The schematic drawing (figure 1) shows the position of the viscera after this operation is completed, which in principle consists of uniting the jejunum to the open end of the stomach. The jejunum may be anastomosed either behind or in front of the colon. In the retrocolic anastomosis, a loop of jejunum is brought through a rent in the mesentery of the colon to the left of the middle colic vessels and near the ligament of Treitz (figure 2). In the antecolic anastomosis, a longer loop must be used in order to pass in front of the colon freed of fatty omentum. If the resection has been done for ulcer to control the acid factor, it is important that the afferent jejunal loop be made reasonably short, since long loops are more prone to subsequent marginal ulceration. The jejunum is grasped with Babcock forceps and brought up through the opening made in the mesocolon, with the proximal portion in juxtaposition to the lesser curvature of the stomach (figure 2). With the Polya technique the gastrojejunostomy uses the entire length of the stomach and jejunum for the anastomosis. The Hofmeister technique shown in Chapter 29 is an alternative in which only a portion of the gastric length is used for the anastomosis (Chapter 29, figure 1). The jejunal loop is approximated to the posterior surface of the stomach adjacent to the staple line by a layer of closely placed, interrupted 00 silk mattress sutures (figure 3). This posterior row should include both the greater curvature and the lesser curvature of the stomach. Otherwise, subsequent closure of the angles may be insecure. The ends of the sutures are cut, except those at the lesser and greater curvatures, B and A, which are retained for purposes of traction (figure 4). The border of the stomach is cut away with scissors or electrocautery. An opening is made lengthwise in the jejunum, approximating in size the opening in the stomach. The fingers hold the jejunum down flat, and the incision is made close to the suture line (figure 5).
The mucous membranes of the stomach and jejunum are approximated by a continuous mucosal absorbable synthetic suture as the opposing surfaces are approximated by Allis clamps applied to either angle (figure 6). A continuous suture is started in the middle and is carried toward either angle as a running suture or as an interlocking continuous suture, if preferred. The corners are inverted with a Connell-type suture that is continued anteriorly, and the final knot is tied on the inside of the midline (figure 7). Some prefer to approximate the mucosa with multiple interrupted 000 silk sutures. The anterior layer is closed with the knots on the inside by using an interrupted Connell-type suture. The anterior serosal layers are then approximated with interrupted 00 silk sutures (figure 8). Finally, at the upper and lower angles of the new stoma, additional sutures are placed so that any strain exerted on the stoma is met by these additional reinforcing serosal sutures and not by the sutures of the anastomosis (figure 9). In the retrocolic anastomosis the new stoma is anchored to the mesocolon with interrupted sutures, care being taken to avoid blood vessels in the mesocolon and prevent the small bowel from herniating through the mesocolon (figure 10).