Abstract

A precise understanding of the surgical anatomy of the stomach and duodenum is essential for safe and effective upper gastrointestinal procedures. These organs present unique anatomical complexities, including intricate vascular networks, critical lymphatic pathways, and close proximity to vital structures. This review outlines key anatomical features, including arterial and venous supply, lymphatic drainage, and nerve innervation, with an emphasis on their clinical relevance in common surgical interventions such as gastrectomy, vagotomy, duodenal ulcer repair, and pancreaticoduodenectomy. By correlating anatomical landmarks with operative strategies, this article aims to enhance intraoperative decision-making, reduce complications, and improve patient outcomes.

Keywords: stomach, duodenum, gastrointestinal surgery, vascular supply, lymphatic drainage, vagotomy, gastrectomy, pancreaticoduodenectomy, duodenal ulcer

Introduction

The stomach and duodenum are central components of the upper gastrointestinal (GI) tract and are frequently involved in a variety of surgical procedures, ranging from peptic ulcer repair and bariatric interventions to oncologic resections and trauma management. Due to their proximity to major vessels, ducts, and adjacent organs, operative interventions in this region require a thorough understanding of complex anatomical relationships.

Surgical outcomes in upper GI procedures are significantly influenced by the surgeon's ability to recognize and preserve critical structures, manage vascular supply, and anticipate anatomical variations. Complications such as hemorrhage, anastomotic leak, or injury to adjacent organs are often preventable with detailed anatomical knowledge. Moreover, the lymphatic drainage patterns of the stomach and duodenum are pivotal in the staging and treatment of gastrointestinal malignancies, particularly gastric cancer.

With advances in minimally invasive surgery and enhanced imaging modalities, the need for accurate anatomical orientation has never been more relevant. This article aims to provide a clinically focused overview of the surgical anatomy of the stomach and duodenum, integrating key insights that aid in safer and more effective operative approaches.

Methodology

This article is a narrative review based on a comprehensive analysis of relevant anatomical, surgical, and clinical literature related to the stomach and duodenum. Peer-reviewed articles, anatomical textbooks, surgical atlases, and clinical guidelines were identified through database searches including PubMed, Scopus, and Google Scholar using keywords such as "surgical anatomy of the stomach", "duodenum anatomy", "gastrectomy", "duodenal ulcer surgery", and "upper gastrointestinal surgery complications".

Sources were selected based on their relevance, clarity of anatomical description, and clinical applicability. Preference was given to recent literature (within the last 10 years), though seminal works and classic anatomical references were also included to ensure foundational accuracy.

Anatomical descriptions were cross-referenced with operative findings reported in surgical case studies and procedural guidelines to highlight clinically significant variations and common intraoperative challenges. The methodology emphasizes the correlation of anatomical knowledge with surgical technique, with the aim of enhancing intraoperative safety and improving patient outcomes.

 Modeling and Analysis

The modeling and analysis component of this review integrates classical anatomical data with contemporary surgical applications to create a clinically oriented framework for operative planning and decision-making in surgeries involving the stomach and duodenum. This involved a multi-tiered approach:

1. Anatomical Modeling Framework

To enhance three-dimensional comprehension of the complex relationships between the stomach, duodenum, and adjacent structures, various anatomical models were studied and correlated, including:

Cadaveric Dissections: Referenced from standard surgical anatomy atlases and academic dissection labs, providing foundational understanding of normal anatomical configurations.

3D Imaging Studies: Cross-sectional imaging (CT, MRI) and angiographic reconstructions were used to visualize vascular patterns, lymph node basins, and organ orientation in live patients.

Laparoscopic and Robotic Views: High-definition intraoperative videos were studied to contextualize anatomy in minimally invasive procedures.

2. Regional Analysis and Surgical Relevance

A. Vascular Anatomy

The celiac trunk and its branches were modeled to understand the dominant blood supply to the stomach. Special focus was placed on the left gastric, right gastric, gastroepiploic, and short gastric arteries, which were analyzed for:

Common branching patterns

Variations such as a replaced right hepatic artery arising from the superior mesenteric artery (SMA)

Vulnerability during gastrectomy, fundoplication, and sleeve gastrectomy

The gastroduodenal artery (GDA) was identified as a critical landmark in pancreaticoduodenectomy (Whipple procedure), with emphasis on its proximity to the posterior duodenal wall and pancreatic head.

B. Lymphatic Mapping

The stomach’s lymphatic drainage was modeled according to the Japanese Gastric Cancer Association (JGCA) node stations (e.g., stations 1–16).

Analysis included:

Lymphatic flow from different stomach zones (e.g., greater curvature → splenic hilum → para-aortic nodes).

Surgical implications during D1, D1+, and D2 dissections in gastric cancer resections.

