Plate 35
###### Figure 28

A row of interrupted 00 silk sutures is placed to approximate the jejunum to the diaphragm on either side of the esophagus, as well as directly behind it (Figure 22). It is necessary to emphasize that the arm of jejunum is anchored to the diaphragm to remove tension from the subsequent anastomosis of the esophagus. After these anchor sutures are tied, angle sutures are placed in either side of the esophagus and jejunum (Figure 23, C, D). The esophageal wall should be anchored to the upper side of the jejunum. An effort should be made to keep the interrupted sutures close to the mesenteric side of the jejunum, since there is a tendency to use all the presenting surface of the jejunum in the subsequent layers of closure. Three or four additional interrupted 00 silk mattress sutures, which include a bite of the esophageal wall with the serosa of the bowel, are required to complete the closure between the angle sutures, C and D (Figure 24). A small opening is then made into the adjacent bowel wall with the jejunum under traction so that during the procedure there is no redundancy of the mucosa from too large an incision. There is a tendency to make too large an opening in the jejunum with prolapse and irregularity of the mucosa, making an accurate anastomosis with the mucosa of the esophagus rather difficult. A layer of interrupted 0000 silk sutures is used to close the mucosal layer, starting at either end of the jejunal incision with angle sutures (Figure 25, E, F). The posterior mucosal layer is closed with a row of interrupted 0000 silk sutures (Figure 26). The Levin tube may be directed downward into the jejunum (Figure 27). The presence of the tube within the lumen tends to facilitate the placement of the interrupted Connell-type sutures closing the anterior mucosal layer (Figure 27). A larger lumen is ensured if the Levin tube is replaced by an Ewald tube of a much larger diameter. This tube is replaced by the Levin tube when the anastomosis is completed. An additional layer will be added as carried out posteriorly. Therefore, ...

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