Antrectomy and Billroth 1 Gastroduodenostomy 
Richard Davis, Ifeanyichukwu Ogbonnaya, Joseph Nderitu, Winnie Mutunga 
 
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Introduction:  
 
Antrectomy 
and 
Billroth 
1 
Gastro- 
duodenostomy is an excellent operation for gastric 
outlet obstruction due to healed peptic ulcer disease 
or small tumors in the antrum of the stomach. It is 
usually not suited to active ulcer disease with 
inflammation in this area, or to larger tumors of the 
stomach. With active ulcer disease, an anastomosis 
to inflamed duodenum is not advised. With larger 
tumors, an adequate proximal margin of 5cm makes 
it impossible to attach the remnant stomach to the 
duodenal stump without tension.  
 
As with all operations involving the 
duodenum, the keys to success are meticulous 
surgical 
technique 
and 
a 
tension-free, 
well 
vascularized anastomosis between two pieces of 
healthy, uninflamed, cancer-free tissue.  
By definition, a patient who needs this 
operation is at risk for preoperative malnutrition. An 
experienced surgeon will understand the subtle signs 
of malnutrition: see “Nutrition and the Surgical 
Patient” for more information. For patients with 
severe malnutrition, consider a lesser operation such 
as a simple loop gastrojejunostomy. The same is 
likely true in cases of advanced cancer, including 
peritoneal metastasis or ascites. Be very cautious 
doing any anastomosis at all in such patients.  
We discuss surgical decision-making in this 
section’s 
Introduction, 
“Benign 
Gastric 
and 
Duodenal Disease.”   
The operation proceeds according to the 
following general steps:  
● Explore the abdomen. 
● Enter into the lesser sac between the omentum 
and the transverse colon. 
● Locate and divide the right gastroepiploic vessels 
at their origin. 
● Mobilize the duodenum. 
● Divide the duodenum distal to the pylorus, 
through the first or second portion.  
● Locate and divide the right gastric artery. 
● Plan where the stomach will be divided. 
● Divide the gastric and gastroepiploic vessels 
● Divide the stomach and omentum. 
● Close the divided stomach at the lesser curvature 
side. 
● Anastomose the stomach body to the duodenum.  
● Place a feeding jejunostomy tube if indicated. 
 
Steps: 
1. Assess the patient for malnutrition, which is 
common 
in 
patients 
with 
gastric 
outlet 
obstruction. In extreme cases a simpler operation 
such as a loop gastrojejunostomy will be more 
appropriate.  
2. Induce general anesthesia and place a nasogastric 
tube.  
3. Perform midline laparotomy and explore the 
abdomen. The operating surgeon will stand on 
the patient’s left.  
4. Enter the lesser sac by dividing the avascular 
plane between the greater omentum and the 
transverse colon. Take care to avoid injury to the 
transverse mesocolic vessels, which will be 
pulled in a caudal direction as the dissection 
proceeds.  
 
The avascular plane between the transverse colon and the 
omentum is most easily entered  on the left side of the abdomen. 
The surgeon’s non-dominant hand (Black Dot) pulls the 
transverse colon downwards while the assistant pulls the 
omentum upwards. A clear avascular plane (Black arrow) that 
leads into the lesser sac, behind the stomach, is visible and can 
be dissected. 
 
Antrectomy and Billroth 1 Gastroduodenostomy 
Richard Davis, Ifeanyichukwu Ogbonnaya, Joseph Nderitu, Winnie Mutunga 
 
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5. Continue dissection in this relatively avascular 
plane until all of the omentum to the right of 
midline is divided off of the transverse colon. 
 
Continued dissection of the plane between the omentum and the 
transverse colon. As the surgeon pulls the colon down with the 
non-dominant hand (Black Dot,) dissection continues in this 
plane. The lesser sac, an open space posterior to the stomach 
(Blue Dots) becomes more visible. This space is variable and is 
not present at all in some individuals; in that case, continue 
dissection in this plane until the stomach is completely 
mobilized.  
 
6. Elevate the stomach anteriorly and dissect 
posterior to it, proceeding to the origin of the 
gastroepiploic vessels. Divide and ligate them. If 
this is an operation for cancer, sweep adjacent 
lymph nodes up with the specimen.  
 
