation

•   Cut between ligatures

•   Specimen sent for histology for confirmation

•   Wound closed in layers.

Instruments

•   General set, 1

•   Gastrointestinal set, 1

•   Red rubber catheter (Sling).

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