The entire abdomen is clipped and aseptically prepared. An incision is made from the xiphoid process to the pubis to allow for adequate exploratory laparotomy and gain the proper exposure to facilitate stomach derotation. Once the abdomen is open, it is immediately clear that the omentum is draped over the ventral aspect of the stomach; this is the pathognomonic sign for GDV. The surgeon takes a quick glance at the serosal surface of the stomach to help determine if there are any nonviable areas and reaches to identify the pylorus and pull it from left to right. In this first case, the patient had a 180° volvulus that was easily reduced with this manipulation.
On occasion, patients can be much more difficult to derotate; in these cases, first exteriorizing the spleen can be helpful. If gas has reintroduced into the stomach, it may also be easier to derotate the stomach if an orogastric tube can be passed to remove the air.
In general, the spleen is extremely large in a patient with GDV; however, GDV patients rarely require splenectomy. The surgeon inspects all of the splenic vasculature to ensure that arteries are beating, that veins have flow, and that there is no evidence of venous thrombosis.
If it is difficult to examine all areas of the stomach, and if there is air remaining in the stomach, an orogastric tube can be passed and the remaining air decompressed from the stomach. This also facilitates the gastropexy procedure.
The second patient presented with the same history. Of particular interest, however, was this case’s questionable viability of the fundic portion of the stomach. The surgeon must inspect the serosal surface, looking for vessels coming into the area and assessing pulses and motility.
This gives the surgeon a reasonably good idea as to whether the stomach will survive or whether a partial gastric resection is necessary. Notice the excellent gastric motility present in this patient.