The Scopinaro Biliopancreatic Derivation
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Stage 4
The transverse colon is lifted anteiorly and the angle of Treitz is again located. A window is now made in the mesocolon, 2 cm to the left and 2 cm anteriorly to the ligamnet of Treitz. The left lateral part of the gastric staple ilne is pulled through this window.
A large bite stitch Polypropylene 2/0 is driven through the staple line in the stomach staple line visible through the window and the needle is driven through the antimesenteric edge of the small bowel, some 6 cm away from the cut end. A running locking suture line is now initiated from right to left, taking big bite across the gastric staple line and in the antimesenteric edge of the small bowel, closing in to thecut end, care being taken not to come closer to the mesentery. Eventually, the entire gastric staple line appearing through the window is incorporated and the running suture is tied. An opening is made in the gastric wall with the coagulating hook, just proximal to the suture line, and a second opening is made just distal to the suture line in the small bowel wall. The punch hole is enlarged as well. A large bore gastric tube can now advanced by the anesthesiologist out of the stomach and into the bowel loop. A second suture line is now placed in a similar fashion as the posterior one, starting at the far end of the stomach staple line and taking generous bites. The large bore gastric tube is pulled back by the anaesthetist until it sits again in he stomach and the integrity of the suture is checked by the immersion-insufflation technique as described earlier. The part of the stomach just distal to the opening in the mesocolon is stitched to the edges of the defect.
A Penrose drain is placed before closing up.
Postoperative management.
The patient is allowed to leave the hospital as soon as liquids can be tolerated. This is usually on the third post operative day. The drain can be removed then. The patient is restricted to a semi-liquid diet for 1 week, followed by a pureed diet for another 4 weeks. An office visit is scheduled for around that time. If there are no problems, the patient is advanced to a regular diet. Sweets, alcohol and carbonated drinks should be banned. Exercising is encouraged from the second post operative week on.