Duodenal Ulcer

Question 1

Bleeding duodenal ulcer

Answer 1

• Supine, arms out, NGT
• Upper midline incision
• Kocher Maneuver
• Duodenotomy to expose underlying ulcer
• 3 point sutures superior, inferior, and medial
• Can ligate GDA if needed at superior duodenal border.
• If needed, can cannulate cystic/common BD with fogarty to ensure you don’t bag it.
• Close duodenotomy with transverse incision, 2 layer.

Question 2

Perforated Duodenal Ulcer

Answer 2

• Supine, arms out, foley
• Upper midline incision
• Kocker maneuver
• Pull off current patch of omentum
• Irrigation
• Perform Graham patch with Vicryl and peice of omentum, irrigate, leave drains.

Question 3

Parietal cell vagotomy

Answer 3

• Upper midline
• Same as truncal vagotomy, isolate esophagus
• identify termination of vagus nerve, or Nerve of Latarjet.
• Enter lesser sac through gastrocolic ligament, preserving gastroepiploic vessels.
• dissect the lesser omentum to incisura angularis, close to lesser curve.
• Dividing neurovascular bundles along this area.
• Stomach reflected upward and same is done posteriorly.

Question 4

Indications for Antrectomy/TV

Answer 4

-Health/stable patients with refractory ulcer disease and or anatomic indications (pylorys scar/large ulcer)