Department of Topographic Anatomy

and Operative Surgery of KSMU

Lection 1
Professor Andreeva S.
 The stomach is located
in the upper floor of the
abdominal cavity.
 It has 2 walls: front and
back,
 two edges – Upper
(small curvature) and
lower (large curvature).
 Departments: cardiac,
bottom, body, pyloric
(pyloric)
 serous membrane
(outer), covered with
peritoneum,
 middle shell (muscular)
- represented by three
layers of smooth
muscles,
 inner (mucous)
membrane - forms folds
and gastric dimples,
formed by a single-layer
cylindrical epithelium.
 Cardia - X thoracic
vertebra (Th X);
 The pyloric part
(gatekeeper ) is the
I lumbar vertebra (L I).
b - rear wall:
1 - facies lienalis - splenic surface,
2 - facies suprarenalis - adrenal surface,
3 - facies renalis - renal surface,
4 - facies pancreatica,
5 - facies colica - intestinal surface

a - front wall:
1 - facies hepatica - hepatic surface,
2 - facies diaphragmatica -
diaphragmatic surface,
3 - facies libera - free surface
 a - front wall:
 1 - facies hepatica - hepatic
surface,
 2 - facies diaphragmatica -
diaphragmatic surface,
 3 - facies libera - free surface

 b - rear wall:
 1 - facies lienalis - splenic
surface,
 2 - facies suprarenalis - adrenal
surface,
 3 - facies renalis - renal surface,
 4 - facies pancreatica,
 5 - facies colica - intestinal
surface
 Surface bonds:
 Gastrocolic (branches of
gastroepiploic vessels, risk
of damage to a.colica
media in mezocolon);
 Gastro-splenic (short
gastric vessels);
 Left gastro-diaphragmatic
(without vessels);
 Hepatogastric (left and
right gastric arteries).
 Hepato-12-duodenal
(pyloric) ligament (pass
the hepatic artery,
common bile duct and
portal vein) ligaments
form a lesser omentum.
 - between the back wall
and the body of the
pancreas: the upper (left)
gastro-pancreatic
ligament (the left gastric
vessels pass);
 Lower (right) pyloric-
pancreatic ligament.
 Lateral diaphragmatic-
esophageal ligaments.
 Arteries of lesser curvature -
 Left gastric a. - in 75% of the
celiac trunk (has retroperitoneal,
intraligamentous and omental
sections);
 The right gastric a. - more often
from its own hepatic - as part of
the hepatoduodenal ligament
anastomoses with the left;
 arteries of greater curvature
 The left gastroepiploic (splenic
branch) forms anastomoses with
the right gastroepiploic a.;
 The right gastroepiploic a.- from
the gastroduodenal artery
between the sheets of the
gastrocolic ligament.
 Short ones - from the splenic
artery - supply the body and
bottom with blood.
 Left gastric vein - drains the
upper 2/3 of the stomach, flows
into the portal vein;
 Right gastric - blood from the
pyloric section and part of the
duodenal 12, flows into the
portal vein.
 Right gastroepiploic vein - blood
from part of the stomach and
pylorus, flows into the superior
mesenteric vein;
 The left gastroepiploic vein -
from the bottom and the greater
omentum - into the splenic vein.
 Short veins drain into the splenic
vein.
 (branches of the vagus nerve
and celiac plexus)
 Parasympathetic innervation.
The anterior (left) trunk of the
vagus nerve - on the anterior
surface of the esophagus and
cardia, along the lesser
curvature;
 Distal branch - n.Letarge -
innervates the antral and pyloric
sections
 Posterior trunk (right) - along
the posterior surface of the
esophagus, in the cardia along
the lesser curvature in the form
of branches to the liver;
 Sympathetic innervation.
Branches of the large and small
splanchnic nerves.
 Spinal (afferent) -from the
phrenic nerve.
 branches of the left
vagus nerve.
 branches of the right
vagus nerve
 1. Right paracardial
lymph nodes; 2
 2. Left paracardial lymph 1
nodes;
 3. Lymph nodes of the
lesser curvature of the
5 3
stomach
 4. Lymph nodes of the
greater curvature of the 6
stomach;
 5. Suprapyloric lymph 4
nodes;
 6. Subpyloric lymph
nodes;
 7. Lymph nodes of the left gastric artery;
 8. Lymph nodes of the common hepatic artery;
 9. Lymph nodes of the celiac trunk;
 10. Lymph nodes of the gate of the spleen;
 11. Lymph nodes in the middle of the splenic artery;
 12. Lymph nodes of the hepato-12-duodenal ligament;
 13. Lymph nodes of the posterior surface of the head of the
pancreas;
 14. Lymph nodes of the base of the superior mesenteric artery;
 15. Lymph nodes of the middle colic artery;
 16. Paraaortic lymph nodes.
 From the lymph nodes of the first 6 groups (paracardial) metastasis to the
celiac trunk, and then to the paraaortic lnn;
 from the group of the hepato-12-duodenal ligament, the lymph flows into
the paraaortic lnn. and into the lymph collector of the hepatic artery;
 in cancer of the body of the stomach along the ln. collector of the left
gastric artery and the common hepatic artery;
 in cancer of the cardial part of the stomach - along the collector of the left
gastric artery and splenic artery.
 Incisions for interventions on the
stomach
- Upper median laparotomy;
- Pararectal access;
- Combined (longitudinal-transverse) incision.
 Gastrotomy
This is an operation in
which the opening of the
lumen of the stomach is
performed, followed by
suturing this incision.

