The pylorus is identified by noting the overlying pyloric vein. Freeing all interfering adhesions and mobilizing the pyloric end of the stomach, the pylorus, and the first and second portions of the duodenum by use of an extensive Kocher maneuver are essential (Chapter 26). A traction suture is placed in the superior margin of the mid pylorus, and a second suture joins a point approximately 5 cm proximal to the pyloric ring on the greater curvature of the stomach to a point 5 cm distal to the pyloric ring on the duodenal wall (figure b). The walls of the stomach and duodenum are sutured together with interrupted 00 or 000 silk as in the start of the usual two layer gastrointestinal anastomosis. These sutures should be placed as near the greater curvature margins of the stomach and the inner margin of the duodenum as possible to ensure adequate room for subsequent closure. A U-shaped incision is then made into the stomach from a point just above the traction suture, around through the pylorus, and down a similar distance on the duodenal wall adjacent to the suture line. If an ulcer is present on the anterior wall, it may be excised. Electrocautery is used to control bleeding. A wedge of the pyloric sphincter may be removed from either side to facilitate the mucosal closure. The posterior mucosal septum between the stomach and duodenum is united with a running absorbable suture in a standard fashion for a side to side anastomosis. These sutures run from the superior aspect and include all layers of the septum (figure 4). The anterior mucosal layer is approximated with inverting interrupted sutures of 000 silk.
As seen in figure 5, a second layer of sutures starts superiorly and brings together the seromuscular layers of the anterior walls of the stomach and duodenum. A portion of the omentum may be sutured over the anastomosis. A temporary gastrostomy may be performed (Chapter 17) or constant nasogastric suction maintained until the stomach empties satisfactorily.