91 - Stomach Flashcards
Describe the arterial vascular supply to the stomach
Aorta => Celiac => Splenic/Left gastric/Hepatic
- Splenic => Left gastroepiploic (greater curvature) & Short gastrics (fundus)
- Left gastric => Lesser curvature, fundus and terminal oesophagus
- Hepatic => Right gastric (lesser curvature) and gastroduodenal => Right gastroepiploic (greater curvature)
Right and left gastric anastomose on lesser curvature
Rihgt and left gastroepiploic anasomoase on greater curvature
Describe the venous drainage of the stomach
SPLENIC VEIN ON THE LEFT
(Left gastric v joins splenic)
GASTRODUODENAL VEIN ON THE RIGHT
(Right gastric v joins gastroduodenal)
DRAIN INTO THE PORTAL VEIN
Describe the innervation to the stomach
Parasympathetic = Vagus n.
- Dorsal and ventral trunks
Sympathetic = Celiacomesenteric plexus
Which LNs does the stomach drain to?
Gastric and Splenic LNs
Label the diagram
A = Fundus
B= Body
C= Pyloric antrum
D = Pyloric canal
E = Angular incisure
F = Major duodenal papilla
G = Minor duodenal papilla
How is the muscularis of the stomach organised?
3 layers
- Longitudinal fibres from oesophagus to duodenum
- Inner circular fibres from the cardia (cardiac sphincter) extendong to greater curvature
- Inner oblique fibres (blend with circular layers) from greater curvature to pylorus = grinding function of the antrum
Circular layer not present at the fundus
Describe the anatomy of the omentum
Greater and lesser omentum attach to respective curvatures
Greater split into =
- Bursal (Greater curvature but courses obliquely to join with lesser to create bursa)
- Splenic (Fors gastrosplenic ligament containing left gastroepiploic vessels)
- **Veil ** (between descending mesocolon and spleen)
Portion of lesser forms hepatogastric ligament
What is the clinical relevence of the angular incisure?
Useful landmark for endoscopy
What are the 3 layers of the gastric mucosa?
Columnar epithelium
Glandualar lamina propria
Lamina muscularis
(Mucosa, Submucosa, Muscularis, Serosa as for elswehere in GIT)
Submucosa = Strength holding layer
What are the gland types within the stomach?
What do they each secrete?
Cardiac = Serous secretions
Pyloric = Mucous secretions
Gastric glands proper = Reside in the body
- Parietal cells => 1) Intrinsic factor and 2) Hydogen ions to reduce pH
- Chief cells => Pepsinogen (converted to pepsin to digest proteins)
- Mucous neck cells => Mucin (protect against low pH)
- Endocrine cells => Seratonin, histamine and gastrin production
Intrinsic factor, mucus and bicarb protect cells from acidic pH
Remember parietal = pH
Chiefs tend to be hench = Pepsinogen > Pepsin > Digests proteins
Describe the the main phases involved in gastric motility
1) Fundic distension
* Swallowing initiates receptive relaxation of the fundus
* Decrease in motor activity and pressure
* Gastric accomodation occurs which decreases rate of emptying of fluids
2) Gastric distension
* Distension of the stomach causes increase in motility
* Food is mixed and moved towards the antrum for churning
3) Contractile retropulsion
* Pylorus closes
* Liquid moves into the duodenum
* Particles > 2mm in size are forced retrograde for further churning
* Particle size reduced to 0.1-0.6mm for gastric emptying
How does the stomach heal depending on the thickness of the lesion?
Partial thickness mucosa = Epithelialisation
Extending to submucosa (ULCER) = Fibrosis
Incisional = Inflammation, debridement, repair, maturation
(Smooth muscle in the stomach contributes to collagen production during healing)
There is constant mucosal renewal in the stomach
Considerations for pre-op fasting for gastric surgery?
8-12 hour fast reduces spillage
- But reduces pH and increases occurence of reflux
Feeding small meal of tinned food 3 hours prior to surgery
- Increases pH and reduces the impact of reflux
When are perioperative antibiotics indicated for gastric surgery?