(D. Shvabe, 1635,

Königsberg medical
faculty)
• Polyps of the stomach
• Infringement in the pylorus
of the prolapsing gastric
mucosa
• Fissures of the gastric
mucosa (Mallory-Weiss
syndrome)
• benign tumors
• Foreign bodies of the
stomach
• Bleeding ulcer (in cases
where resection is not
indicated)
 The imposition of an external artificial fistula with
obstruction of the esophagus or its functional
shutdown.
Indications:
 Wounds of the thoracic esophagus;
 Presence of esophago-tracheal (bronchial) fistula;
 Cicatricial strictures of the esophagus (burns);
 Malignant tumors with obturation of the lumen.
Gastrostomy methods:
 Creation of a temporary gastrostomy (tubular or
canal fistula);
 Formation of a permanent gastrostomy (formation
of a labial fistula).
Operation progress
Gastrostomy according
to Stamm-Kader
the imposition of an
anastomosis between the
stomach and the small
(jejunum) intestine.
Indications: Stenosis of the
outlet section of the
stomach of an ulcerative or
cancerous nature.
Options:
Anterior anterior colonic
gastroenterostomy;
Posterior anterior colic;
Anterior retrocolic;
Posterior retrocolic
Anterior anterior colonic
gastroenterostomy
(according to Wölfler)

