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Fig. 10.23A-C. Amputation of the enterotomy used to create the anastomosis is facilitated by placement of a third holding suture midway between the initial two sutures. A) The stapler is oriented such that it parallels the knots seen on each holding suture in both the anterior-posterior and left-right directions. B) The stapler is closed and inspected to determine that each knot is visible. C) The stapler is rotated to confirm that adequate tissue is being amputed to ensure closure, but that excessive tissue is not included in the jaws which would narrow the anastomosis.

Fig. 10.24. The staple line is inspected to ensure complete closure. A holding suture is then placed between the 2 pieces of bowel to reinforce the staple line. Retraction of this suture anteriorly by the assistant allows visualization of the mesenteric defect. The mesenteric defect is closed with running suture (2-0 Surgidak®, Tyco/USSurgical).

Fig. 10.24. The staple line is inspected to ensure complete closure. A holding suture is then placed between the 2 pieces of bowel to reinforce the staple line. Retraction of this suture anteriorly by the assistant allows visualization of the mesenteric defect. The mesenteric defect is closed with running suture (2-0 Surgidak®, Tyco/USSurgical).

Mesentery Gastric Bypass

Fig. 10.25. A) The soft rubber drain protruding from the mesocolon is attached to the Roux limb by suture. B) The Roux limb is then advanced into the mesenteric defect without altering its orientation in order to prevent twisting or kinking. C) The drain is retracted anteriorly and cephalad above the bypassed stomach in order to deliver the roux limb into proximity with the proximal gastric pouch without tension. D) Correct orientation of the limb is confirmed once it has passed up through the tunnel.

Fig. 10.25. A) The soft rubber drain protruding from the mesocolon is attached to the Roux limb by suture. B) The Roux limb is then advanced into the mesenteric defect without altering its orientation in order to prevent twisting or kinking. C) The drain is retracted anteriorly and cephalad above the bypassed stomach in order to deliver the roux limb into proximity with the proximal gastric pouch without tension. D) Correct orientation of the limb is confirmed once it has passed up through the tunnel.

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