Gastrointestinal anastomosis technique – Roux-en-Y esophagojejunostomy

Open the distal esophagus by transverse transection of its anterior wall and secure it proximally with an Allis forceps; this will prevent the distal esophagus from retracting craniad into the mediastinum. Now transect the posterior wall of the esophagus. Preplace a purse string suture (monofilament, nonabsorbable, 2/0, continuous full-thickness over-and-over) and gently dilate the esophagus with a dressing forceps. Insert the anvil of a circular EEA stapler and secure it by tying the preplaced purse string suture.

In order to achieve a good functional result, the segment of the jejunum must be dissected sufficiently long. To this end, lift the transverse colon craniad, hold up and spread the jejunal mesentery and under transillumination with the surgical light assess the arterial supply of the second jejunal loop. The intestine and mesentery of the efferent limb should be transected such that the transected end of the limb will easily reach the esophagus.

Incise the mesenteric peritoneum and gently divide the mesenteric arcades such that the arterial supply at the site of the bowel transection remains adequate. Now transect the intestine with the electrocautery.

Transect the mesocolon in an avascular region at the ligament of Treitz and transpose the mobile Roux limb into the upper abdomen. Verify that the mesentery is not twisted.

Fashion the anastomosis with the esophagus in end-to-side technique with the circular EEA stapler by introducing it into the open end of the Roux limb (“shepherd’s crook”). About 8cm distad of the cut end of the bowel unscrew the spiked shank, thereby perforating the antimesenteric border of the bowel, and insert the spike into the anvil shaft. Fashion the end-to-side esophagojejunostomy by closing and firing the stapler.