Risk zones for skip metastasis and sentinel node mapping in minimally invasive surgeries.

C. Nervous Supply and Functional Zones

The vagus nerve was dissected into its anterior (mainly hepatic branches) and posterior trunks (celiac and gastric branches). These were modeled using imaging and surgical videos to:

Understand selective vagotomy techniques.

Preserve gastric motility and minimize dumping syndrome in ulcer surgery.

The enteric nervous system’s interaction with myenteric plexuses was briefly analyzed in relation to gastric emptying and pyloric function.

3. Duodenal Zonation and Clinical Application

The duodenum was divided into four zones with their anatomical landmarks and clinical significance:

First Part (Superior): Mobile, intraperitoneal; common site of peptic ulcer perforation. Risk: free air under diaphragm.

Second Part (Descending): Receives bile and pancreatic ducts at the major duodenal papilla (Ampulla of Vater). Modeled due to its involvement in ERCP, pancreatitis, and periampullary tumors.

Third Part (Horizontal): Lies over the IVC and aorta; related to superior mesenteric artery syndrome and vulnerable during trauma.

Fourth Part (Ascending): Transition to the jejunum at the ligament of Treitz; landmark in GI bleeding and small bowel obstructions.

5. Anatomical Variation Analysis

High prevalence of vascular variants (e.g., replaced hepatic artery) modeled using imaging studies and anatomical databases.

Duodenal duplication, annular pancreas, and malrotation discussed briefly as rare anomalies influencing surgical access and outcomes.

 Results and Discussion

The review and anatomical synthesis conducted reveal several critical insights into the surgical anatomy of the stomach and duodenum, each bearing direct implications for clinical practice. The findings emphasize the need for an in-depth understanding of structural relationships, anatomical variations, and their impact on surgical decision-making and outcomes.

1. Vascular Architecture: A Double-Edged Sword

The stomach receives its blood supply from the celiac trunk and its branches: the left gastric, right gastric, left gastroepiploic, right gastroepiploic, and short gastric arteries. The duodenum derives vascular input primarily from the gastroduodenal artery (GDA), a branch of the common hepatic artery, and the inferior pancreaticoduodenal artery, originating from the superior mesenteric artery (SMA).

A key finding is the high variability in vascular patterns—especially the hepatic arterial system—observed in nearly 20% of individuals. Replaced or accessory hepatic arteries can originate from the left gastric or superior mesenteric artery, necessitating precise preoperative imaging to avoid inadvertent ligation.

Clinical Implication: Injury to variant vessels during gastrectomy or duodenectomy may lead to ischemia of liver segments or biliary tree, compromising postoperative recovery. Awareness and early identification through imaging or intraoperative Doppler ultrasonography are essential.

2. Lymphatic Drainage: Guiding Oncologic Safety

Lymphatic drainage of the stomach follows a predictable pattern, aligning with vascular anatomy. The Japanese Gastric Cancer Association (JGCA) nodal stations—particularly stations 1 through 16—provide a framework for systematic lymphadenectomy. The duodenum’s drainage involves pancreaticoduodenal, pyloric, and superior mesenteric nodes.

Key Insight: The extent of lymphadenectomy (D1 vs. D2) significantly affects long-term survival in gastric cancer surgery. Adequate anatomical understanding enables appropriate nodal clearance while preserving adjacent neurovascular bundles, thus reducing morbidity.

Clinical Correlation: Inadequate dissection of perigastric nodes (stations 3–7) or failure to address second-tier nodes (stations 8–12) may result in recurrence. Conversely, overzealous dissection increases the risk of pancreatic or vascular injury.

3. Neural Anatomy: Preserving Function While Controlling Disease

The stomach’s parasympathetic supply via the vagus nerve contributes to acid secretion and gastric motility. Truncal, selective, and highly selective vagotomy procedures rely on precise identification and preservation of specific vagal branches.

Observation: The anterior vagus nerve gives off hepatic branches near the lesser curvature, while the posterior vagus often supplies the celiac plexus. Anatomical variation in branching patterns can complicate surgical intervention.

Clinical Impact: Preservation of hepatic branches during vagotomy prevents postoperative gallbladder dysmotility. Misidentification or incomplete vagotomy may lead to recurrence of ulcer disease or severe gastric emptying dysfunction.

4. Duodenal Relations and Surgical Access Challenges

The duodenum’s C-shaped configuration, retroperitoneal positioning (except for the first part), and its proximity to the pancreas, common bile duct, and major vessels make it a challenging structure during surgical exposure.

Findings: The second part of the duodenum is fixed and intimately related to the head of the pancreas and the ampulla of Vater. The third part crosses anterior to the aorta and inferior vena cava, placing it at risk during retroperitoneal dissection or trauma surgery.

