The following operations are performed on the stomach: gastrotomy, or the opening of the stomach to remove foreign bodies or to treat ulcers; gastrostomy, or the making of a gastric fistula to introduce food; Pyloroplasty, or the widening of a constricted pylorus; pylorectomy, for the removal of cancerous or strictured pylorus; gastrectomy, or the removal of a part or the whole of the stomach; gastroplication, or the folding of the walls to reduce its size; and gastroenterostomy, or the establishing of a fistula between the stomach and the small intestine.

Technic

The incision for gastrostomy is 4 cm. (1 1/2 in.) long, over the outer third of the left rectus muscle, beginning 2 cm. ( 3/4 in.) below the edge of the ribs. The fibres of the rectus are to be parted by blunt dissection from above downward, as this is less apt to tear the lateral branches of the superior epigastric artery than if made in the opposite direction. The incisions for pyloroplasty and partial or complete gastrectomy are made in or near the median line and reach from the tip of the ensi-form cartilage to the umbilicus. That for pyloroplasty is placed usually to the right of the median line, all others to the left. In incising to the right of the median line the incision should not be carried down to the umbilicus or the round ligament will be cut. The incisions are placed to one side of the median line in order to open the sheath of the rectus and pass through the muscular fibres, thus allowing of a more secure closure of the wound and diminishing the liability to hernia. In incising the posterior layer of the sheath of the rectus and peritoneum one should avoid wounding the edge of the liver, which crosses the median line midway between the xiphosternal articulation and umbilicus, being higher or lower according to its size. The stomach is recognized as lying immediately below and in contact with the under surface of the left lobe of the liver. If in doubt, follow the under surface of the liver to the transverse fissure, thence over the lesser or gastrohepatic omentum to the lesser curvature of the stomach. The omentum may present in the wound instead of the stomach. It is to be pushed downward and the stomach sought for under the liver. The transverse colon should not be mistaken for the stomach. It lies under the omentum and can be identified by its longitudinal bands. In operating on the pylorus it may be found lying in the median line or 5 cm. (2 in.) or even 7.5 cm. (3 in.) to the right. The normal pylorus will readily admit the index finger. The incision advised by Finney for pyloroplasty is 15 to 20 cm. (6 to 8 in.) long through the right rectus muscle.

Partial gastrectomy is the operation usually done for carcinoma. Pylorectomy is too incomplete and total gastrectomy is too dangerous. In performing a partial gastrectomy, as done by the Mayo brothers, an incision just to the left of, or in, the median line is made from the ensiform process to the umbilicus. The gastrohepatic omentum is then ligated from the pyloric end toward the cardiac end, well beyond the limits of the tumor. The ligatures are to be placed close to the liver and suffi-ciently far away from the lesser curvature to allow of the removal of the lymphatic nodes lying along it. The gastric artery is ligated below the cardiac opening, where it reaches the lesser curvature (see Fig. 416, page 402). The pyloric branch of the hepatic is ligated as it reaches the stomach. Ligate the gastroduodenal artery behind the pylorus and the gastro-epiploica sinistra on the greater curvature; the gastrocolic omentum is then to be ligated between the two. Care is to be taken not to ligate the colica media in the transverse mesocolon beneath or gangrene of the colon will result. The duodenum is then clamped and cut, and also the stomach, in what has been called the Hartmann-Mikulicz line (Fig. 416), which will remove most of the lesser curvature and at least a third of the greater curvature. The two cut ends are then closed with sutures and the lowest portion of the remainder of the stomach connected with the ileum either anteriorly or posteriorly.

In performing a gastro-enterostomy the upper portion of the jejunum is brought up and anastomosed with the anterior or posterior wall of the stomach. If the omentum is not seen at once on opening the peritoneum it will, perhaps, be found lying rolled up along the lower border of the stomach. It is to be brought out of the wound and turned upward. On its lower surface is seen the colon running transversely from right to left. Follow the transverse mesocolon down to the spine and the commencement of the jejunum will immediately be felt and can be seen coming through the mesocolon, with the ligament of Treitz running from its upper border to the parietal peritoneum. Follow the jejunum down for 40 cm. (16 in.) and bring it up in front of the great omentum and colon and anastomose with the lower border of the stomach anteriorly, preferably near the pyloric end. If it is desired to do a posterior gastro-enterostomy the transverse mesocolon is divided and the stomach pushed forward through the opening (Fig. 418). The commencement of the jejunum as it emerges from the transverse mesocolon is then brought up and anastomosed with the posterior wall of the stomach.

Fig. 418.   Posterior gastroenterostomy. The omentum and colon have been turned up and the two openings shown in the stomach and commencement of jejunum are to be sewn together along their edges, thus establishing a communication between the stomach and small intestine.

Fig. 418. - Posterior gastroenterostomy. The omentum and colon have been turned up and the two openings shown in the stomach and commencement of jejunum are to be sewn together along their edges, thus establishing a communication between the stomach and small intestine.