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James C. Rosser, Jr.,MD, FACS
Assistant Professor, Department of Surgery
Director, Yale Endo-Laparoscopic Center
Yale University School of Medicine
A NEW Option for An OLD Problem
Distinguishing Characteristics:
Rationale for this Approach:Cost effective appliances accelerate procedure Allows most novice of surgeons to successfully perform this procedure
Assures more distal feeding to drastically reduce reflux and aspiration Four point fixation allows guidewire replacement in event of early dislodgment Ambulatory procedure Facilitates care for Nursing Home patients
PRE-OPERATIVE PROCEDURE
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Plate 9  Plate 10  Plate 11  Plate 12  Plate 13  |
Room Setup The patient should be places in a supine position at 30 degree reverse Trendelenberg. This promotes the relocation of the small bowel into the pelvis, and makes locating the Ligament of Trietz less difficult.. See Plate 1 The proper room setup is achieved by utilizing the concept called optical correctness and the establishment of an operating suite ergonomic strategy. Optical correctness is achieved by placing the monitor opposite the surgeon with the operative site between. Instrument directional stability is further assured by the surgeon never looking over his or her shoulder while operating. Employing this strategy the surgeon should be placed on the right side of the surgeon. The first assistant is positioned opposite the surgeon on the left side of the patient. The camera operator is on the right side of the patient to the right of the surgeon. The scrub nurse is at the foot of the table on the same side as the surgeon. See Plate 2 If staffing is limited, the procedure can be done with a total staff of three. The scrub nurse takes the camera position, and the first assistant is on the opposite side of the surgeon. See Plate 3 Jejunostomy Site Preparation This is a picture of the abdomen showing the trocar site placement in relation to the jejunostomy tube exit site. This is the first site that must be identified before you can properly position all of the trocars. The general location is usually the left upper quadrant. The exact site may vary according to the patient's abdominal landmarks. This position is at least 2 fingerbreadths lateral to the rectus muscle sheath and 2-3 fingerbreadths from the costal margin. Once this site has been determined, you may mark the sites of the trocars. To prepare the site, a transverse incision 3-4 cm in length is then performed. Hemostats are used to clear the subcutaneous tissue until the fascia is identified. A clearing, 2.5 cm X 2.5 cm, is made over the fascia and a diamond shaped suture deployment pattern should be identified. Each point of the diamond represents a suture exit site. The center of the diamond repreents the entry site of the tube. See Plate 4 Trocar Placement Trocar site #1: An alternate pneumoperitoneum insufflation site is used. It is located in the right upper quadrant halfway between the umbilicus and the anterior axillary line, lateral to the rectus muscle at least two fingerbreaths away from the costal margin. Trocar site #2: The position for the camera is located halfway between the umbilicus and anterior superior iliac spine. It is the lateral margin of the rectus muscle. Trocar site #3: This trocar is situated fifteen centmeters from the #1 trocar site. All of the trocars are AutoSuture VERSAPORT* 12mm trocars. If a smaller laparoscope is used the #1 and #2 trocars may be smaller. See Plate 5 OPERATIVE STEPSAfter the pneumoperitoneum has been established and the trocars have been positioned, place the laparoscope through the #2 port. .First, identify the Ligament of Trietz. See Plate 6 This is accomplished by first locating the greater omentum. The greater omentum is lifted and displaced cephalad with the non-dominant hand. Once this is accomplished, gently tug on the loops of bowel in an area to the left of the root of the mesentery. The small bowel should be displacedin the pelvis and this will aid in locating the ligament of Treitz. If the ligament of Treitz is not quickly found, select a piece of small bowel and use a two handed shuffle technique to run the bowel proximally until the ligament is identified. This identification of the ligament of Treitz is paramount if you are going to have proper placement of the jejunostomy tube. The next step is to use the same shuffle technique to move 30 to 40 cm away from the ligament of Treitz in order to identify the entry site of the jejunostomy tube itself. See Plate 7 With the proximal point of bowel being identified by the non-dominant hand; left bowel and the distal portion in the dominant hand; bring the bowel to the anterior abdominal wall without tension. Then, correlate the proximal and distal points of the bowel with the cephalad and caudal points of the diamond shaped suture placement grid. Expose the tube exit site and identify 4 points of a diamond fixation pattern. The ENDOCLOSE* instrument is placed through the apex of the diamond suture placement pattern. This helps to localize exactly where the suture should be placed through the bowel. At this point, the ENDOSTITCH* instrument with approximately 12 inches of suture is brought into the abdomen via the #3 port. Its advantages are readily apparent. Instead of having to go through tortuous instrument manipulations to perform intracorporeal suturing, the ENDOSTITCH* instrument brings the suture through the tissue with one pass. With the left grasper identifying the cephalad point of fixation, the ENDOSTITCH* instrument places the suture through this point. . See Plate 8 The ENDOSHEARS* instrument is brought into the abdomen to cut and release the suture from the jaws of the ENDOSTITCH* instrument. Use the ENDOCLOSE* instrument to engage first one, then the other limb of the suture and bring these out the anterior abdominal wall, being careful not to twist the sutures. At this time there must be a hemostat ready to grab the suture to hold it in place. The ENDOCLOSE* instrument captures the suture in an aircraft carrier landing like fashion. Now pass the ENDOCLOSE* instrument back into the abdomen very close to the previous entry site. The ENDOCLOSE* instrument then repeats the aircraft carrier like technique and removes the suture from the abdomen. This is repeated until a diamond shaped suture pattern has been established. [The next fixation point is the lateral point furthest from the camera; then the caudal point followed by the medial point closest to the camera.] Once all fixation sutures are placed, the suture-intestinal complex is allowed to hang in a hammock-like configuration with the proximal portion of the bowel being lifted to the anterior abdominal wall. Remember, this suture pattern is approximately 1 inch long and 1 inch wide. See Plate 9 A needle is passed through the abdominal wall, that is, the center of the 4 fixation points (the diamond shaped suture pattern). A guidewire is passed through the needle into the intestinal lumen. Distal placement is promoted by keeping the proximal bowel higher than the distal segment. See Plate 10 The introducer and tear away sheath is placed over the guide wire and, as atraumatically as possible, inserted into the small intestine. This can be assisted by supporting the abdominal wall with the non-dominant hand instrument. See Plate 11 We also suggest that the apex of the triangle be lifted close to the abdominal wall. Next, the introducer is removed and the jejunostomy tube is placed into the bowel. Once that is done, the tear away sheath is removed. See Plate 12 Sutures are then tightened and contrast is placed down tube to check final placement. See Plate 13 SUMMARY
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