With the stomach dissected from its posterior attachments and 
retracted anteriorly, the origin of the right gastroepiploic 
artery (Black Arrow) can be found by following the greater 
curvature distally. The transverse mesocolon, not seen in this 
drawing, is represented by a Black Dot over the superior 
mesenteric artery. 
 
 
The same view as above, with the stomach held anteriorly. The  
transverse mesocolon (Black Dot) has been preserved during 
the dissection. The second portion of the duodenum (Blue Dot) 
and the pancreatic head (Green Dot) are visible. The right 
gastroepiploic artery (Black Arrow) can now be encircled, 
Antrectomy and Billroth 1 Gastroduodenostomy 
Richard Davis, Ifeanyichukwu Ogbonnaya, Joseph Nderitu, Winnie Mutunga 
 
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ligated and divided. Directly behind this ligated vessel, a plane 
between the pancreas and the duodenum can be dissected. 
 
7. Dissect the plane between the pancreas and the 
first and second portion of the duodenum, being 
mindful of where the pylorus is. There will be 
some variable small blood vessels between the 
duodenum and pancreas in this plane. The goal is 
to divide the duodenum in an area where it is not 
tethered to the pancreas, but distal to the pylorus. 
Excessive inflammation in this area sometimes 
makes this distinction difficult. If the stomach is 
divided instead of the duodenum, some of the 
antrum can be left behind, leading to continued 
gastrin 
secretion 
and 
“Retained 
Antrum 
Syndrome.”  
 
The surgeon has dissected the plane posterior to the first 
portion of the duodenum and is able to grasp behind this 
structure. The pylorus is directly below the thumb of the 
surgeon’s non-dominant hand (Red Dot.) The transverse colon 
(Black Dot) will need to be mobilized in a caudal direction to 
allow full visualization of the pancreatic head for the next step.  
 
8. Mobilize the right transverse colon and hepatic 
flexure of the colon downwards away from the 
liver, exposing all of the 3rd portion of the 
duodenum. 
 
The first portion of the duodenum (Blue Dot) has been exposed 
but the second and third portions remain hidden. Pull the colon 
(Black Dot) downwards gently to apply tension to the peritoneal 
layer that holds it in the right upper abdomen. Once this layer 
has been divided (along the Blue Line,) the plane between the 
colon and retroperitoneum is relatively avascular and the colon 
can be swept downwards, revealing the head of the pancreas 
and “C” loop of the duodenum.  
 
9. Mobilize the duodenum by dividing the lateral 
retroperitoneal attachments of the 2nd and 3rd 
portions, until all of the head of the pancreas is 
free from the retroperitoneum. This maneuver 
allows a tension-free anastomosis. It also delivers 
the anastomosis to the center of the operative 
field, making it technically easier to perform. 
During this dissection, grasp and pull gently on 
the antrum of the stomach with your non-
dominant hand as you dissect with the right-angle 
clamp and your assistant divides the tissue you 
elevate with electrocautery.  
Antrectomy and Billroth 1 Gastroduodenostomy 
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Dissection of the duodenum and head of the pancreas off the 
retroperitoneum, sometimes called the Kocher maneuver. The 
colon (Black Dot) has been reflected downwards and the 
duodenum (Blue Dot) can be seen. The attachments between the 
duodenum and retroperitoneum are now elevated with a Right 
Angle clamp and divided with electrocautery. This maneuver 
will bring the duodenum into the center of the operative field.  
 
