Selecting and Affixing loop of jejunum
A loop of jejunum has been selected and affixed to the greater curvature of the stomach, above the gastroepiploic vessels, with two stay sutures. Two enterotomies have been made and the stapling device inserted.
Division of the base
A. Division of the appendiceal base using pretied sutures. B. Division of the base using the endoscopic stapling device.
Passing the Silastic feeding jejunostomy tube
Passing the Silastic feeding jejunostomy tube into the lumen of the jejunum and tying the sutures.
Placing anchoring sutures
The anchoring sutures are being placed. The suture is passed through the abdominal wall, a seromuscular bite of intestine is taken, and the suture is then passed out of the abdomen. Four sutures are placed in a diamondshaped configuration, providing both
Subsequent dissection of mesenteric vessels
The small bowel segment chosen for resection has been suspended by traction sutures passed through the anterior abdominal wall. This facilitates subsequent dissection of mesenteric vessels and provides retraction without additional graspers or trocars.
360 Degree wrap
A 2-cm, 360 degree wrap is created using three interrupted, nonabsorbable sutures with care to avoid the anterior vagus.
Exposure of the crura
A. Three to six interrupted 0-gauge silk sutures are used to close the crura. B. Exposure of the crura and posterior aspect of the esophagus is facilitated by traction on a Penrose drain encircling the gastroesophageal junction.
CBD Exploration via Laparoscopic Choledochotomy
A. The folded T-tube is inserted into the choledochotomy. B. Ttube in place. The choledochotomy will be closed from above downward. The T-tube will exit from the lower end of the choledochotomy when the sutures are placed.
