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Preferably there is at least a 1 cm stump of left gastric artery beyond these ties. Inspect the pedicle carefully for hemosta- sis, as occasionally the bulky ligature permits a trickle of blood to continue through the lumen of the artery.
Allen clamp should equal the width of the gastrojejunal or gas- troduodenal anastomosis to be performed in a subsequent step. Initiate this suture on the lesser curvature of the gastric pouch just underneath the Allen clamp.
Then pass the straight needle back and forth under- neath the Allen clamp to make a basting stitch, terminating it at the base of the Allen clamp Fig.
Then invert the mucosa using one layer of interrupted 4-0 silk Lembert sutures Fig. Invert the stapled portion of the gastric pouch expose the posterior wall of the duodenum and the anterior using a layer of interrupted 4-0 silk Lembert sutures surface of the pancreas.
In this case, freed from the underlying pancreas, as this amount is ade- control the bleeding with a mattress suture of 4-0 silk.
No quate for turning in the duodenal stump or for gastroduode- nal end-to-end anastomosis.
Before discarding the speci- men, remove the clamp and inspect the distal end of the speci- men to ascertain that a rim of duodenal mucosa has been removed. This ensures that there is no remaining antral mucosa left behind in the duodenal stump. The ampulla is situated on the posteromedial aspect of the descending duodenum at a point approximately 7 cm behind the pylorus.
If the duodenal dissection has not continued beyond the gastroduodenal artery, there need be no concern about damage to the duct of Santorini or the main pancreatic duct.
When the dissection continues beyond this point, special attention must be paid to these structures. If the ampulla has been divided inadvertently and is separated from the duodenum, replant it into the duodenal Fig.
When at least 1 cm of healthy posterior duodenal wall is Approximate the anterior mucosal layer with a continu- available, a routine gastroduodenal anastomosis is con- ous Connell or Cushing suture, which should be termi- structed.
The Allen clamp previously applied to the unsu- nated at the midpoint of the anterior layer Fig. Complete the remainder of the posterior layer with tric pouch meets the duodenal suture line at its lateral interrupted 4-0 silk seromuscular Lembert sutures margin, insert a crown stitch by taking seromuscular bites Fig.
To prevent postoperative obstruction, take care of the anterior wall of the gastric pouch and then of the not to invert an excessive amount of tissue.
Initiate the Connell suture by placing Though it is simple to insert a layer of interrupted Lembert a half purse-string stitch at the right lateral margin of the seromuscular sutures as a second layer when the tissues are 316 C. A common error is to insert the seromuscular Lembert stitch too close to the Connell suture line.
The anterior operation is preferred as the tumour shows a tendency to invade the omental bursa posteriorly purchase discount norfloxacin antibiotic antimycotic. One thing must be remembered that postoperative duration of life is not proper measure of palliation in case of incurable cancer.