Operating Room Setup & Nursing Guide
A practical guide written from the perspective of an Operating Room Nurse.
The workflows, surgeon preferences, and nursing tips presented in this article are based on the author’s real clinical experience. Surgical techniques and operating room practices may vary depending on the surgeon, hospital, and institutional protocols.
📌Quick Facts
| Item | Description |
|---|---|
| Procedure | Distal Gastrectomy with Billroth I Reconstruction |
| Organ | Stomach, Duodenum |
| Reconstruction | Gastroduodenostomy (Billroth I) |
| Common Indications | Early gastric cancer, distal gastric cancer, refractory gastric ulcer |
| Anastomosis | End-to-end or end-to-side Gastroduodenostomy |
| Reconstruction Method | Hand-sewn or Circular/Linear Stapled |
Introduction
Distal gastrectomy with Billroth I reconstruction is a standard procedure for diseases involving the distal stomach. After removing the antrum and pylorus, continuity of the gastrointestinal tract is restored by directly connecting the remnant stomach to the duodenum (gastroduodenostomy).
Billroth I is preferred whenever the duodenum can be safely mobilized and tension-free anastomosis is achievable because it preserves the normal physiological food passage.
Indications
- Early gastric cancer
- Distal gastric adenocarcinoma
- Selected gastric ulcers
- Gastric adenoma
- Gastrointestinal stromal tumors (selected cases)
Contraindications
Billroth I reconstruction may not be appropriate when:
- Duodenal mobilization is inadequate
- Excessive anastomotic tension exists
- Large gastric resections are required
- Tumor invasion involves the proximal duodenum
In these situations, Billroth II or Roux-en-Y reconstruction is generally preferred.
Surgical Anatomy
Important structures include:
- Distal stomach
- Pylorus
- First portion of duodenum
- Greater omentum
- Lesser omentum
- Right gastric artery
- Right gastroepiploic artery
- Left gastric artery
- Vagus nerve branches
🕒Procedure Timeline
1. Midline Laparotomy
Upper midline abdominal incision.
2. Exploration
- Inspect abdomen
- Confirm resectability
- Exclude distant metastasis
3. Mobilization
- Divide greater omentum
- Divide gastrocolic ligament
- Mobilize pylorus
- Kocher maneuver if necessary
4. Lymph Node Dissection
Typical D1+ or D2 lymphadenectomy including:
- Station 1
- Station 3
- Station 4
- Station 5
- Station 6
- Station 7
- Station 8a
- Station 9
(depending on disease stage)
5. Gastric Transection
The stomach is divided using:
- Linear stapler
or - Hand-sewn technique
The resection margin is confirmed before transection.
6. Duodenal Transection
The duodenum is divided approximately 1–2 cm distal to the pylorus.
7. Specimen Removal
The specimen is sent for:
- Frozen section (if needed)
- Permanent pathology
Billroth I Reconstruction
Option 1. Hand-sewn Anastomosis
The posterior wall is usually sutured first.
Typical sequence:
- Posterior seromuscular layer
- Posterior full-thickness layer
- Anterior full-thickness layer
- Anterior seromuscular reinforcement
Interrupted Lembert sutures are commonly used for reinforcement.
The anastomosis should remain:
- Well perfused
- Tension free
- Wide enough to prevent stenosis
The PDF also demonstrates reinforcement sutures such as Lembert, Connell/Cushing, and the final Crown stitch placed around the Angle of Sorrow, where leakage commonly occurs.
Option 2. Stapled Anastomosis
A circular stapler is frequently used.
General steps:
- Purse-string suture on duodenum
- Anvil insertion
- Gastrotomy creation
- Stapler body insertion
- Docking of anvil
- Fire stapler
- Remove stapler
- Inspect donuts
- Close gastrotomy with linear stapler
OR Nurse’s Role
Before Reconstruction
Prepare:
- Linear staplers
- Circular stapler (EEA)
- Appropriate cartridge sizes
- Purse-string instrument (if used)
- Silk ties
- Absorbable sutures
- Non-absorbable sutures
During Anastomosis
Monitor:
- Stapler loading
- Anvil assembly
- Stapler firing
- Integrity of tissue donuts
- Leak test preparation
Count all needles before closure.
Common Instruments
Basic Instruments
- DeBakey Forceps
- Metzenbaum Scissors
- Mayo Scissors
- Kelly Clamp
- Kocher Clamp
- Allis Clamp
- Babcock Forceps
- Needle Holder
Energy Devices
- Harmonic Scalpel
- LigaSure
Retractors
- Bookwalter Retractor
- Thompson Retractor
Stapling Devices
- Linear Cutter
- Linear Stapler
- Circular Stapler (EEA)
- TA Stapler (optional)
Common Suture Materials
- Vicryl 3-0
- Vicryl 4-0
- PDS 3-0
- Silk 3-0
- Prolene (occasionally)
⚠️Common Pitfalls
| Pitfall | Prevention |
|---|---|
| Anastomotic leak | Tension-free anastomosis with good blood supply |
| Anastomotic stricture | Create an adequately sized stoma |
| Bleeding | Careful inspection before closure |
| Stapler misfire | Verify cartridge and tissue thickness |
| Ischemia | Preserve vascular supply |
💎Pearls from the OR
✅ Ensure the anastomosis is completely tension-free.
✅ Verify adequate blood supply before reconstruction.
✅ Inspect both stapler donuts after firing.
✅ Reinforce the Angle of Sorrow, the most vulnerable point for leakage.
✅ Always perform a meticulous leak test before abdominal closure.
Postoperative Care
Monitor for:
- Anastomotic leak
- Bleeding
- Delayed gastric emptying
- Ileus
- Infection
- Nutritional status
Early ambulation and gradual diet advancement are encouraged.
FAQ
Why choose Billroth I over Billroth II?
Billroth I preserves the normal physiological route of food through the duodenum, which may provide better digestive function when a tension-free gastroduodenostomy is feasible.
When is Billroth I not possible?
If the duodenum cannot be mobilized sufficiently or the anastomosis would be under tension, Billroth II or Roux-en-Y reconstruction is generally selected.
What is the “Angle of Sorrow”?
The Angle of Sorrow refers to the junction where the gastric stump and duodenum meet during Billroth I reconstruction. It is considered a common site for leakage, so many surgeons reinforce this area with a Crown stitch.
Key Takeaways
- Billroth I reconstruction restores continuity by directly anastomosing the remnant stomach to the duodenum.
- A tension-free, well-vascularized anastomosis is essential for successful healing.
- Both hand-sewn and stapled techniques are widely practiced, depending on surgeon preference and intraoperative conditions.
- Careful reinforcement of the Angle of Sorrow and inspection of the anastomosis help reduce postoperative complications.
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