With Laparotomy

ARTICLE BY RICHARD E. WILLS, MD, AND PEGGY E. GRUSENDORF, MS, RNP

agotomy with chyme. The stomach lies under the tinuous above with the cardia and laparotomy is per- ribs and the costal cartilage that below with the pyloric antrum, formed in order to form the upper left quadrant. which connects with the pyloric reduce the amount The cardia (see Figure 1) is canal. The pylorus is apparent by a of gastric juices pro- located behind the 7th costal carti- small prepyloric vein in a shallow duced by the stom- lage, 2 to 3 cm left of midline. The groove, which is used as a landmark ach, which may cause intractable pylorus is 2.0 to 2.5 cm right of mid- during surgery. The stomach is duodenal or gastrojejunal ulcers. line in the trans-pyloric plane. The oblique and extends from the fundus The vagus nerves, which control pylorus is found in the area of L-1, downward, anteriorly and to the the amount of gastric acid present but the cardia is some distance ante- right. The lesser curvature is the in the stomach, are surgically tran- rior to T-11. These points and posi- right border, and the greater curva- sected, thereby interrupting the tions may vary considerably with ture is the left and inferior border of neural pathway. individual body build. Between the the stomach (see Figure 1). There are three methods used to cardia and pylorus of the stomach is The stomach is covered by peri- interrupt the vagus nerves. The the fundus, pyloric antrum, and the toneum except for an area posterior proximal gastric vagotomy divides pyloric canal (see Figure 1). In the to the cardiac orifice and one area the vagal nerves to the proximal upper left area of the cardia is the where the blood vessels course the stomach, but maintains the entire cardiac incisure (see Figure 1). This two curvatures. The two layers of stomach and the vagal nerves to area is between the left border of the peritoneum continue as the lesser the antrum. The selective esophagus and the stomach (see Fig- omentum at the lesser curvature and vagotomy transects the gastric ure 1). I at the greater curvature where the branches, preserving the innerva- The body of the stomach is con- I greate; omentum spreads out into tion of organs other than the stomach. The truncal vagotomy divides the vagal nerves at the distal Cardiac incisure esophagus and provides total vagal denervation of all structures below the diaphragm. This article will focus on the surgical procedure for the truncal vagotomy, including anatomic and physiologic considerations.

Anatomy The stomach (Figures 1and 2) is a saclike area of the alimentary canal. Superiorly it is closed off from the esophagus (see Figure 1)by the cardiac sphincter and from the duodenum by the pyloric sphincter (see Figures 1and 2). The stomach functions by peristaltic activity that chums and homogenizes the swallowed foods, liquids, and saliva enzymes in addition to its own enzymes. The end product that is passed into the duodenum is called Figure 1. Longitudinal section of the stomach.

THE SURGICAL TECHNOLOGIST APRIL 1993 the gastrophrenic, gastrosplenic, and gastrocolic ligaments.

