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Additional sutures of fine silk are taken around the edge of the mucosal opening until the end of the stomach has been puckered to fit relatively snugly around the surgeon's index finger. This opening should be approximately 2.5 to 3 cm wide (Figure 6). These sutures are then cut in anticipation of a direct end-to-end anastomosis with the duodenum (Figure 7). If the margins of the lesser and greater curvatures of the stomach as well as the superior and inferior margins of the duodenum have been properly prepared, it is relatively easy to insert angle sutures of 00 silk. Successful closure of the angles depends upon starting the suture on the anterior gastric as well as the anterior duodenal wall rather than more posteriorly. Interrupted sutures of 00 silk are then taken to close the stomach and duodenum together. Slightly bigger bites are necessary on the gastric side as a rule rather than on the duodenal side, depending upon the discrepancy in size between the two openings (Figure 8). The sutures should be tied, starting at the lesser curvature and progressing downward to the greater curvature. The angle sutures are retained while additional 0000 silk or fine absorbable synthetic sutures are placed to approximate the mucosa (Figure 9, A–A′ and B–B′). Some prefer a continuous synthetic absorbable suture to approximate the mucosa. No clamps are applied to the stomach or duodenum to control bleeding, since the sutures on the gastric side, if properly placed, should provide complete hemostasis as far as the stomach is concerned. Bleeding from the duodenal side is controlled by placing interrupted 0000 silk sutures. The anterior mucosal layer is closed with a series of interrupted sutures of 0000 silk or a continuous synthetic absorbable suture. The seromuscular coat is then approximated to the duodenal wall with a layer of interrupted mattress sutures (Figure 10). It has been found that a cuff of gastric wall can be brought over the duodenum, resulting in a “pseudo-pylorus,” if two bites are taken on the gastric side and one bite on the duodenal side. When this suture is tied (Figure 10), the gastric wall is pulled over the initial mucosal suture line.
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The vascular pedicles on the gastric side are anchored to the ligated right gastric pedicle along the top surface of the duodenum as well as the ligated right gastroepiploic artery ...