Generally, low bacterial numbers due to low pH
GI Obstruction => Bacterial overgrowth so consider periop ABs for this
Name 3 GA concerns for gastric surgery and give solutions
1) Reflux
- Anticholinergics (glyco/atropine) to reduce secretions
- H2 receptor antagonist and PPIs to increase pH
2) Vomiting
- Rapid induction (propofol) and intubation
- Antiemetics?
3) Abdominal distension
- Mechanical ventilation
Describe the paracostal approach to the stomach
Incision 2cm caudal to last rib
Skin, subcut, EAO, IAO, TA, peritoneum
Muscles split in direction of fibres
What temperature is appropriate for abdominal lavage?
What is the risk of using warmer fluids?
37-39°
Risks of warmer
- Vasodilation
- Hypotension
- Increased adhesions (41-45°)
What suture patterns does Tobias recommend for closure of the stomach?
Double layer continuous with inversion
Either double inversion
- First full thickness
- Second seromuscular
Or
-Mucosal/submucosal apposition
Seromuscular inversion
First layer = Haemostasis
Second layer = Creates seal
Where should invertion NOT be performed and why ?
Pylorus
Inversion reduces luminal size
Interrupted or continous appositional recommended for pyloroplasty
Which suture material is negatively impacted by low pH?
PDS
But in clinical situation, generally fine
Half life PDS 12 days vs 75 days for Maxon vs 15 days for monocryl
Name 3 tests for assessment of gastric viability
- Fluorosceine dye injection (58% accurate)
- Scintigraphy (79% accurate)
- Laser Doppler Flowmetry
How accurate are subjective assessments of gastric viability in experience surgeons hands?
85%
Standard subjective measures - Thickness, colour, serosal capillary perfusion, peristalsis
Remember mucosa viability does not equate to overall viability
Briefly described a hand sewn partial gastrectomy
Resect affected tissue and margin of normal tissue with Metz so actively bleeding
Close defect with 2/0-3/0 Monofilament absorbable
Close Perpendicular or parallel to the long axis depending on defect shape
Two layer closure
Omentalisation
Other than hand sewn, name 3 other options for partial gastrectomy
Stapling device
* TA/GIA, plus oversew
Gastric wall invagination
* Simple continous and inverting second layer
* Necrotic region sloughs into lumen
Autologous intestinal submucosal graft
* Useful when resection results in inadequate functional lumenal diameter
Name 4 complications of gastric wall invagination
- Gastric ulceration
- Gastric wall abscess
- Obstruction due to sloughing material
- Haemorrhage secondary to deep ulceration
Name 12 techniques for gastropexy
Open =
* Incisional
* Belt loop
* Circumcostal
* Incorperating
* Gastrocolopexy
* (Stapled gastropexy)
* (Tube gastropexy via gastrostomy)
Minimally invasive =
* Grid approach
* Endoscopically assisted
* Laparoscopic assisted
* Laparoscopic gastropexy
* (Percutaenous endoscopic gastostomy - PEG tube)
In brackets, not in tobias or mentioned elsewhere
How long should the incision be for incisional gastropexy
At what location should the incisions be made?
In which layers should the incision be made?
4-5cm long
Pyloric antrum and 2-3 caudal to last rib
Seromuscular layer and through peritoneum and transverse abdominis
Simple continous, 2/0 monofilament
Start at craniodorsal aspect of incision
Where should the flap be created from for belt loop gastropexy and flap dimensions?
What should be included in the flap?
How long should the incisions in the transverse abdominis be?
Seromuscular flap in the pyloric antrum
- 4 cm long, 3cm wide, base at the greater curvature
- Gastriepiploic branches included
Incision in TA
- 5cm long, 3 cm apart
- Muscle undermined to create tunnel
Use stay suture to pass flap through tunnel
Suture back to site with 2/0-3/0 monofilament
At what location should the flap be passed around the rib during circumcostal gastropexy?
Chostochondral junction of the 11-12th rib
5-6cm incision made over the rib and blunt dissection performed circumfrentially
Flap otherwise as for belt loop
Can be single or double hinged
Avoid pneumothorax and rib fracture
How is gastrocolopexy performed?
Suture between greater curvature and transverse colon
No incision in seromuscular layers
Surfaces scarified and apposed with non-absorbable suture
Describe the incorperating gastopexy
What is the specific risk of this technique?
Pyloric antrum incorperated into CRANIAL linea alba during closure. No seromuscular incision. Quick!