Histology Inside the esophagus and at the opening of the stomach, the epithe- Duodenal bulb, lium of the esophagus changes abruptly from stratified squamous cells to simple columnar cells. The mucosa of the stomach has numer- ous folds or ridges, known as rugae. The rugae vary in height and number with the degree of distention of the organ. The entire surface of the Jejunum- gastric area is lined with depressions called gastric pits or foveolae. These depressions are shallow within the fundus while in the pyloric region they are much deeper. The epithe- lium that lines the inner surface of :@re 2. Barium swallow of the stomach and small intestine the stomach and gastric pits is made of columnar cells that function dif- jejunum. Gastrin is carried to the overlooked since it is more easily ferently from the cells of the gastric fundus, causing the parietal cells to separated from the esophagus. The glands. Overall, the characteristics of produce hydrochloric acid. posterior vagus also goes to the the stomach lining cells differentiate Hydrochloric acid then converts celiac ganglion (see Figure 3), where them from the lining cells of all other inactive pepsinogen from the chief parasympathetic fibers are distrib- parts of the digestive tract. cells into active pepsin, which acts uted to the body and the tail of the as a digestive protein. pancreas with communication to the Physiology entire small intestine and proximal The three functions of the stomach Neurophysiology colon. are to (1)mix food with gastric secre- Extrinsic innervation to the stomach The sympathetic nerves innervate tions, (2)store large quantities of comes from both sympathetic and via the greater splanchnic nerves food immediately after a meal, and parasympathetic branches of the and the celiac ganglion. The afferent (3)empty food from the stomach autonomic nervous system. Both branches from T-6 to T-10 conduct into the small intestine. carry afferent and efferent fibers. the visceral gastric pain impulses, A myriad of microscopic glands The parasympathetic innervation which are stimulated by muscle con- penetrate the mucous layer of the occurs via branches of the vagus traction, distention, and inflamma- stomach, which is lined with nerve that, when stimulated, cause tion. The efferent fibers inhibit gas- mucous-secreting cells. The glands increased gastric secretion of acid, tric secretion and motility. are categorized according to their gastrin, and pepsin, as well as There are two nerve plexus in the anatomic location within the stom- increased gastric moto; activity. The gastric wall: (1) Auerbach's, which ach. Cardiac glands are near the car- vagus nerve splits, forming two influence gastric motility, and(2) diac orifice and secrete mucous. main trunks at the level of the hiatus Meissner's, which provide innerva- Fundic glands of the stomach body (Figure 3). The anterior, or left, tion to the stomach and cause the are composed of three types of cells: vagus (see Figure 3) is found on the release of gastrin from the antrum. (1)chief cells that secrete mucous anterior wall of the.esophagus and Together they coordinate the motor and pepsinogen, (2)parietal cells divides into the hepatic and anterior and secretory activity of the gastric that secrete hydrochloric acid and gastric branches. The anterior mucosa. water, and (3) mucous neck cells that branch runs on to the front of the secrete only mucous. fundus and body of the stomach Use of Truncal Vagotomy The unstimulated stomach is while the hepatic branch runs into Bilateral resection of the vagus coated with visceral mucous mixed the lesser omentum of the liver, bile nerves in the region of the lower with an alkaline fluid. Argentaffin ducts, gallbladder, duodenum, esophagus reduces the amount of cells produce an intrinsic factor and pylorus, and right side of the pan- gastric juices produced by the stom- an antiemetic factor that allow vita- creas. ach and is one method for trea ting min BIZto be absorbed. The posterior, or right, vagus (see intractable duodenal or gastrojejunal The pyloric glands are near the Figure 3) divides into two branches: ulcers. pylorus and secrete pepsinogen and one at the posterior wall of the fun- Vagotomy eliminates cephalic mucous. A hormone called gastrin is dus at the body of the stomach and (vaga) stimulation of acid secretion secreted within the pyloric glands one at the posterior wall of the and reduces basal acid output by and the upper proximal part of the antrum. During surgery, it may be 80%to 90% and maximal (peak) acid

THE SURGICAL TECHNOLOGIST APRIL 1993 output by 50nh to 60%. Truncal vago- secreted). just under the skin. This layer is usu- tomy also denervates the antral For controlling acid in managing ally incised with the cautery pencil pump mechanism, leading to chronic recurrent pancreatitis, the or knife. The surgeon clamps large delayed gastric emptying. With the vagotomy has been used in combi- bleeders in this layer with Kelly or motor paralysis, gastric retention nation with other procedures, Crile hemostats and ligates them that follows the vagotomy must be including the use of nasogastric with an absorbable suture, size 3-0, accompanied by a concomitant gas- feeding tubes, treatment with an H, or the surgeon may simply cauterize tric resection and/or drainage proce- blocker, and pancreatico- them.