10. If the location of the pylorus is clear, the first 
portion of the duodenum should also be clear. 
This is the part of the duodenum that has no 
attachments to the head of the pancreas. In cases 
of excessive inflammation, this area may be 
difficult to distinguish. External clues such as the 
prepyloric vein of Mayo may help. If you 
encounter excessive inflammation here, or if the 
anatomy is at all unclear, divide the duodenum 
proximally and examine the inside of the divided 
tissue. Duodenal mucosa has a characteristic 
“sparkle” that gastric mucosa will not. It is 
acceptable to divide further distally if one has 
divided gastric tissue proximal to the pylorus; it 
is unacceptable to divide the duodenum too 
distally and damage the Ampulla. Attempt also 
to identify the right gastric artery, which should 
enter the stomach proximal to the pylorus. Again, 
if the location of the pylorus is not clear, do not 
divide any vessels.  
If this is an operation for peptic ulcer disease, 
divide the right gastric artery where it is found. If 
this is an operation for cancer, locate its origin at 
the common hepatic artery and ligate it here, 
leaving at least a 5mm stump to avoid narrowing 
the common hepatic artery as you ligate the right 
gastric. Sweep lymphatic tissue around the artery 
inferiorly so it comes with the specimen. It is not 
worth risking injury to the hepatic vessels or the 
common bile duct in order to remove a few more 
lymph nodes here, so be careful.  
Again, divide only a vessel that is clearly 
entering into the body of the stomach, proximal 
to the pylorus, to avoid the possibility of 
damaging the common hepatic artery or the 
common bile duct.  
 
Illustration of the relationship between the right gastric artery, 
the common hepatic artery, and the gastroduodenal artery. 
Note also that the structures of the porta hepatis are nearby. 
Note that the right gastric artery enters the stomach proximal 
to the pylorus. If the location of the pylorus is not clear, do not 
Antrectomy and Billroth 1 Gastroduodenostomy 
Richard Davis, Ifeanyichukwu Ogbonnaya, Joseph Nderitu, Winnie Mutunga 
 
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divide any vessels until it is, to avoid damaging the common 
bile duct or the proper hepatic artery.  
 
 
In the absence of inflammation or scarring, the pylorus can 
easily be felt as a thickening of the sub-serosal tissue. If the 
patient has had longstanding ulcer disease, the pylorus can be 
difficult to palpate. However it is crucial to divide the 
duodenum, distal to this structure. One external clue to the 
pylorus’ location is the prepyloric vein of mayo, which has the 
appearance of a “Crow’s foot” and is more distinct than the 
other veins on the anterior stomach. 
 
 
Another image of the porta hepatis, containing the common bile 
duct (Black line) and the duodenum; the vertical part of the 
duodenum is the 2nd portion, under the Green dot. This 
relationship can easily be seen, as the entire duodenum and 
head of pancreas have been mobilized.  
 
11. Divide the duodenum in a location where it is not 
attached to the pancreas with electrocautery, 
controlling bleeding as you proceed. We prefer 
to not use bowel clamps here, to avoid trauma to 
the small vessels of the duodenal wall which 
would increase the risk of anastomotic leak.  
 
Dividing the duodenum with electrocautery. Proceed slowly, it 
is easier to get hemostasis during division than afterwards.  
 
12. If there is excessive inflammation in the 
duodenal stump, consider an alternative method 
of reconstruction. Safe closure of the inflamed 
duodenal stump is discussed in the Chapter, 
“Gastrectomy and Reconstruction.”  
 
Antrectomy and Billroth 1 Gastroduodenostomy 
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The divided duodenum, showing normal eversion of the 
mucosa. This tissue is soft and healthy, reaching the midline 
easily after Kocher’s maneuver. It can be safely anastomosed 
to the stomach if the two structures reach each other without 
tension. Alternatively, it could be closed in 2 layers as 
described in the chapter, Gastrectomy and Reconstruction.   
 
13. The entire stomach antrum and first portion of the 
duodenum should now be free from the 
surrounding 
pancreas 
head, 
gastrohepatic 
ligament, and any attachments to the lesser sac. 
Choose where the body of the stomach will be 
divided. For peptic ulcer disease, locate the 
incisura angularis, the right angle along the lesser 
curvature that denotes the junction between the 
body and antrum of the stomach. For cancer, 
divide the stomach at least 5cm proximal to the 
most proximal palpable extent of the tumor. 
Mark the planned line of division by scoring the 
serosa with the electrocautery.  
 
If available, a ruler is helpful for measuring a 5cm proximal 
margin from a gastric tumor.  
 
14. Divide the vascular arcade of the lesser curvature 
adjacent to where the stomach is to be divided. 
This will likely require separate ligation of tissue 
several times. Continue until the serosa of the 
lesser curvature is plainly seen. Careful attention 
to this step avoids bleeding from these vessels 
when the stomach is divided. 
 
