Duodenotomy and Oversew Bleeding Duodenal Ulcer 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
 
Bleeding duodenal ulcers present with upper 
gastrointestinal 
hemorrhage 
on 
a 
possible 
background of chronic epigastric pain or previous 
treatment for ulcer disease. Bleeding can be 
catastrophic and life-threatening, or slow and 
gradual. Patients need to be treated according to the 
principles described in 
Approach to Upper 
Gastrointestinal Hemorrhage. The most important 
decision is whether to intervene immediately after 
resuscitation, or to watch closely. This is decided  
based on the patient’s presentation, amount of blood 
lost, and response to resuscitation. As with all 
patients in resource-limited settings, a careful history 
and thorough physical examination prevent the 
surgeon from pursuing an inappropriate treatment.  
 
When upper endoscopy is available, it will be 
done first. This allows diagnosis and possibly 
intervention. All patients going for endoscopic 
intervention are also consented for open surgery.  
Guidelines recommend two attempts at 
endoscopic intervention before proceeding with 
surgery. In our setting, without expertise in 
endoscopic intervention and with limited equipment, 
we make one attempt at endoscopic intervention and 
then proceed with laparotomy. Most in resource-
limited settings do not have the ability to inject 
epinephrine around an ulcer, apply a heater probe, or 
clip exposed vessels endoscopically. In this case, 
endoscopy is used only to determine the location of 
the bleeding: treatment will either be surgical or 
conservative with high dose proton-pump inhibitors. 
It is much easier to localize the site of bleeding at 
endoscopy than at open surgery; we describe how to 
approach this scenario without an endoscope, if you 
have to, in the “Approach” chapter cited above.  
Bleeding gastric ulcers are better treated with 
resection if the patient is stable, because of the risk 
of malignancy and also to decrease the risk of future 
bleeding. See the chapters in this Manual for details 
on different types of gastric resection and 
reconstruction.  
Duodenal ulcers that are not located in the 
posterior bulb are less prone to life-threatening 
hemorrhage. If these require surgery, simple 
oversewing of the ulcer with several interrupted 
absorbable stitches is effective. (In a resource-rich 
setting, such ulcers would probably have responded 
to endoscopic intervention and would never have had 
surgery at all.) This article deals with the specific 
issue of the posterior duodenal bulb, where an ulcer 
erodes into the gastroduodenal artery. Specific 
measures are needed to control hemorrhage here.  
The role of vagotomy is still controversial. 
Certainly, patients who are hemodynamically 
unstable should have the least surgery necessary to 
restore hemostasis, which is duodenotomy and 
oversew of the ulcer only. Our practice is to not 
perform vagotomy if the patient is naive to 
Helicobacter pylori treatment. We perform truncal 
vagotomy only if the patient has a history of one or 
more treatments for H. pylori, and if they are stable 
enough to tolerate further surgery after hemostasis is 
achieved. Such patients come along only rarely- in 
our experience there is usually no previous diagnosis 
or treatment for ulcer disease. These patients are 
cured of H. pylori infection with antibacterial therapy 
after recovering from the surgery.  
Duodenotomy and oversew of duodenal ulcer 
proceeds in the following steps:  
● Laparotomy and abdominal exploration 
● Longitudinal gastro-duodenotomy 
● Ligating the vessels at the base of the ulcer.  
● Transverse closure of the gastro-duodenotomy 
(pyloroplasty.)  
● Truncal vagotomy if indicated 
 
Steps: 
1. Patients in hemorrhagic shock should be treated 
with “Permissive Hypotension.” Administer 
fluids and blood to maintain perfusion of the 
brain and vital organs, but not to return to 
normotension, which increases blood loss and 
mortality. 
The 
strategy 
of 
permissive 
hypotension is used only on patients who are 
headed to the operating room, to have their 
bleeding controlled.  
2. Anesthesia 
is 
general, 
with 
endotracheal 
intubation and careful monitoring of vital signs 
by a skilled and experienced anesthetist. 
Duodenotomy and Oversew Bleeding Duodenal Ulcer 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
3. Make an upper midline laparotomy incision 
extending from the xiphoid process to just above 
the umbilicus.  
4. Explore the upper abdomen thoroughly, looking 
for signs of malignancy or portal hypertension, 
especially if an endoscopy has not been done 
before the surgery.  
5. Locate the pylorus by palpation and plan an 
incision along the gastroduodenal junction. This 
incision will have the pylorus at the midpoint (or 
2/5 duodenal and 3/5 gastric as shown in the 
illustration below.) 
 
Some stomach landmarks help identify the pylorus if it is not 
palpable due to inflammation in the area. It is usually 2-5cm 
distal to the incisura angularis (Black arrow) which can be 
enhanced by gentle traction on the greater curvature. Often 
there is a collection of veins over the pylorus, an indentation at 
its location, or both as in this picture (Black circle.) 
 
Once the pylorus is located, plan an incision centered over it. 
An incision 2/5 on the duodenum side prevents excessive 
incision into the duodenum, yet allows sufficient access to the 
bulb. Source: Primary Surgery Vol. 1 : Non Trauma 
https://global-help.org/products/primary-surgery/  
 
6. Make the incision, proceeding in layers. This 
technique achieves better hemostasis and also 
keeps the intestine full of gas, making the 
incision easier to see. Some surgeons prefer to 
place traction sutures to elevate the serosa, others 
do not. We demonstrate both techniques here.  
 
Make an incision through all of the serosa, then all of the 
muscularis, before entering the mucosa. Control bleeding here, 
the patient has lost enough already!  
 