' dure. This can be done with a jejunostomy. The incision is carried through to pyloroplasty or a gastroenterostomy the next layer, the fascia. At this placed in the pyloric antrum. There Surgical Procedure level the scrub person should have is a slight preference for pyloro- The first step is to perform a laparo- small Richardson or USA retractors plasty over gastroenterostomy in tomy. Routines that are followed available for the assistant. The sur- combination with vagotomy for the during every abdominal procedure geon incises the layer with a number treatment of peptic ulcers. are discussed here (adapted from 10 or 20 knife blade, from then on The use of truncal vagotomy to Schwartz S. Principles of Surgery). referred to as the deep knife. control the cephalic phase of secre- The patient is placed in the Throughout the procedure, the tech- tion (the phase mediated by efferent supine position, prepped, and nologist must exchange soiled lap activity of the vagus nerve) is pre- draped for the specific abdominal sponges for clean ones. ferred when it is desirable to retain incision. Once'draping is completed, The surgeon may lengthen the as much gastric capacity as possible the technologist moves the Mayo fascia1 incision with the cautery pen- because of the preoperative nutri- stand up to the field below the cil or may use curved Mayo scissors. tional status of the patient with a wound site. The cautery and suction If the incision is on the midline, no duodenal ulcer. Truncal vagotomy tubing are clamped to ;he top drape muscle tissue is encountered. If, with pyloroplasty or gastroenteros- by the technologist or surgeon. The however, the incision lies off the tomy conserves the gastric reservoir technologist places two dry lap midline, there will be a layer of mus- and can be performed with a lower sponges on the field and passes a cle tissue that the surgeon will sepa- risk to these patients, who may have number 10 or 20 knife blade to the rate manually or with the scalpel. In incompletely corrected fluid and surgeon. This knife will hereafter be preparation for entrance into the electrolyte imbalance or malnutri- referred to as the skin knife and is abdomen, the technologist should tion. designated for use only on the skin. have several lap sponges and a self- While the vagotomy may control Most surgeons believe that the skin retaining retractor such as a Balfour the cephalic phase of secretion, a knife carries bacteria from the skin retractor available. The lap sponges combination of vagotomy with a into deeper layers, although some are dipped in warm (not hot) saline hemigastrectomy may be required to surgeons dispute this. solution and wrung as dry as possi- control the gastric phase of secretion The skin incision exposes the ble. If small 4x4 sponges have been (the phase during which gastrin is subcutaneous or fatty layer that lies used prior to the opening of the peritoneum, the technologist must remove them from the field immediately. They may not be used again (unless mounted on a sponge forcep) until the peritoneal layer has bpn closed. The surgeon and the first assistant each pick up the peritoneum with hemostats and ele- vate it. The surgeon then nicks the peritoneum with the deep knife and extends the incision with Metzen- baum scissors. The abdominal contents are now exposed. From this point on, only saline-moistened sponges are allowed on the field to protect the abdominal contents from injury. The technologist passes the moistened sponges to the surgeon, who covers the tissue edges to protect them from the self-retaining retractor. The Bal- four retractor is now placed in position by the surgeon and assistant. When the area of dissection has been Figure 3. Neurophysiology of the stomach.

