Page 512 - WSAVA2018
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 25-28 September, 2018 | Singapore
the 13th rib).
Disadvantages include: heavy sedation or general anesthesia is necessary for placement of tube.
Rarely a temporary gastrostomy may need to be performed. The patient is placed in left lateral recumbancy with the right flank area clipped and surgically prepared. Heavy sedation and local infiltration of lidocaine or light general anesthesia is performed.
A 4 - 5 cm incision is made in the skin over the point
of greatest gastric distention (generally 1 - 2 cm caudal to the 13th rib and 2 - 3 cm distal to the transverse processes of the lumbar vertebrae). A grid technique is used to gain entrance into the peritoneal cavity. Due to severe gastric distention the stomach wall is pressed against the abdominal wall and easily identified through the flank incision. The stomach wall is sutured to the skin using a simple continuous pattern with 3-0 Maxon. This is done prior to incising into the stomach lumen. A #11 BP scalpel blade is used to puncture into the lumen of the stomach. Gas and stomach contents are expelled under pressure so stand back! The gastric mucosa is evaluated for viability. Disadvantages of gastrostomy include: the stomach is sutured in its rotated position and more time is required when definitive surgical treatment is performed due to the necessity of closing the gastrostomy.
Successful stomach tube placement: Once the stomach tube has been passed into the stomach or gastrostomy performed, the stomach is lavaged with warm water. If
a stomach tube was successfully passed, the stomach contents should be evaluated for color and presence or absence of necrotic gastric mucosa. This may give an impression of gastric viability.
Surgical Treatment;: Surgical procedures utilized in the treatment of gastric dilatation-volvulus can be divided into two categories; 1) immediate decompression and
2) therapeutic gastropexy. Immediate decompression
is performed with a successfully passed stomach tube secured to the patient or temporary gastrostomy as described above. Therapeutic or prophylactic gastropexy techniques are described below.
Gastric repositioning: Anatomic repositioning of the stomach is necessary to perform prior to permanent gastropexy. Repositioning occasionally occurs spontaneously at the time of gastric decompression. Knowledge of normal anatomy is necessary to understand how repositioning is performed.
A specific ‘Surgical Plan’ should be in mind before entering the operating room theatre. This will improve the efficiency of surgery and thus decrease overall surgery time. The ‘authors’ surgical plan is as follows:
Stand on the right side of the patient.
Provide generous abdominal exposure via xyphoid to
pubis midline laparotomy.
Remove of all of the falciform ligament to the level of the xyphoid.
Place a 10’’ Balfour self retaining abdominal retractor with full retraction.
Confirm that the omentum is draped over the exposed surface of the stomach (pathagnomonic for GDV)
Exteriorize the spleen from the abdominal cavity. Evaluate color, texture, blood flow (splenomegaly is always present and is NOT an indication for splenectomy)
Splenectomy is rarely performed but may be necessary if splenic vessels are infarcted.
If the stomach is full of air or fluid it should be emptied, if possible, prior to attempting derotation. If the stomach is full of food and several attempts to derotate (see author’s technique below) are unsuccessful, perform a gastrotomy and manually remove the food from the stomach lumen. Suture the gastrotomy and attempt derotation again.
Attempt derotation by:
Standing on the patients’ right side, first reach your right hand across the abdomen and place it between the left body wall and dilated stomach.
Slide your right hand along the sublumbar body wall and grasp the deep (dorsal) aspect of the stomach.
Next, place the open palm of your left hand on the exposed surface of the right side of the dilated stomach.
Using both hands simultaneously, pull the deep part of the stomach with your right hand to begin derotation whilst you push the right surface of the stomach down toward the patients sublumbar body wall with your left hand. This maneuver will be successful in the majority of cases.
See this maneuver performed on the Emergency Surgery I, Gastrointestinal Surgery I, and Soft Tissue Surgery II DVD’s available at
Once the stomach is derotated, evaluate the stomach
for evidence of viability abnormalities (particularly the greater curvature and fundus) and for evidence of gastric motility.
Commence your gastropexy procedure.
Incisional gastropexy: This technique is based on a 3-4cm long seromuscular antral incision sutured to a similar length incision in the transversus abdominus muscle.
With the Balfour retractors still in place visually locate
the ideal position for the antral wall incision. It should
be located equidistant between the pylorus and gastric incisure and equidistant between the greater curvature and lesser curvature of the stomach. A 3-4 cm sero- muscular incision is made in this antral location. An easy way to safely make the sero-muscular incision is to grasp the full thickness antral wall with your thumb and finger

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