. Manual of operative surgery. Fig. 539.—Inner row of catgut through-and-through sutures applied to the posteriorwalls, uniting jejunum to cut end of the stomach and continuing part way down the anteriorwall. {Mayo.) stomach for a short distance alcove the site of anastomosis so thatthe unopenedjejunum acts as a patch applied to a part of the line of suture closing thestomach (Fig. 541). PYLORECTOMY 403 Moynihans Technic.—The sequence of steps in the operation as per-formed by Moynihan is as follows: The belly having been opened and parts exposed. (a) Divide the duodenum between crushing clamp
. Manual of operative surgery. Fig. 539.—Inner row of catgut through-and-through sutures applied to the posteriorwalls, uniting jejunum to cut end of the stomach and continuing part way down the anteriorwall. {Mayo.) stomach for a short distance alcove the site of anastomosis so thatthe unopenedjejunum acts as a patch applied to a part of the line of suture closing thestomach (Fig. 541). PYLORECTOMY 403 Moynihans Technic.—The sequence of steps in the operation as per-formed by Moynihan is as follows: The belly having been opened and parts exposed. (a) Divide the duodenum between crushing clamps. Catch and ligatevessels individually. Find and remove the subpyloric (subduodenal) lymphnodes which lie near the second part of the Fig. 540.—Anastomosis completed by an anterior row of scro-muscular sutures. Anas-tomosed end brought through the opening in transverse mesocolon, and margins of openingsutured to the stomach. (Mayo.) (b) Divide, between ligatures, the gastro-colic omentum. (c) Divide, between ligatures, the gastro-hepatic omentum as high up aspossible. Ligate the coronary artery late; this permits access to it at a highlevel and gives access to some high lymph nodes into which lymphatics draindirectly from the pyloric region. Remove the nodes. (rf) Tear a hole in the mesocolon and pull a loop of jejunum through posterior gastro-enterostomy using the cardiac portion of the stomach. 404 THE STOMACH The anastomosis is more easily performed before rather than after excising theportion of stomach to be removed. ?(e) Choose the line of section on stomach. Put in a stay or traction sutureon the lesser curvature well proximal to the line of section. Apply a clamp tothe stomach ^4 inch proximal
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