THE SURGICAL TECHNOLOGIST APRIL 1993 located, the surgeon packs the esophageal junction. Good expo- touch. abdominal contents away from the sure at the lower end of the esopha- Following irrigation, the wound area with several lap sponges. The gus is needed; the xiphoid may be is closed. The surgeon and assistant esophagus is exposed using long removed and the left lobe of the remove all sponges and instruments Metzenbaum scissors and long fine liver may be mobilized for better from the abdomen and grasp the tissue forceps. The vagotomy can visualization of the lower esopha- edges of the peritoneum with sev- then be initiated. During the proce- gus. eral Mayo clamps. The peritoneum dure, the responsibilities of the tech- It is up to the surgeon whether to is usually closed with absorbable nologist in the scrub role include the use hemoclips or ligatures in the sutures swaged to a taper needle, following: (1)passing the dissection. Most surgeons will lig- size 0 or 2-0. Next, the fascia is instruments; (2) keeping the field ate the posterior vagus to control closed with any of a variety of mate- clear of instruments not in use; (3) possible bleeding that may take rials-silk, polyester, and polygly- ensuring the cau tery pencil is free of place in the mediastinum. colic acid sutures are commonly tissue debris; (4) exchanging soiled The surgeon first divides the used. Since the fascia is the sponges for clean ones; (5)keeping esophagus from the attached peri- strongest layer of the abdominal loose items such as needles, small toneal membrane. Once it has been wall and the integrity of the closure dissecting sponges, and suture detached from peritoneal depends upon its strength, wrappers off the Mayo stand (nee- membrane, the esophagus is interrupted sutures are used to close dles and sponges go on the field or retracted to the side with a long, 1- it in most cases. Size 2-0 suture is Mayo tray only when mounted on inch Penrose drain that has been most commonly used, although size the appropriate clamp); (6)protect- dipped in saline solution by the 0 may be used if the patient is very ing the field from contamination technologist. large or obese. The suture may be through proper aseptic technique The surgeon catches a portion of mounted on a taper or cutting nee- and notifying the surgeon of any the vagus nerve with a long nerve dle, according to the surgeon's pref- breaks in technique; (7) anticipating hook. Two long right-angle clamps erence. During fascia closure, the the surgeon's needs; (8)notifying are placed over the vagus nerve assistant retracts the skin and sub- the circulator when the surgeon proximal and distal, allowing the cutaneous layer with USA or needs his/her brow wiped; and (9) nerve to be cut with the Metzen- Richardson retractors. The subcuta- participating in sponge counts at the baum scissors between the two neous layer is closed next with inter- appropriate times. right-angle clamps. The sectioned rupted sutures of 3-0 polyglycolic During the procedure, the sur- nerve is passed to the technologist acid, chromic catgut, or plain catgut. geon may request that the patient be as either right or left vagus nerve Fine tapered needles are used. tipped into the reverse Trendelen- specimens. These specimens are At the completion of skin closure, burg position if necessary to push sent to the pathologist to confirm the technologist or surgeon places the bowel downward for more the type of nerve tissue excised. The the dressings over the wound. The visual exposure. As soon as this severed edges of the nerve are drapes are then removed and tape is request is made, the technologist clamped with ligation clips or liga- applied to the dressings. should immediately raise the Mayo tures and the procedure is repeated stand to prevent injury to the on the other side. Complications patient's legs and feet. The Mayo Many surgeons irrigate the Operative mortality with vagotomy stand must never be allowed to rest wound with warm saline solution and pyloroplasty is less than 1% on the patient. just before the abdomen is closed. (Table I). Even when this procedure For the truncal vagotomy, the The technologist must check the is performed as an emergency, oper- vagus nekes may be divided sev- saline to be sure that it is not too ative mortality is relatively low in eral centimeters above the hot; it should feel comfortable to (Continued on page 24)

Table 1. Surgical Procedures for Treatment of Peptic Ulcer Disease*

Procedure Operative Mortality Late Postoperative Complications A / 4 - Dumping *Diarrhea Recurrent Ulcers Elective Emergencv -Mild Severe Mild Severe Truncal vagotomy and 4% <7% 20% 2% 20% 2% 7%-10% pyloroplasty Truncal vagotomy and 1O/O 9%-15% 30% 2%-5% 20%-30% 2% 1O/O antrectomy Proximal gastric 0.1% 1% 0.5% 0% 1%-2% 0% 10% vagotomy *Adapted from Kinney et al. Manual of Preoperntivr and Postoperative Care.

