STEP 7Anastomosis

Open anastomosis:

Through a small midline laparotomy a standard Billroth II or Roux-en-Y reconstruction can be performed (A).

Laparoscopic anastomosis (Billroth II):

To perform a laparoscopic side-to-side gastrojejunostomy, ligament of Treitz and the proximal jejunum are identified by lifting the transverse colon and tilting the table into a Trendelenburg position (head down). A loop of proximal jejunum is brought up in an antecolic or retrocolic fashion. This loop of jejunum is sutured to the anterior aspect of the stomach remnant with two resorbable, seromuscular stay sutures, approximately 2 cm apart. A stab incision in both the stomach and the jejunum is made with diathermia. Care should be taken that the incision in the stomach is made through all gastric wall layers. The stab incisions are enlarged, and the endostapler is introduced with one blade in the stomach and the other in the jejunum. Subsequently the stapler is fired one or two times, dependent on the size of the cartridges (60 or 45 mm). In case a 60-mm stapler is used, a 15-mm trocar should be introduced (B).

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