300 THE ABDOMEN AND PELVIS 



Pylorectomy. The feasibility of pylorectomy or partial 

 gastrectomy having been recognised, the first step in the 

 operation consists of the division of the lesser omentum near 

 the liver. It is then stripped away with gauze in a downward 

 direction, care being taken to avoid injury to the important 

 structures in its right free margin. The first part of the 

 duodenum is separated from the portal vein and the head of the 

 pancreas (Fig. 87), and rendered freely movable. At the 

 same time the gastro-duodenal (or right gastro-epiploic) and 

 the right gastric vessels are exposed, ligatured, and divided. 

 The duodenum is then cut through between two clamps, about 

 i or i inches beyond the pylorus, and its distal stump is 

 invaginated. Next, the stomach is drawn downwards and to 

 the left, and the left gastric vessels are ligatured close to the 

 cardia. The lower blade of a clamp is now passed through the 

 greater omentum below the gastro-epiploic vessels and carried 

 upwards through the omental bursa behind the stomach. The 

 superficial blade follows anteriorly, and the clamp is then fixed 

 in such a way as to remove as much of the lesser curvature and 

 as little of the greater as may be necessary. After ligature of 

 the left gastro-epiploic vessels, the area thus mapped out is 

 removed along with its associated lymph glands. The proximal 

 cut surface of the stomach is closed, and a posterior gastro- 

 enterostomy completes the operation. 



In the course of malignant disease of the lesser curvature, the 

 cceliac lymph glands are involved secondarily to the coronary 

 and supra-pyloric, and the infection may be carried down into 

 the pelvis by retro-peritoneal lymph vessels. Secondary 

 deposits frequently occur in the liver. They may be due to the 

 primary growth ulcerating into the gastric veins and the passage 

 of cancerous emboli along the portal vein ; or the spread may 

 be by the lymph vessels. In this case the coronary lymph 

 glands become obstructed by the disease, and, as a result, stasis, 

 or a reversal of the direction of the flow, occurs in the lymph 

 vessels which they receive from the liver. 



If cancer cells pass along the efferents of the cceliac lymph 

 glands and enter the thoracic duct, they may subsequently 

 infect the left lower anterior group of the deep cervical lymph 

 glands (p. 133); which are sometimes found enlarged in malignant 

 disease of the stomach. From the thoracic duct the cells may 

 pass into the left innominate vein and so be deposited in any 

 part of the body. 



