Plate 29

The schematic drawing shows the position of the viscera after this operation is completed, along with the alternative antecolic placement of the jejunal loop. 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 (Figure 1). This operation is favored when very high resections are indicated, because it provides a safer closure of the lesser curvature. It may also retard sudden over distention 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 (Plate 28, Figure 2).

There are many ways of closing the opening of the stomach adjacent to the lesser curvature. The older but effective Payr clamp is shown (Figure 2), as it provides a protruding cuff of gastric wall and as stapling instruments may not be universally available.

The crushed gastric cuff adjacent to the greater curvature is grasped with Babcock forceps to ensure a stoma approximately two fingers wide. A continuous absorbably 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 prefer to approximate the mucosa with interrupted 000 silk sutures. The crushing clamp is then 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 effected at the very top of the lesser curvature. The sutures are not cut but may be retained and subsequently utilized 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 portion of the jejunum is anchored to the lesser curvature of the stomach. An enterostomy clamp is maintained on the gastric remnant unless this is impossible because of its high location. Under these circumstances it is necessary to make the anastomosis without applying clamps to the stomach.

The posterior serosal layer of interrupted mattress sutures of 00 silk anchors the jejunum to the entire remaining end of the stomach. This is done to avoid undue angulation of the jejunum; it removes strain from the site of the stoma and reinforces the closed upper half of the stomach posteriorly (Figure 5). Following this, the crushed or stapled gastric wall still retained in the Babcock forceps is excised with scissors, and any active bleeding points are tied (Figure 6). The contents of the stomach are aspirated by suction unless it has been possible to apply an enterostomy clamp on the gastric side. The mucosa of the stomach and the jejunum toward the greater curvature are approximated by a continuous fine absorbable suture on an atraumatic needle (Figure 7). Some prefer interrupted sutures of 000 silk. A Connell-type stitch is used to invert the angles and the anterior mucosal layer (Figure 8). A layer of interrupted mattress sutures is continued anteriorly from the closed portion to the margin at the greater curvature. Both the angles of the lesser and greater curvatures are reinforced with additional interrupted sutures. The long tails retained from closing the upper portion of the stomach are rethreaded on a spring-eye French needle (if still available to the surgeon). Otherwise, new nonabsorbable sutures are placed (Figure 9). These sutures are utilized to anchor the jejunum to the anterior gastric wall and buttress the closed end of the stomach anteriorly, as was previously done on the posterior surface. The stoma is tested for patency as well as for the degree of tension placed on the mesentery of the jejunum. The transverse colon is adjusted behind the jejunal loops going to and from the anastomosis. If a retrocolic anastomosis has been performed, the margins of the mesocolon are anchored to the stomach about the anastomosis (Plate 28, Figure 10).

The wound is closed in the routine manner. Retention sutures should be used in emaciated or cachectic patients.

See Postoperative Care, Plate 28.