Illustration of the vascular arcades of the lesser (Black Circle) 
and greater (Blue Circle) curvatures of the stomach. The 
Antrectomy and Billroth 1 Gastroduodenostomy 
Richard Davis, Ifeanyichukwu Ogbonnaya, Joseph Nderitu, Winnie Mutunga 
 
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vessels of the lesser curvature usually cannot be divided all at 
once, whereas the vessels of the greater curvature usually can. 
Following division of the greater curvature vessels, any 
omentum to the (patient’s) right of the divided greater 
curvature vessels must be divided from the omentum that will 
remain.  
 
 
Divide the vessels of the lesser curvature. This step usually 
needs several applications of the clamps, it can not be done all 
at once.  
 
15. Divide the vascular arcade of the greater 
curvature. Compared to the lesser curvature, this 
is more often a single set of vessels that can be 
ligated and divided in one step.  
 
Divide the gastroepiploic vessels on the greater curvature.  
 
16. Divide the omentum, as it has now been 
separated by dividing its blood supply.  
17. Assure that the nasogastric tube has been 
withdrawn, especially if using a stapler to divide 
the body of the stomach. Incorporating a 
nasogastric tube in a staple line would be a 
serious complication.  
18. Divide the stomach body with electrocautery, 
taking care to control any bleeding points. We do 
not use bowel clamps on the proximal stomach, 
as they make the operation more cumbersome 
without providing a real advantage.  If the 
stomach is obstructed and full of contaminated 
debris, we open the stomach in a controlled 
manner and remove the debris at this time, 
avoiding spillage as much as possible.  
 
Division of the stomach with diathermy. As with the duodenum, 
going slowly and dividing the stomach in layers, as shown here, 
allows you to get hemostasis as you go, rather than after 
division which is more difficult.  
 
Antrectomy and Billroth 1 Gastroduodenostomy 
Richard Davis, Ifeanyichukwu Ogbonnaya, Joseph Nderitu, Winnie Mutunga 
 
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Stomach after division with diathermy. The mucosa (Black 
Arrow) typically protrudes beyond the serosa (Black Dot.) Two 
layer closure is easily accomplished; the first layer of closure 
involves the mucosa and submucosa only and the second layer 
closes the serosa over the first layer.  
 
19. Close the stomach in two layers, beginning with 
a running suture of the mucosa and submucosa, 
beginning at the lesser curvature and proceeding 
until there is a defect remaining that matches the 
size of the duodenum. Then invert and “bury” 
this suture line with a second layer of interrupted 
seromuscular sutures.  
 
Closure of the divided stomach proceeds from the lesser 
curvature downwards, in two layers, leaving a portion of the 
stomach unclosed of the same diameter as the duodenal stump. 
This photo is taken after closure of the first layer.  
 
 
The second layer of sutures, interrupted in this case, is 
seromuscular. It completely inverts and “buries” the first layer 
of sutures 
 
20. Place seromuscular retention sutures at the 
cranial and caudal side of the anastomosis 
through both the stomach and the duodenum, 
bringing them into apposition.  
Antrectomy and Billroth 1 Gastroduodenostomy 
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Retention sutures at the cranial and caudal side of both 
structures align the stomach and the duodenum.  
 
21. If at this point the tension is excessive, consider 
whether a complete Kocher maneuver has been 
done. Examine the body of the stomach for 
adhesions to the lesser sac, splenic flexure of the 
colon, or left upper quadrant. If there are 
adhesions that can be easily divided and the 
stomach can be mobilized, do so. If the stomach 
and duodenum can not be brought together 
without tension, use an alternate form of 
reconstruction. 
We 
prefer 
Roux-en-Y 
reconstruction over Billroth 2 in almost all 
situations (See Chapter, Gastrectomy and 
Reconstruction.)  
22. Perform a hand-sewn, two layer anastomosis. 
Start with interrupted seromuscular sutures to 
make the posterior outer anastomosis.  
 
By passing the cranial side retention suture below and behind 
the planned anastomosis, and gently retracting the caudal side 
suture anteriorly, the posterior outer layer of sutures can be 
placed from behind the planned anastomosis.  
 
