In brief the operation is as follows: Incision is made a little to the right of the median line, the transverse colon is withdrawn by steady traction to the right and upward, and the mesocolon made to follow it until the jejunum comes into view. The latter is then grasped at a distance of three or four inches from its origin. When, now, it is drawn tight the fold of peritoneum which covers the so-called ligament of Treitz is demonstrated; this is a small band containing muscle fibers, having its origin on the transverse mesocolon and extending down to the beginning of the jejunum, thus acting as a suspensory ligament. It leads to the base of the vascular arch of the middle colic artery, and indicates the place where the mesocolon should be torn through in order to expose the posterior wall of the stomach. At this point, in the least vascular area which can be discovered, the mesocolon is first incised and then torn, until a good liberal opening is made, through which the posterior wall of the stomach is easily exposed, and, later, drained. It should be forced through this opening by combined manipulation with one hand introduced above it and gently urging it through the opening where it presents. It may be easily identified by its resemblance to its anterior surface in its thickness, the arrangement of its vessel and the like. The posterior wall alone is then secured and drawn through the mesocolic window, in such a way that after the jejunum is attached to it the anastomotic opening can be made at a point one inch above the greater curvature and ending at the bottom of the stomach two and a half inches to the left of the pylorus. This area having been exposed and prepared, a considerable portion of it is drawn into a pair of specially constructed clamps (Doyen’s or Moynihan’s), whose blades are usually protected with rubber. The Mayos prefer to have the handles lying to the right and to direct the forceps transversely to the body axis. Moynihan prefers to reverse this direction and make them point to the right shoulder. The stomach being thus protected, and prevented from slipping by suitable tightening of the clamps, the jejunum is similarly secured with forceps lying in a direction parallel to the first, having within their grasp a portion of the gut extending between points one and a half and three and a half inches from its origin. If this be properly effected the left low point of the stomach lies in the grasp of one pair of clamps and the first part of the jejunum in that of the other, and these two portions should be easily brought into close contact with each other. A gauze pad having been placed behind the damps in order to avoid soiling, should there be any leakage of intestinal contents, the clamps should now be carefully and attentively held by an assistant, and their distal ends may even be bound together in such a way that, after the suturing process has once begun, nothing shall disturb the perfect contact between the surfaces thus mutually applied. The first row of sutures, usually of the ordinary continuous type, is made of silk or thread, the serous and muscular coats being seized and united over a line some two inches in length, the suture being carefully secured at either end of this line. Next, with a scalpel, an incision is made through the serous and muscular coats, parallel to the line of sutures, at a distance of about one-quarter of an inch, and over a length a trifle less than that of the line which they occupy. Here the vessels will bleed freely and forceps may be momentarily used for their securement. Through the opening thus made the mucous membrane will prolapse. Moynihan especially has shown that it is not enough to merely incise this membrane in the same direction as the other coats, but that a narrow elliptical portion of it should be excised, since it tends to prolapse. Therefore with knife or scissors a strip of the mucosa, perhaps a half-inch in width, should be cut away from either surface, thus widely opening into and exposing the interior respectively of the stomach and of the gut. Extreme pains should now be given to prevent both leakage and soiling, and instruments used upon the mucosa should be discarded after it has been divided and sutured. Now with reliable chromicized catgut a row of continuous sutures is applied by which all three coats of both cavities are bound snugly together, the needle passing through six distinct layers as each stitch is made. These sutures should be drawn sufficiently and secured at frequent intervals so as not only to ensure perfect application but sufficient pressure to prevent hemorrhage when the clamps are released. The lower side having been first closed the same character of sutures is continued until the upper margin of the buttonhole-like opening is thus completely closed. The fourth line of sutures, this time of the same material as those used in the first, is applied in a similar fashion, and with it the serous and muscular coats are accurately affixed to each other in such a way that there can be no leakage. Two or three extra sutures at either end of the line may be inserted for greater security. The clamps are now withdrawn, the gauze behind the anastomotic opening is removed, and it should be found that the smaller bowel is neatly and perfectly fastened to the posterior stomach wall and that no possibility either of hemorrhage or of leakage remains. This being accomplished there remains only to tack the margins of the mesenteric opening to the posterior wall of the stomach, at a distance sufficient to prevent all possibility of subsequent constriction or strangulation, after which the parts are carefully cleansed, restored to the abdomen, the colon and omentum dropped back and made to cover them, and the abdominal wound closed as usual. (See [Figs. 556], [557] and [558].)
Fig. 556
Anterior wall of stomach grasped by forceps passed through from behind. (Case of saddle-ulcer of lesser curvature near pylorus.) (Mayo.)
Fig. 557
Mesocolon lifted and posterior wall of stomach drawn through the opening made in it. Dotted lines show site of proposed anastomotic openings. (Mayo.)
Fig. 558
Stomach and jejunum in the grasp of the large clamps, made ready for suturing. Small forceps still marking low point of stomach. (Mayo.)