The stomach and duodenum are visualized and palpated to determine the type and extent of the pathologic lesion present. A short loop of jejunum is utilized for gastrojejunostomy, with the proximal portion anchored to the lesser curvature. The stoma is made on the posterior gastric wall and extends from the lesser to the greater curvature, about two fingers in length. It is located at the most dependent part of the stomach (figure 1a).
When the gastroenterostomy is performed with vagotomy in the treatment of duodenal ulcer, the location and size of the stoma are very important. In order to ensure adequate drainage of the paralyzed antrum and keep postoperative side effects to a minimum, a small stoma parallel to the greater curvature and near the pylorus is indicated (figure 1b). The jejunum should be anchored for several centimeters to the gastric wall on either side of the stoma. This permits circular uncut muscles going away from the stoma to contract and improve gastric emptying. Special effort is required as a rule to ensure placement of the stoma within 3 to 5 cm of the pylorus because of the inflammation and fixation of the pylorus associated with duodenal ulceration. Accordingly, it may be impractical to perform an anastomosis on the greater curvature as shown in figure 1b.
The location of the stoma is first outlined on the anterior gastric wall with Babcock forceps. The greater omentum may be brought outside the wound so that the contour of the stomach is not distorted, and the most dependent portion of the greater curvature may be more accurately determined (figure 2). The Babcock forceps are left in place as the greater omentum is reflected upward over the stomach and the inferior aspect of the mesocolon is visualized (figure 3). The transverse colon is held firmly by an assistant as the surgeon invaginates the Babcock forceps on the anterior gastric wall. This produces a bulge in the mesentery of the colon at the point through which the stomach is to be drawn (figure 3). The mesocolon is carefully incised to the left of the middle colic vessels and near the ligament of Treitz, great care being taken to avoid any of the large vessels in the arcade. Four to six guide sutures (sutures a, b, c, d, e, and f) are placed in the margins of the incised mesocolon to be utilized after the anastomosis to the stomach at the proper level. The presenting posterior wall of the stomach is grasped with a Babcock forceps (figure 4a and b) adjacent to the lesser and greater curvatures, and opposite the points of counter pressure from the similarly placed forceps on the anterior gastric wall (figure 4). A portion of the gastric wall is pulled through the opening. In many instances, the inflammatory reaction associated with the duodenal ulcer may anchor the posterior surface of the antrum to the capsule of the pancreas. Sharp and blunt dissection may be required to mobilize the stomach in order to ensure placement of the stoma sufficiently near the pylorus. Some surgeons prefer to anchor the mesocolon to the stomach at this time. The forceps on the greater curvature is swung toward the operator on the patient’s right side, while the forceps on the lesser curvature is rotated to a position opposite the first assistant.
The ligament of Treitz is identified, and a loop of jejunum 10 to 15 cm distal to this fixed point is delivered into the wound. The jejunum at this point is held with Babcock forceps and stay sutures placed (figure 5). The orientation of the bowel is shown in figure 6. The technique of the anastomosis is shown in the continuing figures 7 through 22 of this Chapter.
The large intestine and omentum are returned within the abdomen above the stomach. The clamps and the anastomotic site usually can be delivered outside the peritoneal cavity, which should be entirely protected with gauze. Retraction on the edges of the abdominal wound is discontinued while the anastomosis is being performed. This mobilization is usually impossible when the stoma must be made within 3 to 5 cm of the pylorus following vagotomy. Under these circumstances, the anastomosis must be made within the peritoneal cavity, lest the stoma be made too far to the left, with recurrent ulcer difficulties due to hormone stimulation from the distended antrum inducing gastric hypersecretion.
