Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)
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C H A P T E R 20
STAMM GASTROSTOMY
Dennis C. Gore
STEP 1: SURGICAL ANATOMY
Allows gastric decompression
Access for enteral feeding (Figure 20-1)
STEP 2: PREOPERATIVE CONSIDERATIONS
Anesthesia: general
Position: supine
STEP 3: OPERATIVE STEPS
1. INCISION
Incision and exposure: upper midline
Use scalpel to create stab wound through skin and anterior fascia just lateral to rectus abdominus muscle left of midline (see Figure 20-1).
2. DISSECTION
With retraction and visualization, the surgeon should use forceps through the stab wound to enter through the peritoneum and into the abdomen.
The surgeon should use the same forceps to grasp a mushroom catheter (12F) and retract the external end of the catheter through the stab wound (Figure 20-2).
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C H A P T E R 20 • Stamm Gastrostomy |
241 |
Exit site
2 cm or more below costal margin
Upper midline incision
MC
FIGURE 20–1
Liver
Mushroom catheter
Stomach
FIGURE 20–2
2 4 2 S E C T I O N I V • TH E A B D O M E N
Place 2-0 silk purse-string suture to the anterior wall of the stomach (Figure 20-3).
Using two Babcock clamps for traction, the surgeon uses the cautery to create gastrotomy within the purse-string suture (Figure 20-4).
First purse-string suture
FIGURE 20–3
Babcock clamp
Gastrotomy
FIGURE 20–4
C H A P T E R 20 • Stamm Gastrostomy |
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Two Babcock clamps are used for traction and forceps are used to stent the mushroom catheter tip, which is placed through gastrotomy (Figure 20-5, A).
The first purse-string suture is secured around the catheter (Figure 20-5, B).
First purse-string suture
Mushroom catheter
A
Second purse-string suture
FIGURE 20–5 |
B |
2 4 4 S E C T I O N I V • TH E A B D O M E N
The second purse-string of 2-0 silk sutures is placed around the tube and secured
(Figure 20-6).
2-0 silk sutures are used to anchor the anterior wall of the stomach to the peritoneum in simple, interrupted fashion (Figure 20-7).
The mushroom catheter is retracted to approximate the anterior stomach wall with the peritoneum, then secured, and silk sutures are tied.
Transversalis muscle |
Parietal |
|
peritoneum |
||
|
Stomach
FIGURE 20–6
Mushroom catheter
Anchor sutures
FIGURE 20–7
C H A P T E R 20 • Stamm Gastrostomy |
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3. CLOSING
Closure of fascia with suture
Closure of skin
STEP 4: POSTOPERATIVE CARE
Routine
STEP 5: PEARLS AND PITFALLS
Two Babcock clamps grasping the edges of the gastrotomy along with a forceps inserted into the tip of the mushroom catheter and then held under tension provide an excellent means of retraction for placing the mushroom catheter within the stomach.
The catheter should remain in place until the gastrostomy tract and the anterior stomach wall are securely healed to the peritoneal surface, which usually takes 10 days.
First place all the sutures from the stomach to the peritoneum, then retract the catheter to approximate the anterior surface of the stomach to the peritoneum and secure ligatures. This sequence allows good visualization and room for placing sutures.
SELECTED REFERENCES
1. Zollinger RM Jr, Zollinger RM: Atlas of Surgical Operations. New York, MacMillan, 1983, p 30.
C H A P T E R 21
WITZEL JEJUNOSTOMY
Dennis C. Gore
STEP 1: SURGICAL ANATOMY
See Figure 21-1.
STEP 2: PREOPERATIVE CONSIDERATIONS
Indication: access for enteral feeds
Anesthesia: general
Position: supine
STEP 3: OPERATIVE STEPS
1.INCISION
Periumbilical midline laparotomy (Figure 21-1).
2.DISSECTION
After entering the peritoneal cavity, use scalpel to create stab wound through skin and anterior fascia, just lateral to rectus abdominus muscle, usually to the left (see Figure 21-1).
With retraction and visualization, use forceps through stab wound to enter through peritoneum and into abdomen (Figure 21-2).
Use this same forceps to grasp mushroom catheter (20F) and retract external end of catheter through stab wound.
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C H A P T E R 21 • Witzel Jejunostomy |
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Exit site of tube through abdominal wall (stab wound)
Periumbilical midline laparotomy incision
MC
FIGURE 21–1
Mushroom catheter
Omentum
FIGURE 21–2
2 4 8 S E C T I O N I V • TH E A B D O M E N
Place 3-0 silk suture as purse string into antimesenteric wall of selected jejunum, usually approximately 30 cm distal to ligament of Treitz yet with sufficient mobility to reach peritoneum at the site of the catheter exit (Figure 21-3).
Using two Babcock clamps for traction, use cautery to create enterotomy within purse string (Figure 21-3).
Mushroom catheter
First purse-string suture
Enterotomy within jejunum
FIGURE 21–3