Gastric Perforation (Gastrotomy)/Necrosis

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Bog'liq
abdominal surgery

• Consequence
Gastrotomy results in the spillage of gastric contents into the abdominal cavity, resulting in peritonitis. This can present immediately in the operating room from direct penetrating injury to the stomach during dissection, or it may present later with a delayed perforation from thermal injury or serosal tears during dissection. Use of a harmonic scalpel near the stomach can contribute to thermal or serosal injuries that may result in delayed perforation.

• Repair

If recognized during the procedure, primary repair of a gastric perforation may be attempted laparoscopically; however, it is recommended to convert to laparotomy. A delayed perforation requires laparotomy for repair.

It is not uncommon for the proximal greater curve of the stomach to directly abut the spleen. Therefore, appropriate traction and clear visualization of tissues during division of the short gastrics are essential. Care must also be taken to appreciate the structures that the heated portion of the dissector may touch. The ultrasonic dissector allows for less dissection around the vessels close to the stomach and spleen, reducing the incidence of gastric perforation.

Treatment
Pyloric atresia can usually be recognized at the time of operation; a fibrous cord may join two blind ends (Fig. 79-3). Gastrotomy and distal passage of a catheter may be required to detect membranous obstructions (Fig. 79-4). Excision of a complete or partial diaphragm with Heineke-Mikulicz or Finney pyloroplasty is the most straightforward corrective procedure.

Haller and Cahill warn against missing a pyloric web in association with a duodenal atresia. They recommend a wide gastrotomy and distal passage of a catheter after excision of the prepyloric diaphragm to identify an associated duodenal diaphragm. In the presence of pyloric atresia with the atretic ends separated by a cordlike or discontinuous segment, gastroduodenostomy is necessary

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