The gastroepiploic vessels are dissected, clamped, divided and ligated starting about 5 cm proximal to the pylorus and moving 6-7cm proximally along the greater curvature of the stomach, so this is completely dissected free from the omentum.
The jejunal loop can be brought either anterior to the transverse colon (antecolic), or through a window in the transverse mesocolon (retrocolic). Although a retrocolic gastrojejunostomy has been considered more prone to obstruction because of its closer proximity to an ever enlarging unresectable periampullary tumor, this has never proved true, especially since patient survival in this context rarely exceeds 6months. On the other hand, the retrocolic route allows more proximal placement of the jejunal stoma and smoother angles between afferent, efferent loops and stomach in both the coronal and the sagittal planes.
The window (wide enough to allow comfortable sliding of both afferent and efferent jejunal loops) is made in an avascular plane of the mesocolon left to the middle colic vessels. The ligament of Treitz is identified by lifting up the transverse colon, and the jejunal loop is brought up through the mesocolic window in apposition to the greater curvature (now free from omental vessels). The length of the afferent jejunal limb should not exceed 20 cm.
The gastrojejunostomy can be placed either on the anterior (easier and thus preferable) or the posterior gastric wall; the latter has not proved superior in terms of gastric emptying. Then 3-0 silk traction seromuscular sutures are placed, taking into account that the incision in the jejunum will not be made exactly at the antimesenteric border, but at a level closer to its mesentery on the stomal side. This provides for more comfortable lining of the completed anastomosis without any undue angles in the transverse plane. At 5-mm intervals 3-0 silk interrupted seromuscular Lembert sutures are placed and tied to create the posterior outer suture line. Two incisions along the gastric and the jejunal apposite segments are then made. Although the gastric incision should be about 4 cm, the jejunal incision should be a bit shorter, since it always tends to dilate and ends up being realistically longer than initially planned or thought to be.
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