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A schematic drawing shows the position of the viscera after this operation is completed, along with the alternative antecolic placement of the jejunal loop (FIGURE 1). In principle, this technique consists of closing about one-half of the gastric outlet adjacent to the lesser curvature and performing a gastrojejunal anastomosis adjacent to the greater curvature, with approximation of the jejunum to the entire end of the gastric remnant. Alternatively, a Roux-en-Y reconstruction should be considered in some cases to avoid the significant bile reflux that can occur with a small gastric pouch. This operation is favored when a very high resection is indicated because it provides a safer closure of the lesser curvature. It may also retard sudden overdistension of the jejunum after eating. The jejunum may be brought up either anterior to the colon or through an opening in the mesocolon to the left of the middle colic vessels (see FIGURE 2 in Chapter 31).

There are many ways to close the opening of the stomach adjacent to the lesser curvature. Linear cutting or noncutting staplers are used most commonly because the staple line can be cut off at the site of the anastomosis. The older but effective Payr clamp is shown (FIGURE 2) because it provides a protruding cuff of gastric wall in situations where stapling instruments are not available.

The staple line adjacent to the greater curvature is grasped with Babcock forceps to ensure a stoma that is approximately two fingers wide. A continuous absorbable synthetic material on a curved needle is started in the mucosa, which protrudes beyond the clamp in the region of the lesser curvature, and is carried downward toward the greater curvature until the Babcock forceps defining the upper end of the stoma is encountered (FIGURE 3). Some surgeons prefer to approximate the mucosa with interrupted 000 silk sutures. The crushing clamp then is removed, and an enterostomy clamp is applied to the gastric wall. A layer of interrupted mattress sutures of 00 silk is placed to invert either the mucosal suture line or the stapled gastric wall (FIGURE 4). It should be carefully ascertained that a good serosal surface approximation has been achieved at the very top of the lesser curvature. The sutures are not cut but may be retained and subsequently used to anchor the jejunum to the anterior gastric wall along the closed end of the gastric pouch.

A loop of jejunum adjacent to the ligament of Treitz is brought up anterior to the colon or posteriorly through the mesocolon in order to approximate it to the remaining stomach. The jejunal loop should be as short as possible but must reach the line of anastomosis without tension when the anastomosis is completed. An enterostomy clamp is applied to the portion of jejunum to be used in making the anastomosis. The proximal ...

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