The document outlines the Billroth surgery, detailing its history, definitions, and procedural steps for both Billroth I and Billroth II operations. It provides anatomical descriptions of the stomach and small intestine involved in the surgery, as well as specific nursing interventions and potential complications. Furthermore, it summarizes indications for each type of surgery, highlighting its significance in treating gastric tumors and ulcers.

1. OBAFEMI AWOLOWO UNIVERSITY
TEACHING HOSPITALS COMPLEX
SCHOOL OF PERIOPERATIVE
NURSING
COURSE-GENERAL SURGERY
LECTURER- MR. OGUNWUSI
DATE- 5TH-JULY-2024

2. GROUP 2 MEMBERS
 OMOLADE KAYODE PON/33/00919
 IGE BIBITAYO PON/33/00909
 AINA OLUWADETAN PON/33/00901
TOPIC:BILLROTH SURGERY

3. INTRODUCTION
• BRIEF HISTORY
• Billroth surgery also known as billroth’s operation, is a surgical operation
developed by Theodor Billroth, an Austrian surgeon, in 1881.
• DEFINITION OF BILLROTH SURGERY
• It can be defined as the partial removal of the stomach and reconnecting the
remaining portion to the small intestine.
• The procedure is considered a milestone in the development of modern
abdominal surgery.

4. ANATOMY OF THE PARTS INVOLVED
THE STOMACH
• DESCRIPTION:
• The stomach is a J-shaped dilated portion of the alimentary tract situated in
the epigastric, umbilical and left hypochondriac regions of the abdominal
cavity.
• PARTS OF THE STOMACH
• CARDIA
 The cardia is the top part of your stomach. It contains the cardiac
sphincter, which prevents food from traveling back up your esophagus.
• FUNDUS
 The fundus is a rounded section next to the cardia. It's below your
diaphragm (the dome-shaped muscle that helps you breathe).

5. ANATOMY OF THE PARTS INVOLVED
• BODY
 The body (corpus) is the largest section of your stomach. In the body, your
stomach contracts and begins to mix food.
• PYLORUS
 The pylorus is the bottom part of your stomach. It includes the pyloric
sphincter. This ring of tissue controls when and how your stomach contents
move to your small intestine.
• BLOOD SUPPLY
 Arterial blood is supplied to the stomach by branches of the coeliac artery
and venous drainage is into the portal vein.
• NERVE SUPPLY
 The sympathetic supply to the stomach is mainly from the coeliac plexus
and the parasympathetic supply is from vagus nerves. Sympathetic
stimulation reduces the motility of the stomach and the secretion of gastric
juice;

6. DIAGRAM OF THE STOMACH

7. ANATOMY OF THE PARTS INVOLVED
• THE SMALL INTESTINE
• DESCRIPTION
 The small intestine is continuous with the stomach at the pyloric sphincter
and leads into the large intestine at the ileocaecal valve. It is a little over 5
metres long and lies in the abdominal cavity surrounded by the large
intestine.
 In the small intestine the chemical digestion of food is completed and most
of the absorption of nutrients takes place.
• PARTS OF THE SMALL INTESTINE
• DUODENUM
 The duodenum is about 25 cm long and curves around the head of the
pancreas. Secretions from the gall bladder and pancreas are released into
the duodenum through a common structure, the hepatopancreatic ampulla,
and the opening into the duodenum is guarded by the hepatopancreatic
sphincter (of Oddi)

8. ANATOMY OF THE PARTS INVOLVED
• JEJUNUM
 The jejunum is the middle section of the small intestine and is about 2
metres long
• ILEUM
 The ileum, or terminal section, is about 3 metres long and ends at the
ileocaecal valve, which controls the flow of material from the ileum to the
caecum, the first part of the large intestine, and prevents regurgitation.
• BLOOD SUPPLY
 The superior mesenteric artery supplies the whole of the small intestine,
and venous drainage is by the superior mesenteric vein which joins other
veins to form the portal vein
• NERVE SUPPLY
 Innervation of the small intestine is both sympathetic and parasympathetic

9. DIAGRAM OF THE SMALL INTESTINE

11. Partial Gastrectomy
• Partial gastrectomy refers to resection of the distal
stomach for treatment of malignant gastric tumors
and complications of peptic ulcer disease such as
bleeding, perforation, and obstruction. The extent
of gastric resection depends on the type and
location of the gastric lesion. The Billroth I
procedure is a distal gastrectomy with GI
reconstruction to connect the gastric remnant to
the duodenum via an end-to-side or end-to-end
anastomosis (gastroduodenostomy). Billroth I
procedures entail resections at, or distal to, the
antrum of the stomach.

