Anastomotic technique, gastrointestinal, end-to-side, open, continuous hand suture, double layer - general and visceral surgery

The anastomosis technique is demonstrated here by means of a duodenojejunostomy during a pylorus-preserving Whipple procedure. The distal duodenum has already been divided with a linear stapler.

First, skeletonize the duodenal wall in steps.

Due to the short gastric mesentery, the anastomosis cannot be rotated. Therefore, a so-called non-rotating technique is used here.
This comprises a double-layered suture technique (with PDS 4-0), with the posterior wall being anastomosed first.

Start with a seromuscular continuous suture. This apposes the posterior wall of the duodenum with the posterior wall of the jejunum.

Keep the suture ends as stay sutures for orientation in the next step.

Now resect the staple line at the proximal duodenum. Follow this by opening the jejunum accordingly along the antimesenteric aspect.

As the next step, place a full-thickness continuous suture on the inside of the posterior wall.

Follow this with a full-thickness continuous suture on the inside of the anterior wall. Use two separate sutures, each starting in the corner and working toward the middle. Stitch direction at the jejunum is from the inside out and at the duodenum from the outside in. Invert the mucosa into the lumen with the forceps when tying the suture.

Follow this with the seromuscular suture of the anterior wall. Here too, use two separate sutures, each starting in the corner and working towards the middle. Then tie the ends of both sutures in the middle.

Now check the suture line and if necessary, place additional stitches wherever direct serosa-serosa contact is lacking.

Then check the anastomosis for any leakage (by forcing intestinal gas and fluid through it). And finally, check the width of the lumen by gently squeezing the site of the anastomosis between the tips of the thumb and index finger (illustrated here for an ileotransversostomy).