 
The completed posterior outer layer of interrupted sutures. The 
retention sutures can now be returned to their proper cranial 
and caudal orientation.  
 
23. Suture the posterior inner layer with a running 
suture through the mucosa and submucosal layer. 
Surgeon and assistant both start in the center of 
the anastomosis and work towards either side. 
 
Beginning the posterior inner layer of the anastomosis. The 
mucosa is already opposed because of the previously placed 
(posterior outer) stitches. On each side, the operator sutures 
through the full thickness of the bowel in the center of the lumen 
and each sews towards the edge in a direction that is most 
“anatomic” for each. In this case, the suture going in the 
Antrectomy and Billroth 1 Gastroduodenostomy 
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direction of the Black arrow is sewn by the surgeon on the side 
of the Black dot, and likewise for the Blue arrow and the Blue 
dot.  
 
24. Upon reaching the farthest lateral point of the 
anastomosis, the transition must be made from 
posterior inner layer, to anterior inner layer. The 
needle will be passed from one operator to the 
other at this point, allowing both surgeon and 
assistant to sew the side that is most “natural” for 
each.  
 
The posterior inner layer is complete, both surgeons have sewn 
to the edge. Each arrow must now change direction. At this 
point, each bite that is taken will be either inside-out, or 
outside-in. For clarity, both surgeons will take their last stitch 
inside-out, as in the next photo. .  
 
 
The surgeon on the side of the black dot takes their final stitch 
with this needle, inside-out.  
 
 
The surgeon on the side of the Blue dot now takes over and 
changes the direction of the suture represented by the Black 
arrow. Now the anterior inner layer of the anastomosis has 
begun. Because the last stitch was inside-out, this one is 
outside-in.  
 
Antrectomy and Billroth 1 Gastroduodenostomy 
Richard Davis, Ifeanyichukwu Ogbonnaya, Joseph Nderitu, Winnie Mutunga 
 
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The completed and tied anterior inner layer. The suture 
represented by the Black arrow has been sewn all the way to 
the anterior midline by the surgeon on the side of the Blue dot. 
The suture represented by the Blue arrow has been sewn all the 
way to the midline by the surgeon on the side of the Black dot.  
 
25. Suture 
the 
anterior 
outer 
layer 
of 
the 
anastomosis, using seromuscular sutures that 
invert the previous suture line.  
 
The completed anterior outer layer.  
 
26. Save the most cranial suture for last. This is the 
“Angle 
of 
Sorrow.” 
Your 
suture 
here 
incorporates both the anterior and posterior 
stomach, across the line where the stomach was 
divided, followed by the duodenum. This suture 
reinforces the part of the anastomosis that is 
under the most tension.  
 
Schematic of the suture that reinforces the Angle of Sorrow. It 
passes through the anterior wall of the stomach, the posterior 
wall, and then the cranial side of the duodenum.  
 
 
The anterior stomach wall seromuscular stitch has been taken, 
now the needle is passed through the posterior wall. 
 
Antrectomy and Billroth 1 Gastroduodenostomy 
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The suture is now passed in the opposite direction through the 
duodenal serosa and muscularis.  
 
27. Inspect for hemostasis, especially from the 
divided right gastric artery. Some surgeons 
suture a piece of omentum, or the round ligament 
of the liver, over the artery stump to protect it 
from digestive juices in case of an anastomotic 
leak.  
28. In malnourished patients (common in our 
setting,) we leave a closed-suction drain, behind 
the anastomosis extending down into the 
hepatorenal recess. In such situations, we often 
place a surgical jejunostomy tube distal to the 
ligament of Treitz. 
29. Irrigate and close the abdomen. 
30. If a jejunostomy feeding tube has been left, start 
tube feeds at 10cc per hour on the first or second 
postoperative 
day, 
when 
the 
patient 
is 
hemodynamically stable but before bowel 
function has returned. Irrigate the feeding tube 
with 10cc of water every 8 hours. A gravity bag 
can be used for jejunostomy feeds but excellent 
nursing care and periodic flushing of the tube is 
needed to prevent blockage.  
 