12. PROCEDURAL CONSIDERATIONS
• Setup requires basic laparotomy instruments, long
instruments, and GI instruments.
• The patient is supine and general anesthesia
induced. The anesthesia provider inserts an NG
tube after endotracheal intubation. Insertion of an
indwelling urinary catheter occurs before
abdominal skin prep.
• Team members take appropriate precautions to
prevent DVT, hypothermia, and pressure injuries.

13. BILLROTH PROCEDURE
1. The surgeon opens and explores the abdomen through an epigastric
midline incision.
2. Mobilization of the greater curve of the stomach begins with sharp
entry into the gastrocolic ligament, midway along the greater
curve.
3. The surgeon mobilizes the first and second portions of the
duodenum to facilitate the gastroduodenostomy.
4. The surgeon next mobilizes the lesser curve of the stomach and
divides and ligates the right gastric vessels between clamps,
preserving the left gastric artery if possible.
5. Anastomosis of the posterior and anterior mucosal layers of the
enterotomies is with two 3-0 running absorbable sutures placed
through the full thickness of the duodenum and stomach walls.

14. SPECIFIC NURSING INTERVENTIONS
• Manage pain and discomfort.
• Monitor for signs of dehydration or electrolyte
imbalance
• Manage nasogastric tubes if present
• Provide emotional support and counselling
• Provide wound care
• Monitor for complications

15. COMPLICATIONS
• Infection
• Adhesions
• Bleeding
• Hernia
• Malabsorption
• Narrowing of the stomach outlet
• Bowel obstruction

16. BILLROTH II
• BILLROTH II also know as Billroth's operation II is
an operation in which a partial gastrectomy is
performed and the cut end of the stomach is
closed.
• The greater curvature of the stomach is
connected to the first part of the jejunum in end-
to -side anastomosis following the resection of
the lower part of the stomach (antrum).

17. BILLROTH II
• The surgical procedure is called " partial
gastrectomy and gastrojejunostomy"
• Billroth II operation is constructed by sewing a
loop of jejunum to the gastric remnant
(gastrojejunostomy). Lastly, a Roux-en-Y
gastrojejunostomy involves the creation of a
“Roux” limb that is brought and connected to
the stomach as well as proximal jejunum.

18. DIAGRAM OF BILLROTH II

19. INDICATIONS FOR BILLROTH II
• Refractory peptic ulcer disease
• Gastric adenocarcinoma
• Billroth II gastrojejunostomy is a procedure
that has been performed for tumor or severe
ulcer disease in the distal stomach.

20. Surgical steps for Billroth II
• Setup requires basic laparotomy instruments, long
instruments, and GI instruments.
• The patient is supine position.
• General anesthesia induced. The anesthesia provider
• NG tube is inserted after endotracheal intubation.
• Insertion of an indwelling urinary catheter is done
occurs
• Abdominal skin prep
• Team members take appropriate precautions to
prevent DVT, hypothermia, and pressure injuries

21. Surgical steps cont'd.
1.The surgeon opens and explores the abdomen through an epigastric midline incision.
2. A self-retaining retractor is positioned to optimize exposure.
3. Mobilization of the greater curve begins with sharp entry into the gastrocolic ligament,
midway along the greater curve.
4. The surgeon mobilizes the lesser curve of the stomach and divides the right gastric vessels
between clamps. The vessels are ligated. The left gastric artery is preserved if possible.
5. The surgeon fires a large GI stapler across the stomach and directs removal of the Gastric
specimen.
6. The surgeon mobilizes a loop of proximal jejunum, pulls it up in front of the colon, and
positions it adjacent to the posterior wall of the remaining stomach.
7. The surgeon anastomoses the posterior and anterior mucosal layers of the enterotomies
with two 3-0 running absorbable.
8. Closure of the front wall of the anastomosis is with a row of interrupted 3-0
nonabsorbable sutures placed in the seromuscular layer. The anastomosis is complete.

22. COMPLICATIONS
• Dumping syndrome
• Gastrojejunocolic fistula
• Afferent loop syndrome
• Increased risk of gastric adenocarcinoma,15-
20 years post surgery.

23. REFERENCES
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Hwang JH, et al. Endoscopic mucosal resection. Gastrointest
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King J, Hines O. Anatomy and physiology of the stomach. Yeo
CJ. Shackelford's surgery of the alimentary tract. ed 7.
Saunders: Philadelphia; 2013.
Kwaan MR, et al. Abdominoperineal resection, pelvic
Exenteration and additional organ resection increase the risk
of surgical site infection after elective colorectal surgery: an
American College of Surgeons national surgical quality
improvement program analysis. Surg Infect (Larchmt).
2015;16(6):675–683.