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Gastrointestinal anastomosis technique – Roux-en-Y esophagojejunostomy
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Anchoring the anvil with a purse string suture
Open the distal esophagus by transverse transection of its anterior wall and secure it proximally with an Allis forceps; this will prevent the distal esophagus from retracting craniad into the mediastinum. Now transect the posterior wall of the esophagus. Preplace a purse string suture (monofilament, nonabsorbable, 2/0, continuous full-thickness over-and-over) and gently dilate the esophagus with a dressing forceps. Insert the anvil of a circular EEA stapler and secure it by tying the preplaced purse string suture.
Assessing the jejunal arcades and determining the length of the afferent limb
In order to achieve a good functional result, the segment of the jejunum must be dissected sufficiently long. To this end, lift the transverse colon craniad, hold up and spread the jejunal mesentery and under transillumination with the surgical light assess the arterial supply of the second jejunal loop. The intestine and mesentery of the efferent limb should be transected such that the transected end of the limb will easily reach the esophagus.
Dissecting the Roux limb
Retrocolic transposition of the Roux limb into the upper abdomen
Fashion the anastomosis with the esophagus in end-to-side technique with the circular EEA stapler by introducing it into the open end of the Roux limb (“shepherd’s crook”). About 8cm distad of the cut end of the bowel unscrew the spiked shank, thereby perforating the antimesenteric border of the bowel, and insert the spike into the anvil shaft. Fashion the end-to-side esophagojejunostomy by closing and firing the stapler.
Inspecting the anastomosis and shortening the blind end
Ensure that two complete rings of tissue are present within the head of the cartridge and check the patency by digital palpation through the open cut end of the jejunum. Advance the nasogastric tube just proximal to the anastomosis, close the open jejunal end with a non-crushing intestinal clamp, instill water through the nasogastric tube and check for any leakage.
Follow this by closing the open cut end of the jejunum with a linear stapler. The staple line may be oversewn with a continuous Lembert suture.
Jejunojejunostomy/ posterior wall
Plan the jejunojejunostomy about 40-60cm distad of the esophagojejunostomy. The anastomosis is fashioned end-to-side between the afferent limb and the transposed Roux limb.
First, anchor the end of the afferent limb at its mesenteric corner to the Roux limb which has been opened longitudinally. Fashion the posterior wall with a full-thickness continuous Maxon suture 4/0 from the inside out.
Jejunojejunostomy/ anterior wall
Anchoring the Roux limb and closing the mesenteric window