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The open end of the jejunal arm is anastomosed over the opened pancreatic duct (Figure 9). The jejunum is anchored to the capsule of the tail of the fibrotic pancreas just beyond the end of the incision into the duct, and the full thickness of the jejunal wall is anchored to the cut margins of the capsule of the pancreas throughout the full length of the opened pancreatic duct. The open (fishmouth) end of the jejunum may need to be tailored from time to time, as outlined by the dotted lines (Figure 9), to ensure a sealed anastomosis around the duct. Again, only the capsule is included in these sutures, and the fibrotic wall of the pancreas is left free to promote drainage of the fine ducts, many of which are filled with small calculi. The anterior layer is also made with interrupted sutures, and the free end of the jejunum is anchored to the capsule with three or four additional sutures toward the tail of the pancreas (Figure 10). When the pancreas is shortened and thickened, a splenectomy may be necessary to adequately mobilize the pancreas and facilitate this anastomosis.
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Some prefer to close the end of the Roux-en-Y arm of jejunum with two layers of interrupted silk sutures (Plate 34) and anastomose the jejunum to the pancreas in a manner similar to a lateral anastomosis of small intestine (Figures 11 and 12). Only one layer of sutures is used, but they must be placed accurately and close enough together to prevent subsequent leakage.
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When the Roux-en-Y principle is used, the jejunum near the ligament of Treitz is anastomosed to the arm of the jejunum going to the pancreas by an end-to-side anastomosis (Figure 13). The free margin of the mesentery should be secured by interrupted sutures (A) to the ascending jejunum to obliterate any opening for the subsequent development of an internal hernia (Figure 13). The opening in the mesocolon is closed about the jejunal arm.
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