Pitfalls 
Category 
Prevention/Treatment 
Tension 
-Be sure the duodenum 
is completely mobilized 
(Kocher’s maneuver.) 
-If unsafe to complete 
the anastomosis: use 
Roux-en-Y 
reconstruction instead. 
Nutrition 
-Choose a lesser 
operation (gastro- 
jejunostomy bypass.) 
-Feed preoperatively 
distal to pylorus if 
possible. 
-Place a jejunostomy 
feeding tube intra-
operatively. 
Anastomotic leakage 
-Meticulous technique 
-Avoid anastomosis in 
inflamed tissue (use 
Roux-en-Y 
reconstruction instead) 
-Recognize early and 
intervene 
Table: Categories of complications after gastrectomy and 
Billroth 1 reconstruction, and their treatment.  
 
● Attempting to reconstruct with a Billroth 1 
gastroduodenostomy after too much stomach has 
been removed, or there is too much inflammation 
in the duodenum. If there is any tension or 
inflammation in the anastomosis, a Roux en Y 
gastrojejunostomy will be more appropriate. 
Billroth 1 reconstruction will be most amenable 
to healed ulcer disease with a stricture, or small 
antral or prepyloric tumors.  
● Underestimating 
the 
patient’s 
degree 
of 
malnutrition. All anastomoses are dangerous in 
malnourished patients. We have a low threshold 
to place a feeding jejunostomy in any patient with 
preoperative 
weight 
loss. 
The 
severely 
malnourished 
patient 
with 
gastric 
outlet 
obstruction will be better served by a loop 
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gastrojejunostomy without resection. If they 
recover enough to suffer from alkaline reflux 
gastritis, they can be converted to a Roux-en-Y 
once they have recovered from their nutritional 
deficit. If possible, nutrition complications can 
be avoided by preoperative nutrition distal to the 
pylorus, either via nasojejunal tube or surgical 
jejunostomy tube. Jejunostomy tube feedings are 
very difficult to manage in a resource-limited 
setting, however. See the Chapter, “Nutrition in 
the Surgical Patient.” 
● Failure to recognize anastomotic leakage: If the 
patient remains tachycardic, has a rising white 
blood cell count, or is febrile, the diagnosis is 
anastomotic leakage until proven otherwise. It is 
all too easy for the surgeon to self-deceive and 
blame these findings on pneumonia or urinary 
tract infection. This is unwise. Do not hesitate to 
study the patient with water soluble contrast or to 
resuscitate and re-explore. Do not wait for bile in 
the drain (or the wound!) Watch these patients 
very closely for the first five days. See the 
Chapter, “Approach to Postoperative Intra-
Abdominal Complications.” 
● Small amount of anastomotic leakage: evaluate 
the degree of leakage with a water soluble 
contrast study. This complication can sometimes 
be managed nonoperatively if all of the leaking 
contrast seen on the contrast study goes directly 
into the drain, the NG tube remains in place, and 
the patient is being fed by jejunostomy tube. 
Nutrition will be the most important element to 
facilitate healing.  
● Large amount of anastomotic leakage: reoperate 
and convert to Roux-en-Y Gastrojejunostomy. 
Close the duodenal stump in 2 layers if you can, 
reinforcing the second layer with an omental 
patch. Leave a drain adjacent to the duodenal 
stump.  
● Wound complications: These are to be expected 
in malnourished patients. If the surgeon opens 
the wound postoperatively due to infection, this 
provides a useful assessment of the patient’s 
nutrition. A malnourished patient will not make 
granulation tissue in a fresh wound. If the fascia 
dehisces, try to avoid reoperation in a 
malnourished patient if possible. If the wound is 
clean, place a vacuum closure device (See 
Section: Wound Care.) If the fascial dehiscence 
is large and there is risk of evisceration, you must 
reoperate (See “Closure of Laparotomy Wound 
Dehiscence.” As described above, nutrition is the 
root cause of this problem, so place a feeding 
jejunostomy tube if you have not already done so.  
 
Richard Davis, MD FACS FCS(ECSA) 
Ifeanyichukwu Ogbonnaya, MBBS 
Joseph Nderitu, MBBS 
Winnie Mutunga MBBS 
AIC Kijabe Hospital 
Kenya 
 
May 2022 