APRIL 1993 weeks postoperatively. The gas- Expanding Horizons-continued trostomy tube is removed noear- lier than 10 days postoperatively On a case such as the one last contrast to an operative mortality and may be done on an out- evening, I was kept busy with set- of 9% to 15%following emer- patient basis. ting up the room, opening sup- gency vagotomy and antrectomy. plies, and assisting with the prep Three months after surgery the in addition to completing the Postoperative Care patient is recalled for a clinical large amount of paperwork gen- The postoperative management is evaluation for an upper gastroin- erated by lab requisitions and identical for pyloroplasty and testinal x-ray evaluation to deter- chartwork. mine the adequacy of gastric gastroenterostomy. Dissection emptying and for a basal gastric Processing is another area from manipulation around the analysis to evaluate the adequacy where surgical technologists are left leaf of the diaphragm makes of the vagotomy. A found. Sterile procurement of the left lower lobe atelectasis a fre- tissue also requires sterile quent occurrence. Adequate ven- Bibliography processing. Having technicians tilation should begin immediately Guyton. CA. Text of Medical Physiology. trained in the art of sterile tech- in the postoperative period. Inter- 5th ed. Philadelphia, Pa: WB Sun- nique is important. They are mittent positive pressure breath- ders; 1989. responsible for preparing the tis- ing should be used freely during Kinney JM, MD, Egdahal RH,MD, sue for transplant: clearing mus- postanesthetic recovery. Particu- Zuidema GD, MD, eds. Manual of cle from the bone and cutting it Preoperative and Postoperative Care. lar attention is paid to tracheo- 2nd ed. Philadelphia, Pa: WB Sun- into pieces and sizes we have bronchial toilet. The patient is ders; 1971. requested. If they are working on encouraged to deep breathe and Lothar, Wicke. Atlas of Radiologic a heart, they will excise the pul- cough, with tracheal aspiration Anatomy. 3rd ed. Baltimore, Md: monary and aortic valves and and bronchoscopy used freely. Urban & Schwarzenberg; 1982. freeze them in liquid nitrogen. Temporary tracheostomy may be Pansky. Review of Gross Anatomy. 2nd Allograft tissue usage has life-saving in patients with pre- ed. London: MacMillan Company; 1984. grown in the past few years. existing chronic lung disease. Schwartz S. Principles ofsurgery. 4th ed. Heart valves are in great demand Temporary gastrostomy is used in New York: McGraw-Hill; 1984. and are used primarily in pedi- all cases to prevent distention of Sodeman W, Sodeman, W. Pathologic atric surgery. Surgeons are able to the vagotomized stomach by Physiology of Disease. 5th ed. Philadel- repair a tear of the anterior cruci- swallowed air and retained secre- phia, Pa: WB Saunders; 1984. ate ligament using an iliac wedge. tions. The gastrostomy catheter is Wyngaarden JB, MD, Smith LH, MD, eds. Cecil's Textbook of Medicine. 18th Limb salvage is now possible, in connected to straight drainage for ed. Philadelphia, Pa:-WBSaunders; some instances, utilizing a large 3 continuous days, and is 1988. allograft such as a distal femur. clamped on the evening of the Using cadaveric tissue eliminates third postoperative day. Gastric the need for additional surgery residual is measured the next and cuts down the possibility of morning; if it is less than 100 cc, infection, as well. Patients whose the tube is reclamped and the lives are enhanced through trans- patient is given 30 cc of water plantation truly feel they have each hour. Residual is measured received a gift. twice daily. If it remains low, As you can see, there are many fluid intake is increased on day 5 changes and challenges to be met to 60 cc of clear liquids each hour. for surgical technologists. The On day 6, clear liquids are permit- field of transplantation will con- ted and intravenous administra- tinue to expand into the twenty- tion of fluids is discontinued. As a first century. My career has been, result of continued low gastric and remains, very rewarding. 1 residual, a soft diet should be would encourage anyone who given for day 7 following surgery. has an interest in transplantation Since the pyloric sphincter has to explore the opportunities avail- been ablated, the patient may be Richard E. Wills,MD,is medical director aM able in this exciting field. A subject to "dumping." High car- Peggy E. Grusendorf, MS, RNP, is president Susan Warren, CS7, CTBS, is a contribut- bohydrate liquids should be of intermountain Medical Research in Orem, ing editor for The Surgical Technologist. specifically prohibited for 6 Utah.

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