Stay sutures are placed to facilitate exposure. Scudder clamps, which are nontraumatic, may be placed on the afferent and efferent limbs to prevent to minimize contamination. The posterior serosal sutures are now begun by placing a mattress suture of 000 silk at either angle (figure 7). The surgeon depresses the presenting portions of the stomach and jejunum with the index and middle fingers as the posterior row of interrupted mattress sutures in the serosa (figure 8). Alternate bites of jejunum and stomach are taken; these include the submucosa but do not enter the lumen of the bowel. Each suture is taken close to the preceding one to ensure a complete closure. It is best to tie them after all have been placed.
An incision is made in the stomach. The serosal incision may be made with a knife (figure 9) but the majority of surgeons use electrocautery. If this incision is too far from the serosal layer, too large a cuff of inverted bowel may result. In making these incisions, the operator should be careful to cut the bowel wall perpendicular to its surface, since there is always a tendency to incise the intestine obliquely, thereby leaving an irregular and unequalized mucosal layer for the next suture line (figure 10). The incision in the jejunum is made slightly shorter than that made in the stomach (figure 11). With the stomach and intestine opened and cleaned, a continuous absorbable suture is started in the midportion of the posterior mucosal layers (figure 12). Swedged on curved needles are most commonly used. As the operator sews away from himself or herself, he or she uses a simple over-and-over suture or a lock stitch, which pulls together the mucosal layers (figure 13). Since this suture is also used to control the blood supply, it must be kept under a tension sufficient for accurate approximation and prevention of hemorrhage, yet not completely strangulating the blood supply and hindering healing. This is a critical step. Interrupted sutures are placed to secure any bleeding points that have not been controlled by the continuous suture. When the operator reaches the angle of the wound, a Connell suture, which allows inversion of the structures as they are sewn, is substituted (figure 14). In figure 14, for example, the needle has just entered the gastric side. It comes out on the gastric side 2 or 3 mm from its point of entrance (figure 15). It is then crossed over, inserted through the jejunal wall from outside as in figure 16, and comes back out through the jejunal wall before being reinserted through the gastric wall (figure 17). After this angle has been closed, the other end, B, of the continuous suture is used to close the opposite angle in a similar fashion (figure 18). The continuous sutures, A and B, finally meet along the anterior surface. The final bite of each suture brings it to the inner wall of the stomach and jejunum (figure 19). The two ends are tied together with the final knot on the inside. If slight oozing persists, additional interrupted sutures may be taken to supplement the anterior mucosal layer.
Approximation of the anterior serosal layer is carried out with interrupted 000silk sutures (figure 20). These are placed approximately 6 to 8 mm apart. Additional interrupted sutures of fine silk are placed at the angles of the anastomosis for reinforcement so that any strain at this point avoids the original suture line (figure 21). The patency and size of the stoma should be determined by palpation. A secure anastomosis is desirable with a stoma approximately the size of the end of the thumb or two fingers.
The stomach is anchored to the mesocolon, with sutures b, c, and d (figure 21) adjacent to the anastomosis in order to close the opening and thus prevent a potential internal hernia. This also prevents any torsion of the jejunum near the anastomosis, which might result if the stoma retracts above the mesocolon (figure 22).
Occasionally, in the presence of extensive inflammation about the pylorus, marked obesity, or extensive malignancy, it may be impossible to mobilize the posterior gastric wall sufficiently for an anastomosis that allows adequate drainage of the antrum. Under these circumstances, anterior gastrostomy or enterostomy should be considered following vagotomy to ensure adequate drainage of the antrum or proximal drainage of an inoperable gastric malignancy. In order to avoid the possibility of poor emptying following anterior gastrojejunostomy, the thick omentum should be divided to permit the upper jejunum to be easily brought up over the transverse colon. Some prefer to clear the greater curvature near the pylorus for 5 to 8 cm and place the gastrojejunal stoma in this area. The antecolic efferent jejunal loop should be anchored to the anterior gastric wall for approximately 3 cm beyond the anastomosis to provide uncut circular muscle contractions to assist in gastric emptying. A Stamm-type gastrostomy should be considered to ensure patient comfort and provide an efficient and readily available method of gastric decompression until gastric emptying is satisfactory.