THE STOMACH. 405 



Adhesions and ulceration are common. They are so marked that peritonitis 

 from acute perforation is moderately rare. The adjacent organs are matted together 

 and purulent collections are liable to occur. The ulceration may open into adjacent 

 organs, as the colon. The colon may be adherent to the stomach and the large 

 omentum contracted into a roll. The adhesions and pressure from the growth often 

 interfere with the biliary ducts, and jaundice ensues ; interference with the portal 

 vein and vena cava causes ascites, and thrombosis of the veins sometimes occurs. 

 In this disease, as in gastric ulcer, adhesions are least liable to form on the anterior 

 wall, and here perforation requiring operation is most likely. 



OPERATIONS ON THE STOMACH. 



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 ; gastroplicalion, or 

 the folding of the walls to reduce its size; and gastro-enterostomy , or the establishing 

 of a fistula between the stomach and the small intestine. 



Technic. The incision for gastrostomy is 4 cm. (i^ in.) long, over the outer 

 third of the left rectus muscle, beginning 2 cm. ( ^ 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 trans- 

 verse 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 stoniach, 



