Technique of anastomosis

The posterior full-thickness inner anastomotic layer is made by two 3-0 PDS running sutures in an over-and-over fashion starting at the middle of the posterior layer and moving in opposite directions towards each corner of the anastomosis, where the two corner traction seromuscular stitches are still present. Then, the two 3-0 PDS running suture lines continue into the anterior wall of the gastrojejunostomy (again full-thickness) using the Connell technique in order to invert all gastric and jejunal mucosa, which might otherwise protrude out through the anastomosis. Moving from the two corners towards the middle, the sutures meet and are tied together. The anastomosis is completed by placing the anterior seromuscular layer with interrupted 3-0 silk Lembert sutures starting at the corner away from the surgeon and moving towards the surgeon, so that there are no sutures tangling in the middle of the operative field. These outer sutures should be first all placed and then tied; "tying as we go" will lead to packing of the serosa towards the inner suture line and thus placement of each successive suture at an ever increasing distance away from the inner suture line, which may then lead to entrapment of a lot of seromuscular tissue within the suture lines and protrusion of this soft tissue mass towards the anastomosis itself with its potential obliteration.

After completion, the anastomosis is brought below the mesocolic window, and the gastric wall (not the jejunal) is tacked circumferentially on the mesocolon with interrupted 3-0 Vicryl sutures. A drain tube does not need to be placed.

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