Duodenotomy and Oversew Bleeding Duodenal Ulcer 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
With gentle traction on the sutures, incise the anterior wall of 
the duodenal-gastric junction. 
 
7. Once the mucosa has been entered, the stomach 
and duodenum will deflate. Use a hemostat to 
elevate the intestine that remains to be cut, or pull 
the bowel gently with the traction sutures if you 
placed them.  
 
Insert a hemostat into the duodenotomy and elevate the mucosa 
that remains to be cut.  
 
 
Elevate the bowel wall as you divide it, as the assistant 
maintains gentle traction on the traction sutures. 
 
8. Once the ulcer is visualized, place simple 
interrupted sutures above, below, and medial to 
the ulcer, right at its border. Do not go deeper 
than 5-6mm. The common bile duct runs within 
the pancreas near here and can be ligated with a 
deep “strangulation” stitch. 
 
Schematic of the vessels that cause bleeding in a posterior 
duodenal bulb ulcer, seen through the ellipse of a longitudinal 
duodenotomy. 
The 
vertically 
oriented 
vessel 
is 
the 
gastroduodenal artery, and the horizontally oriented one is the 
transverse pancreatic artery. Although all of these vessels will 
not be visible at the base of a bleeding ulcer, ligatures must be 
placed in these positions during surgery.  
 
Duodenotomy and Oversew Bleeding Duodenal Ulcer 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Occasionally you will find only a superficial ulcer that is oozing 
slowly from its edges, NOT located in the posterior duodenal 
bulb. In this case, encircle the ulcer with interrupted stitches as 
shown here. The needle should pass no deeper than the full 
thickness of the bowel, to prevent damage to any structures 
underneath such as the common bile duct.  
 
9. The gastroduodenotomy is closed transversely to 
prevent narrowing at the pylorus. We prefer a 
two layer closure using absorbable sutures.  The 
inner layer is running incorporating the mucosa 
and submucosa, and the outer layer interrupted 
seromuscular inverting (“Lembert” stitches.) If 
there is any tension on the closure, completely 
mobilize the 1st-3rd sections of the duodenum off 
the retroperitoneum (Kocher’s maneuver.) We 
mobilize the duodenum at this stage of the 
procedure rather than before duodenotomy, to 
avoid a delay in getting hemostasis.  
 
Mobilization of the duodenum (Blue dot) off of the 
retroperitoneum. In some cases you need to mobilize the 
transverse colon (Black dot) inferiorly, away from the area to 
have full access to the duodenum.  
 
 
Duodenotomy and Oversew Bleeding Duodenal Ulcer 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Schematic of a pyloroplasty: transverse closure of a 
longitudinal gastroduodenotomy. Source: Primary Surgery 
Vol. 1 : Non Trauma 
https://global-help.org/products/primary-surgery/  
 
 
Beginning the inner layer closure with running absorbable 
suture through the mucosa and submucosa.  
 
 
The inner layer, partially completed.  
 
 
The completed first layer of the closure; the closure is wide and 
there is little chance of gastric outlet obstruction, which would 
have been a possibility if the gastroduodenotomy had been 
closed longitudinally.  
 
 
The cranial half of the outer layer has been completed (top of 
photo) with interrupted seromuscular inverting (Lembert) 
sutures.  
 
Duodenotomy and Oversew Bleeding Duodenal Ulcer 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Pitfalls 
● Recurrence of bleeding is unlikely if the sutures 
are placed properly as described here.  
● Leakage of the gastroduodenotomy closure is a 
feared complication, but is rare in this situation. 
Make sure to fully mobilize the duodenum 
(Kocher maneuver) to make sure the suture line 
is not under tension. Wound dehiscence is more 
likely if the patient is malnourished or taking 
chronic steroids. Malnutrition and other wound 
healing problems are more common in patients 
with obstructed ulcer disease or variceal bleeding 
due to cirrhosis. 
● In patients who are hemodynamically unstable, 
we would not perform a truncal vagotomy. In 
patients who have never received Helicobacter 
pylori therapy, we also do not perform vagotomy. 
For intractable or recurrent disease, or if H. pylori 
treatment is not available, a truncal vagotomy is 
effective. See below.  
● Wound infection is more likely after this 
operation, so watch for it.  
 
Truncal Vagotomy 
Truncal vagotomy was used much more 
previously than now. The main reason for this is that 
acid-reducing medicines, especially proton pump 
inhibitors, are so effective against gastritis and ulcer 
disease. Eradication of helicobacter pylori virtually 
cures ulcer disease.  
Nevertheless, the indication for truncal 
vagotomy in this era is as follows: A life-threatening 
complication (perforation, hemorrhage) in a patient 
who is on adequate anti-ulcer treatment. The patient 
must be stable enough to tolerate a second operation 
that has no effect on the immediate outcome, but 
prevents the likelihood of it occurring again.  
In our experience, this is extremely rare. 
Most patients who present with life-threatening 
complications are not on anti-ulcer therapy. And 
most such patients are in extremis; the surgeon is 
attempting to do the minimum operation to 
effectively close the perforation or stop the bleeding.  
Another operation for intractable ulcer 
disease, Antrectomy and Bilroth 1 Reconstruction, 
effectively removes all of the gastrin-producing cells 
of the stomach- one could argue that even in this 
situation, a truncal vagotomy is not necessary.  
The end result is that most experienced 
surgeons, even those practicing in resource-limited 
settings, do not perform this operation very often. 
Nevertheless, we are in the process of writing a 
chapter on truncal vagotomy and it will be added to 
this Manual.  
 
 
Richard Davis, MD FACS FCS(ECSA) 
AIC Kijabe Hospital 
Kenya 