Risk = inadvertant penetraiton of stomach during future abdominal surgery
Briefly describe the grid approach for gastropexy
- 6cm long incision - Caudal and ventral to 13th rib
- Skin, SC, EAO, IAO, TA, peritoneum
- Pyloric antrum grabbed with Babcocks
- Stays placed to mobilise into surgical site
- 3cm longitudinal incision through seromusclar layer
- Edges of gastric incision sutures to edges of TA fascia and muscle
- Superficial layers reapposed
Describe the technique for endoscopically assisted gastropexy
- Left oblique recumbency
- Gastroscope passed and stomach insufflated
- Antrum assessed and right abdominal wall palpated
- 2 Prolene on 76 mm needle
- Stay suture passed through body wall, caudal to13th rib, into stomach lumen and out through body wall
- Minimum 2cm gastric tissue incorperated
- Second suture placed 5cm aboral to first under in same way
- Incision made in body wall between sutures
- Gastric seromuscular layer incised and edges sutured to TA
Describe the
Fredet-Ramstedt Pyloromyotomy
Longitidinal seromuscular incision
Ventral pylorus
Extending 1-2cm orad and aborad
Can be performed laparoscopically
Describe the
Heineke-Mikulicz Pyloroplasty
Full thickness LONGITUDINAL incision made in the same location as the Fredet-Ramstedt
Stay sutures placed to reorientate incision
CLOSED TRANSVERSELY
Appositional interrupted closure
Describe the technique for Y-U pyloroplasty
Full thickness Y shaped incision
- Stem = Ventral antemesenteric duodenum
- Arms = Pyloric atrum
- Should curve into a U shape (rather than a V) to maximise vascular supply
Full thickness biopsy of the margin of the pyloric incision
Mucosa and submucosa resected as needed
U shaped flap advanced using stays
Sutured using 2/0 Absorbable monofilament
Appositional (interrupted or continous)
Assess patency of pylorus after closure
Place J-G tube to avoid feeding into stomach?
Regurge post op common - pylorus has impact on motility
Describe the bilroth 1 approach
Stays placed in somach and duodenum
Atraumatic clamps placed
Hepatogastric ligament transected, avoiding the bule duct
Leave 5-10mm between resection site and major duodenal papilla bile duct
Ligate ant transect right gastric and right gastroepiploic branches
Divide omental and mesenteric attachments
Remove pylorus with Metz or blade
Assess luminal disparity
Spatulate antemesenteric duodenum if needed or close pyloric antrum to itself to narrow diameter
Single or double layer end to end or EEA stapler
Stent common bile duct if neededd
What is a Bilroth II?
Gastrojejunal anastomosis
(Side to side anastomosis)
Cholecystoenerostomy required for biliary flow
Poor prognosis not recommended
What is the diagnosis?
Type I Hiatal hernia
Apple coring appearance around GEJ within the thorax
Define Hiatal hernia
What are the 4 types?
Name one additional class of hiatal hernia
Herniation of abdominal contents through the oesophageal hiatus
Type I = Sliding hiatal hernia
- GEJ intermittently moves into the thorax
Type II = Paraoesophageal
- GEJ remains within the abdomen but the fundus moves into the thorax
Type III = Elements of II and III
- GEJ and fundus move into the thorax
Type IV = Herniation of other organs into thorax
GASTROESOPHAGEAL INTUSUSCEPTION =
- Stomach invaginates orad to into the oesophagus
Describe the technique for repair of hiatal hernia
Considerations
- Transect the left hepatic triangular ligament to retract the liver to the right
- Place Orogastric tube to identify oesophagus/hiatus
- Avoid vagal trunks and oesophageal vessels
- Ventilation and evacuation of pneumothorax required post op
Phrenoplasty Technique:
* With or without Incision of phrenicoesophageal ligament circumferentially
* Reduce the size of the hiatal opening
* Place 2/0 Monofilament nylon Horizontal mattress sutures dorsal and ventral through crura
Oesophagopexy technique:
* 3cm partial thickness incision in left oesophagus
* Seromuscular incision in left diaprhagm
* Apposed with 2/0 or 3/0 Monofilament
Left fundic gastropexy
* Anchor fundus to body wall or left sided tube gastropexy
Review the pathophysiology of GDV
