Preprocedural Planning
A blood transfusion may be needed for patients with a bleeding peptic ulcer.
Resuscitation, fluid and electrolyte imbalance correction, and antibiotics should be administered, as needed, in patients with a perforated peptic ulcer.
Patients with pyloric stenosis due to peptic ulcer disease (PUD) causing gastric outlet obstruction (GOO) have dehydration, alkalosis, and hypokalemia, which should be corrected with the administration of normal saline solution and potassium chloride. Gastric aspiration and lavage are required to decompress the dilated stomach.
A nasogastric tube in situ allows easier intraoperative identification (palpation) of the esophagus.
In patients who have undergone previous vagotomy (or any gastric surgery) and in whom another vagotomy is required for recurrence of an ulcer, a thoracic approach (thoracotomy or thoracoscopy) is better than an abdominal approach because of the presence of adhesions in the abdomen.
Equipment
A table-mounted sternal elevator and a self-retaining abdominal wall retractor may obviate the need for an assistant.
Patient Preparation
Anesthesia
General anesthesia is used for this procedure.
Positioning
The patient is placed in the supine position; a slight reverse Trendelenburg (head up) orientation may be used in order to displace the intestines caudad. For the thoracic approach, the patient is placed in a right lateral (left side up) position.