Operational reception:
On the site of the jejunum (40-60 cm
from the 12-duod-jejunal bend-
ligament of Treitz) and the anterior wall
of the stomach, anastomosis is applied
with a gray-serous continuous suture;
The lumen is opened and the posterior
and then the anterior lips of the
anastomosis (Schmiden suture +
Lambert suture) are sutured through all
layers with a continuous suture.
Imposition of an entero-
enteroanastomosis according to Brown
to prevent the formation of a "vicious
circle".
 Posterior retrocolic gastroenterostomy
(according to Gakker in Petersen's
modification).
Operational reception:
A loop of the jejunum 10 cm
from the ligament of Treitz to
the handles;
In the avascular zone, a window
is made in the mesentery of the
transverse colon;
Positioning the afferent end
above the outlet end, a posterior
retrocolic HEA is applied
according to the described
method (without Brownian).
 Resection of
the stomach
is the removal of part of the
stomach with the restoration of
the continuity of the
gastrointestinal tract
Indications:
Peptic ulcer and its
complications;
Tumors of the stomach.
Operative access: upper median,
transverse laparotomy and
thoracolaparotomy.
Operational reception:
Mobilization of the stomach;
Resection of the stomach;
Made anastomosis.
STAGES:
1. Mobilization of the stomach.
Resection borders - along the lesser curvature - at the level of the 1st
transverse branch of the left gastric artery;
- along the greater curvature - 1-2 cm above the lower branch of the
gastroepiploic artery.
2. Cutting off the stomach:
a) intersection of the ligaments of the stomach - along the greater
curvature, the intersection of the gastrocolic ligament; along the
lesser curvature - hepatic-gastric;
b) ligation and intersection of the main vessels of the stomach at the
level of resection: along the lesser curvature - the right and left
gastric arteries and veins, along the greater curvature - the right and
left gastroepiploic arteries and veins.
3. Resection of the stomach after applying clamps - Payr's intestinal
pulp and Payr's gastric pulp, a part of the stomach is resected on
the vessels of the Kocher clamps with a scalpel.
Anastomosis
(Operation Billroth - 1 and Operation Billroth - 2 and
their modifications).
OPERATION Billroth -1 - suturing the stomach stump
from the side of the lesser curvature, suturing the
ends of the duodenum and the lumen of the stomach
(end-to-end anastomosis and its modifications).
Flaws:
 the possibility of divergence of the seams due to poor
vascularization and the absence of a serous cover of
the posterior wall of the duodenum;
 the possibility of failure due to the tension of the
seams.
 The stump of the duodenum after resection is sutured
tightly;
 after suturing the stomach stump, a gastrojejunal
anastomosis is applied (various options).
 Methods for closing the stump: two-row suture
(continuous catgut and purse-string gray-serous), or
interrupted sutures. The stump of the stomach after the
imposition of hemostatic sutures is immersed with serous-
muscular sutures.
 Types of GE anastomoses: end of the stomach to the side
of the intestine; side of the stomach to the side of the
intestine; side of the stomach to the end of the intestine.
 - different location of the anastomosis in relation to the
POC; iso- and anti-peristaltic direction.
1. 2/3 of the stomach stump is sutured, and the
end-to-side anastomosis is applied at the
greater curvature;
2. GEA on a short loop of the jejunum is carried
out behind the POC;
3. The afferent loop of the jejunum is sutured to
the sutured part of the stomach and the lesser
curvature (creating a spur-valve).
Crossing of the trunks and branches of the vagus nerve and
plastic interventions on the pyloroduodenal zone.
1. Vagotomy: bilateral supra- and subdiaphragmatic;
2. Selective proximal vagotomy (SPV) - isolated intersection of
the branches while maintaining the branches of n.Latorge
that innervates the pylorus; (according to Inberg and Hall);
3. Selective vagotomy (SV) - the intersection of all branches of
n.vagus while maintaining the main trunks going to the
hepatic and celiac plexuses.
Proximal selective
vagotomy
 Complications of
gastroduodenal ulcers
Classification of complications of
gastroduodenal ulcers:
Perivisceritis,
Deformities of the stomach or duodenum;
Gastroduodenal bleeding;
ulcer penetration;
ulcer perforation;
Stenosis of the pylorus
or 12 duodenal ulcer.
 The main causes of gastroduodenal
bleeding
• Ulcers of the stomach and duodenum (40%);
• Hemorrhagic gastritis (20%);
• Mallory-Weiss syndrome (10%);
• Varicose veins of the esophagus
and cardia (15%);
• Tumors (benign and malignant)
of the stomach (5%)
• Other reasons (10%).
 Principles of surgical treatment of a
bleeding ulcer
1.Medicated hemostatic correction:
a) temperature effects (local hypothermia);
b) medicinal hemostatic effect (E-AAC, octreatide, etc. and
replenishment of blood loss;
c) endoscopic methods of hemostasis (introduction of film-forming
adhesives, electrocoagulation, laser photocoagulation, ferracol,
caprofer, etc.)
2. Operations (emergency, urgent and planned):
a) gastro(duodeno)tomy, stitching (ligation) of a bleeding vessel
(laparoscopically);
b) stitching of the ulcer;
c) excision of the ulcer (anterior wall).
d) stem vagotomy and pyloroplasty;
e) selective vagotomy and antrumectomy;
g)resection of 2/3 of the stomach (or subtotal).
Perforation of the ulcer into the
free abdominal cavity
 Indications for surgical
treatment of gastric ulcer
Indications

Absolute Relative

• Malignization • Puberty in any of the organs

• Perforation (often in the pancreas)
• Bleeding • Compensated stenoses
• Decompensated stenosis of outlet of the stomach
the outlet of the stomach or • Calous ulcer
duodenum • long-standing peptic ulcer, which
not amenable to treatment
 Methods of surgical treatment
 Sewing up the perforated
hole;
 Suturing with omentopexy;
 Excision of the ulcer and
vagotomy;
 resection interventions;
 ! Mandatory sanitation and
drainage of the abdominal
cavity.
 compensated;
 Sub-compensated;
 decompensated.
 Operations: Palliative - bypass anastomosis;
Radical: organ-preserving (pyloroplasty and
vagotomy) and resection.