Gastrointestinal anastomosis technique – Roux-en-Y esophagojejunostomy - general and visceral surgery
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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
Esophagojejunal anastomosis
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
Jejunojejunostomy/ posterior wall
Jejunojejunostomy/ anterior wall
Anchoring the Roux limb and closing the mesenteric window
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