Plate 13

The enterostomy clamps applied to the stomach and the jejunum are held in apposition by ligatures or rubber bands (Figure 7, x and y). 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.

The posterior serosal sutures are now begun by placing a mattress suture of fine 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, parallel with the enterostomy clamp, is completed (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.

When the posterior serosal layer is completed, fresh moist toweling is laid on both sides of the field; the only instruments left on this toweling are those to be used for opening the stomach and jejunum, for cleaning the lumen, and for closing the bowel with the mucosal sutures.

Short, lengthwise incisions in the stomach and jejunum are made by depressing the bowel and incising the scalpel several millimeters from the serosal suture and not in the middle of the presenting contents of the clamp (Figure 9). 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 larger vessels in the stomach wall are then ligated with 0000 transfixing sutures of silk. The contents of the bowel are wiped out with a small piece of gauze moistened with saline, and the mucosal incision is completed with straight scissors. 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 on straight needles is started in the midportion of the posterior mucosal layers (Figure 12). Although straight needles are shown, absorbable sutures 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. The amount of tension is adjusted by the surgeon, who should hold the suture in the left hand while he or she works with the right. The first assistant exposes the point to be sutured and pulls the needle through. 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. The clamps may then be released to see whether there is any bleeding. If slight oozing persists, additional interrupted sutures may be taken to supplement the anterior mucosal layer.

Some surgeons prefer to do the anastomosis without clamps and tie each individual bleeding point before approximating the mucosa. Others prefer interrupted fine 0000 silk sutures for the mucosa instead of a continuous suture. The interrupted sutures on the anterior surface are tied with the knot on the inside. This series of interrupted Connell-type sutures ensures an even inversion of the mucosa.

The special toweling and the instruments used for the preceding stage of the operation are discarded, the gloves are changed, or gloved hands are thoroughly washed in an antiseptic solution, and approximation of the anterior serosal layer is carried out with interrupted fine silk sutures (Figure 20). These are placed very close together. 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.

A stoma about one-half the size illustrated is indicated when vagotomy is performed. The lumen should not be larger in diameter than the adult thumb in order to reduce the incidence and severity of postoperative complaints. 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.

The wound is closed in the routine manner. It is not drained.

Constant gastric suction is maintained for several days until it is evident that the stomach is emptying satisfactorily. The use of fluids, glucose, vitamins, and parenteral alimentation depends upon daily clinical and laboratory evaluation. The patient may be permitted out of bed on the first day after operation. Water in sips is given within 24 hours, and the fluid and food intake is increased gradually thereafter. Six small feedings per day are gradually replaced by a full diet as tolerated. Gastric secretion studies should be done to evaluate the completeness of the vagotomy when the latter procedure has been performed in the treatment of duodenal ulcer. If a gastrostomy has been done, the tube can usually be withdrawn in 10 days unless there is evidence of a delay in gastric emptying.