What states require strict obedience to dillon's rule

Exploratory laparotomy. 2. P artial gastrectomy (antrectomy). 3. Truncal vagotomy. 4. Gastrojejunostomy. 5. Cholecystectomy with intraoperative cholangiogram. rNDrcATroN: The patient is a 60-year-old female who presented with a nonhealing gastric ulcer. She has had symptoms for about a year. She complains of epigastric pain. Medical therapy with prilosec failed, as did therapy for H. pylori. Biopsy of the ulcer has been done, and it was benign. The patient had a negative workup for gastrinoma. calcium level was also normal. The patient now presents for exploratory laparotomy and partial gastrectomy. The risks and benefits were discussed with the patient in detail. She understood and agreed to proceed.

PROCEDURE: The patient was brought to the operating room. Her abdomen was prepped and draped in a sterile fashion. A midline umbilical incision was made. The peritoneal cavity was entered. Initial inspection of the peritoneal cavity showed normal liver, spleen, colon, and small bowe1. There was an ulcer along the first portion of the duodenum just beyond the pylorus with some scarring. There was also an ulcer in the posterior part of the duodenal bulb, which was penetrating to the pancreas. we started dissection along the greater curvature of the stomach. vessels were ligated wrth 2-0 silk ties. There was an enlarged lymph node along the greater curvature of the stomach, which was sent for frozen section. It proved to be a benign lymph node. This was the only enlarged node found during dissection. we then proceeded with truncal vagotomy. The anterior r,agus

Copyright @ 2015 by Saunders, an imprint of Elsevier Inc. A11 rights reserved.

APPENDIX A .r Reports

and posterior vagus were identifled. They were clipped proximally and

distaily, and a segment of each nerve was excised and sent for frozen

section, and a segment of both vagus nerves was excised and confirmed by

frozensection. An incision was made around the gastrohepatic ligament'

The mesentery along the lesser culvatule of the stomach was dissected.

The vessels were ligited with 2-0 silk ties along the lesser-curvatule of the

stomach. A Kocheimaneuvel was performed to aid mobilization. The

pancreas was completely normal. No masses were found in the pancfeas.

tfr"r. was penetraiion of the ulcer in the superior part of the head of the pancreas. iissection was continued posterior to the stomach. The adhesions

iosterior to the stomach were taken down. The ulcer was in the posterior

i"grrr.rrt of the duodenal bulb iust beyond the pylorus and it had pJnetrated the pancreas. All the posterior layer of the ulcer that was left

idherent to the pancreas was shaved off. The stomach was divided with

ift" Cn stapler * tttut the complete antrum would be in the specimen. The duodenum was divided betweert clamps. The stomach pylorus and

f,rst part of the duodenum were sent to pathology for-examination' Then

the duodenal stump was closed with running suture. Using 3-0 Lembert

sutures, the posterior wall of the ulcer was incorporated for duodenal

closure. The^base of the duodenum was rolled over the ulcer, and it was all-incorporating to the duodenal closure. Our next step was to proceed

with cholecysteitomy. The galibladder was separated from-the liver,

reflected, and taken do*r, ind the gallbladder was divided from the liver with blunt dissection and cautery. The cystic altely was doubly ligated

with silk. The cystic duct was identified. The cystic duct and gallbladder junction and gittbtadder ducts were identified. Intraoperative thoiangiogram was performed showing free flow of bile into the

intrahJpatlc duct ur'd i.rto the duodenum. No leaks were seen. The cystic

duct wis doubly ligated, and the gallbladder was sent to pathology. The

staple line in the pioximal stomaih was oversewn with 3-0 silk Lembert ,rtirr.r. A retrocoiic isoperistaltic Hofmeister-t)?e gastrojejunostomy was performed on the remaining stomach and loop of ieiunum. This was an

isoperistaltic end-to-side two-layer anastomosis with 3-0 chromic and 3-0 silk. The stomach was secured to the transverse mesocolon with several interrupted silk sutures to prevent any herniation along the retrocolic space. The anastomosis had a good lumen and good blood supply. There was no twist along the anastomosis. Before the anastomosis was finished, a nasogastric tube was placed along the afferent limb of the jejunum to decompress the duodenum and prevent blow out of the duodenal stump. Extra holes were made in the NG tube to provide adequate drainage. The anastomosis was marked with two clips on each