302 THE ABDOMEN AND PELVIS 



closed, the transverse colon is again lifted out of the abdomen 

 and the jejunum is lightly drawn upon until the anastomosis 

 appears at the opening in the transverse meso-colon. The 

 margins of this opening are stitched to the posterior wall of the 

 stomach or to the jejunum. This hinders the latter from being 

 retracted through the opening and prevents the occurrence of 

 hernia of small intestine into the omental bursa. 



It is important to remember that during this or any other 

 intestinal anastomosis the haemorrhage from the wounded 

 bowel is controlled by those sutures which pierce all three coats ; 

 they must therefore be kept taut until the suturing is completed. 

 The reasons for the choice of the method described above may 

 be briefly stated as follows : 



1. The posterior anastomosis is preferable because, in the 

 conditions for which the operation is performed, the most 

 dependent part of the stomach is on the postero-inferior surface 

 near the greater curvature. 



2. The union of the proximal part of the jejunum to the 

 stomach without any loop is very rarely followed by the formation 

 of kinks or spurs. 



3. The original direction and position of the first coil of the 

 jejunum, which is directed towards the left, are preserved ; the 

 anastomosis is therefore antiperistaltic. 



4. The anastomosis is carried out through an opening in 

 the greater omentum. While it is being established, all the 

 viscera except those parts immediately concerned in the suturing 

 are within the abdominal cavity. Thus the more movable 

 jejunum is approximated to the less movable stomach (Stiles). 



5. Both the hands of the assistant are left free. 



It may sometimes be found impossible to perform the 

 posterior operation, if adhesions, which may obliterate the 

 omental bursa, render the stomach less freely movable or if 

 the transverse meso-colon is too short. Under these circum- 

 stances the anterior method of anastomosis is adopted. 



Anterior Gastro-Enterostomy. This route necessitates 

 the use of a loop, as it is impossible to bring the proximal end 

 of the jejunum into contact with the anterior surface of the 

 stomach in a satisfactory manner. The duodeno-jejunal flexure 

 is found and the gut is traced distally for eighteen or twenty 

 inches. A loop of jejunum is then brought upwards in front 

 of the greater omentum and sutured to the anterior surface of 

 the stomach near the greater curvature. The loop is intentionally 



