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 ...