The schematic drawing shows the position of the viscera after this operation is completed, along with the alternative antecolic placement of the jejunal loop. In principle, this technique consists of closing about one-half of the gastric outlet adjacent to the lesser curvature and performing a gastrojejunal anastomosis adjacent to the greater curvature, with approximation of the jejunum to the entire end of the gastric remnant (figure 1). Alternatively a Roux-en-Y reconstruction should be considered in some cases to avoid significant bile reflux that can occur with a small gastric pouch. This operation is favored when very high resections are indicated, because it provides a safer closure of the lesser curvature. It may also retard sudden overdistention of the jejunum after eating. The jejunum may be brought up either anterior to the colon or through an opening in the mesocolon to the left of the middle colic vessels (Chapter 28, figure 2).

There are many ways of closing the opening of the stomach adjacent to the lesser curvature. Linear cutting or noncutting staplers are most commonly used as the staple line can be cut off at the site of the anastomosis. The older but effective Payr clamp is shown (figure 2), as it provides a protruding cuff of gastric wall in situations where stapling instruments are not available.

The Staple line adjacent to the greater curvature is grasped with Babcock forceps to ensure a stoma approximately two fingers wide. A continuous absorbable synthetic material on a curved needle is started in the mucosa, which protrudes beyond the clamp in the region of the lesser curvature, and is carried downward toward the greater curvature until the Babcock forceps defining the upper end of the stoma is encountered (figure 3). Some prefer to approximate the mucosa with interrupted 000 silk sutures. The crushing clamp is then removed, and an enterostomy clamp is applied to the gastric wall. A layer of interrupted mattress sutures of 00 silk is placed to invert either the mucosal suture line or the stapled gastric wall (figure 4). It should be carefully ascertained that a good serosal surface approximation has been effected at the very top of the lesser curvature. The sutures are not cut but may be retained and subsequently utilized to anchor the jejunum to the anterior gastric wall along the closed end of the gastric pouch.