OR Procedure Note
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 II Reconstruction |
| Organ | Stomach, Jejunum |
| Reconstruction | Gastrojejunostomy |
| Common Indications | Distal gastric cancer, advanced gastric cancer, complicated peptic ulcer disease |
| Anastomosis | Side-to-side Gastrojejunostomy |
| Reconstruction Method | Stapled or Hand-sewn |
Introduction
Distal gastrectomy with Billroth II reconstruction is a common procedure following distal gastric resection when direct gastroduodenostomy is not feasible. Instead of connecting the remnant stomach to the duodenum, the remnant stomach is anastomosed to the proximal jejunum, bypassing the duodenum.
Billroth II reconstruction is technically less demanding than Billroth I in patients with limited duodenal mobility and provides a tension-free reconstruction after extensive distal gastric resection.
Indications
- Distal gastric adenocarcinoma
- Advanced gastric cancer
- Duodenal invasion preventing Billroth I
- Severe peptic ulcer disease
- Inadequate duodenal mobility
- Excessive tension for gastroduodenostomy
Contraindications
Billroth II reconstruction may not be appropriate in patients requiring reflux prevention or physiologic reconstruction. In these situations, Roux-en-Y reconstruction may be preferred.
Surgical Anatomy
Important anatomical structures include:
- Remnant stomach
- Duodenal stump
- Proximal jejunum
- Ligament of Treitz
- Afferent loop
- Efferent loop
- Greater omentum
- Mesocolon (when retrocolic reconstruction is performed)
🕒Procedure Timeline
1. Midline Laparotomy
An upper midline incision is performed to expose the stomach and upper abdomen.
2. Exploration
- Evaluate tumor extent
- Rule out peritoneal metastasis
- Confirm resectability
3. Distal Gastrectomy
Following lymph node dissection, the distal stomach is transected using a linear stapler or hand-sewn technique.
4. Duodenal Transection
The duodenum is divided and the duodenal stump is securely closed.
5. Jejunal Selection
The proximal jejunum is identified approximately 20–30 cm distal to the ligament of Treitz.
Depending on surgeon preference, reconstruction may be performed through:
- Antecolic route
- Retrocolic route
The uploaded reference also illustrates selecting the afferent and efferent limbs and positioning the jejunal loop to avoid tension before gastrojejunostomy.
👨⚕️Billroth II Reconstruction
Option 1. Stapled Method
The stapled technique is commonly performed with a linear stapler.
Typical sequence:
- Align the remnant stomach with the jejunal loop.
- Create small enterotomies in both the stomach and jejunum.
- Insert the linear stapler into both lumens.
- Fire the stapler to create a side-to-side gastrojejunostomy.
- Close the common entry hole using a linear stapler or hand-sewn closure.
- Inspect the staple line for bleeding or leakage.
The reference text recommends creating a 6–8 cm gastrojejunostomy and ensuring that the anastomosis is located at least 2 cm from the gastric staple line to reduce tension.
Option 2. Hand-sewn Method
Hand-sewn gastrojejunostomy is performed in two layers.
Typical sequence:
- Posterior seromuscular layer
- Posterior full-thickness layer
- Anterior full-thickness layer
- Anterior seromuscular reinforcement
Running sutures are commonly used for the mucosal layer, followed by interrupted Lembert sutures for reinforcement.
Braun Anastomosis
Some surgeons perform a Braun jejunojejunostomy between the afferent and efferent limbs to reduce bile reflux and improve gastric emptying.
The uploaded surgical reference specifically describes Braun anastomosis as an adjunct to decrease bile reflux into the remnant stomach.
OR Nurse’s Role
Before Reconstruction
Prepare:
- Linear staplers
- Stapler cartridges (appropriate tissue thickness)
- Silk sutures
- Vicryl
- PDS
- Bowel clamps
- Suction
- Energy devices
During Anastomosis
Confirm:
- Correct afferent and efferent limb orientation
- No twisting of the jejunal mesentery
- Adequate bowel perfusion
- Proper stapler cartridge selection
- Complete staple lines
- Leak test preparation
Common Instruments
Basic Instruments
- DeBakey Forceps
- Metzenbaum Scissors
- Mayo Scissors
- Kelly Clamp
- Babcock Forceps
- Allis Clamp
- Needle Holder
Energy Devices
- Harmonic Scalpel
- LigaSure
Retractors
- Bookwalter Retractor
- Thompson Retractor
Staplers
- Linear Cutter
- Linear Stapler (GIA)
- TA Stapler (optional)
Common Suture Materials
- Vicryl 2-3,3-0(CR)
- Vicryl 4-0
- PDS 3-0
- Silk 3-0
- Prolene (optional)
💎Pearls from the OR
✅ Confirm the orientation of the afferent and efferent limbs before creating the anastomosis.
✅ Ensure a tension-free gastrojejunostomy.
✅ Avoid twisting of the jejunal mesentery.
✅ Create an adequately wide anastomosis to reduce postoperative obstruction.
✅ Carefully inspect all staple lines before abdominal closure.
⚠️Common Pitfalls
| Pitfall | Prevention |
|---|---|
| Anastomotic leak | Tension-free anastomosis with good blood supply |
| Bile reflux gastritis | Consider Braun anastomosis when appropriate |
| Afferent loop syndrome | Correct loop orientation |
| Internal hernia | Close mesenteric defects |
| Anastomotic bleeding | Careful staple line inspection |
| Anastomotic stricture | Create an adequate stoma |
Postoperative Care
Monitor for:
- Anastomotic leak
- Bleeding
- Delayed gastric emptying
- Bile reflux gastritis
- Afferent loop syndrome
- Ileus
- Nutritional status
Early ambulation and gradual diet advancement are encouraged.
FAQ
Why choose Billroth II instead of Billroth I?
Billroth II is selected when direct gastroduodenostomy is not possible because of limited duodenal mobility, extensive gastric resection, or excessive tension.
What is the difference between Billroth I and Billroth II?
Billroth I reconnects the remnant stomach to the duodenum, whereas Billroth II connects the remnant stomach to the jejunum, bypassing the duodenum.
What is Braun anastomosis?
Braun anastomosis is a side-to-side jejunojejunostomy performed between the afferent and efferent loops to reduce bile reflux and facilitate intestinal flow.
Key Takeaways
- Billroth II reconstruction restores gastrointestinal continuity by creating a gastrojejunostomy after distal gastrectomy.
- It is commonly chosen when Billroth I reconstruction cannot be performed safely.
- Both stapled and hand-sewn techniques are widely used.
- Proper orientation of the jejunal loop, adequate blood supply, and a tension-free anastomosis are essential for successful outcomes.
- Braun anastomosis may be added to reduce bile reflux in selected patients.
📚 Related Articles
🔗 Intestinal Anastomosis: Understanding Small Bowel Resection and Anastomosis
🔗 Vagotomy: Surgical Technique, Anatomy, and Operating Room Guide
🔗 Distal Gastrectomy with Billroth I Reconstruction
🔗 Gastrojejunostomy (GJ): Complete Operating Room Guide for Surgical Nurses