Surgical Relevance: During pancreaticoduodenectomy, the Kocher maneuver is essential for safe mobilization. However, aggressive mobilization may injure the IVC or portal vein. Understanding fascial planes (e.g., the fusion fascia of Treitz) guides safe dissection.

Integration and Surgical Safety

The collective findings underscore that meticulous preoperative planning, based on individual anatomical variations, leads to improved intraoperative safety and better outcomes. Surgeons must not only be familiar with classical anatomy but also anticipate and identify deviations. Incorporating 3D imaging, intraoperative navigation, and simulation-based rehearsals can further enhance anatomical orientation.

Limitations

This review is based on secondary data and anatomical literature, lacking primary clinical or intraoperative datasets. While it integrates findings from cadaveric studies, imaging analysis, and surgical reports, further research including prospective surgical registries and operative video analysis is warranted for quantifiable outcome correlation.

 Conclusion

The surgical anatomy of the stomach and duodenum is complex and highly variable, with significant implications for surgical practice. An in-depth understanding of the vascular supply, lymphatic drainage, neural innervation, and structural relationships of these organs is essential for successful operative outcomes, particularly in the context of gastrectomy, duodenal ulcer repair, pancreaticoduodenectomy, and bariatric surgery.

Key anatomical features, such as the variability in the vascular system, the intricate patterns of lymphatic drainage, and the functional significance of the vagus nerve, must be carefully considered during preoperative planning to minimize intraoperative complications and ensure optimal post-surgical recovery. Additionally, recognizing the anatomical variations within these structures allows for personalized approaches to surgery, enhancing both the safety and efficacy of interventions.

This review underscores the critical role of preoperative imaging, surgical simulations, and ongoing anatomical education in fostering a deeper understanding of the stomach and duodenum’s anatomy. Surgeons must integrate knowledge of both standard and variant anatomy into their operative strategies to avoid complications such as hemorrhage, injury to adjacent organs, or incomplete tumor resection in oncological procedures.

In conclusion, a thorough mastery of the anatomical intricacies of the stomach and duodenum is indispensable for achieving safer and more effective surgical outcomes. As minimally invasive techniques and advanced imaging technologies continue to evolve, the emphasis on precise anatomical knowledge will remain a cornerstone of high-quality surgical care.

Acknowledgment

I would like to express my deepest and most sincere gratitude to Kurmanbaev N A Sir, my esteemed practical teacher in the Surgical Discipline with Traumatology Department, whose expertise, dedication, and guidance have significantly influenced my academic and professional development. I am truly fortunate to have had the opportunity to learn from such an accomplished and compassionate mentor.

From the very beginning of my training, Sir’s profound knowledge of surgery and traumatology has been a constant source of inspiration. His ability to explain complex surgical principles and techniques with clarity and precision has greatly enriched my understanding of the subject. Whether in theoretical lessons or during hands-on practical sessions, his teaching methods have always been structured, systematic, and easily comprehensible, making even the most challenging concepts accessible.

Throughout my training, Sir’s patience and attention to detail have been invaluable. His feedback, both constructive and encouraging, has allowed me to refine my skills and approach to surgery. The confidence I have gained in the operating room and in clinical practice can be attributed to his guidance and the trust he placed in me to take on progressively more complex procedures. His approach to teaching is not just about imparting knowledge but also about instilling in his students the values of critical thinking, attention to detail, and ethical practice in every aspect of medicine.

Moreover, Sir has always demonstrated a deep commitment to his students' growth, going beyond the academic curriculum to foster professionalism, empathy, and a patient-centered approach to care. His mentorship extends beyond the classroom and the operating theater, encouraging us to develop not only as surgeons but as compassionate and responsible medical professionals.

I am particularly grateful for his unwavering support during difficult times and for always making himself available for guidance, whether it was regarding surgical techniques, academic challenges, or career advice. His mentorship has played a key role in helping me navigate the demands of medical school while maintaining a clear focus on the importance of lifelong learning and patient welfare.

Kurmanbaev N A Sir has not only taught me the art and science of surgery but also shown me the profound impact a compassionate and skilled surgeon can have on patients' lives. His approach to teaching, grounded in a deep understanding of the human body and an even deeper respect for human dignity, has shaped my values and the way I approach medicine. His influence will undoubtedly resonate with me throughout my career, and I will forever be grateful for the wisdom he has shared.

In conclusion, I wish to acknowledge and thank Kurmanbaev N A Sir for his outstanding dedication to teaching and for being a constant source of inspiration. His guidance has shaped my journey in medicine, and I am incredibly honored to have had him as a mentor. His impact on my education and personal growth will remain with me as I move forward in my medical career.

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