Operative management of a posterior wall of duodenal bulb bleeding ulcer

Relevent anatomy

• GDA - branch of common hepatic artery
  • Runs retroduodenally and bifurcates into two branches
    • Right gastroepiploic
    • Superior pancreatoduodenal arteries
    • This bifurcation may occur at any level between the superior and inferior borders of the duodenum.
  • Right angle anastomosis of the transverse pancreatic artery
    • The transverse pancreatic artery joins with the dorsal pancreatic artery in about 60% and frequently anastomoses with the great pancreatic artery
  • Bleeding at this T-junctions creates a three-vessel situation Procedure
• Position supine with arms out
• Prep entire abdomen
• Incision - upper midline laparotomy
• May need to Kocherise duodenum
• Place stay sutures either side
• Open duodenum longitudinally and across pylorus (Heineke-Mikulicz pyloroplasty)
• Oversew vessel – 3-point control
  • 0 PDS on UR6
  • First place a superior and inferior interrupted stitch
    • To ligate the GDA proximally and distally
  • Then place a U-stitch medialm
    • To ligate transverse pancreatic artery (prevent back bleeding)
  • Careful not to incorporate CBD
    • Can probe ampulla to determine location
• Close duodenum transversally
• Leave drain and NG

Operative Control of Bleeding Ulcer at Posterior Wall of Duodenal Bulb- How I Do It., page 1

• If from the Gatric
  • Extend your prior incision from the duodenum or if no incision made make an incision over the stomach
  • Identify the ulcer
  • Oversew the bleeding ulcer or wedge excision and primary closure