Chinese Medical Journal

2 THE CHINESE MEDICAL JOURNAL

anastomoses, because in our hospital we prefer the antecolic anastomosis. The length of the proximal jejunal loop may have some bearing on the - occurrence of the proximal loop hernias, as a long loop is more likely to herniate through an opening, and too short a proximal loop may twist under the pull of a short tense mesentery. But the length of the proximal loop has no influence whatsoever on the distal or efferent loop hernias. The cause of these internal hernias is the opening or openings left unclosed after partial gastrectomy and gastrojejunostomy. After an antecolic gastrojejunostomy, an opening is created which is bounded in front by the gastric stump and the mesentery of the jejunal _ loop forming the anastomosis, behind by the transverse colon with its mesocolon and the posterior parietal peritoneum, superiorly by the reflection of the peritoneal attachments of the gastric stump, and inferiorly by the root of the mesentery of the jejunum at the ligament of Treitz (Fig. 3). After a retrocolic gastrojejunostomy, two openings are

Fig. 3. Hernia ring resulting from antecolic gastrojejunostomy. Sketch also shows the appendices epiploicae of the transverse colon which may be utilized to close the ring.

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created, an upper one formed by the gastric stump, the posterior parietal peritoneum and the transverse mesocolon, and a lower one beneath the transverse mesocolon formed by the posterior parietal peritoneum, the ligament of Treitz, and the mesentery of the jejunal loop used for the anastomosis (Fig. 4). These openings are potentially dangerous because

Fig. 4. Two hernia rings are created after a retrocolic gastrojejunostomy, one above and one below the transverse mesocolon.

they may give rise to internal hernias. In most clinics such openings are left unclosed routinely, hence it is surprising that internal hernias after gastrectomies are not reported more frequently. Recently, Morton