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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_670_Библиотеки_им_академика_М_И_Перельмана
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132 Atlas of Gastrointestinal Surgery: Stomach
Duodenal Switch with Biliopancreatic Diversion
Esophagus
Stomach
The bougie is removed and the Roux limb is
clamped off. An orogastric tube is inserted into the
stomach and any blood is removed. An air leak or
14
Duodenoileostomy
Colon
Jejunum
liquid dye test is then performed on the stomach
staple line and duodenoileostomy. The mesen-
teric defect is closed between the Roux limb
mesentery and the transverse mesocolon, up
to the transverse colon (14).
The lateral stomach specimen is removed
through a port site, which may need to be
enlarged, and then have its fascia closed. A
drain is left by the stomach, the duodenal
stump, and the duodenoileal anastomosis.
The trocars are removed and local anesthetic
is injected followed by a subcuticular closure
of the trocar sites.
Cecum
Biliopancreatic
limb
Ileoileostomy
GASTROSTOMY
Operative Gastrostomy
Operative Indications
There are a variety of indications for placement of a gastrostomy. Generally, gastrostomies are used for gastric decompres-
sion or for external tube feedings. In many instances the gastrostomy can be performed percutaneously and endoscopical-
ly. However, in some instances that is not possible. An obstructing benign stricture or tumor of the esophagus or pharynx
may make esophagoscopy impossible. Prior intraabdominal surgery with scars and adhesions may make approximation of
the anterior gastric wall with the abdominal wall uncertain. Prior gastric surgery resulting in a small gastric remnant may also
eliminate the possibility of percutaneous endoscopic gastrostomy (PEG). In many instances the patient is explored for
other intraabdominal processes, and at the end a gastrostomy is performed as part of the operative procedure. Although
there are numerous techniques for operative gastrostomy, only one is shown here.
Operative Technique
The patient is explored through a short upper midline incision. The
stomach is identified and grasped along the greater curvature with two
Babcock clamps.
134 Atlas of Gastrointestinal Surgery: The Stomach
Two concentric purse strings of 2-0
silk are placed (1). The site of the
gastrostomy is picked in the left
upper quadrant, and with the elec-
trocautery a small opening is made
through skin, subcutaneous tissue,
muscle, and fascia. From inside out a
Rienhoff clamp is passed through this
opening, and a No. 24 Silastic Foley
Concentric
purse string
sutures
catheter is grasped and pulled into the
abdominal cavity (2).
Anterior
gastric wall
1
Linea alba
Silastic
Foley
catheter
2
Gastrotomy
Operative Gastrostomy 135
Mucosa
Balloon
inflated
3
Purse strings
secured
An opening is then made through the center of the two
concentric purse strings using the electrocautery (3 and inset).
Once the gastric opening is made, the Silastic catheter is
inserted, and both purse strings are secured (4).
4
136 Atlas of Gastrointestinal Surgery: The Stomach
The Foley balloon is filled with 10 mL of saline. The
Four quadrant
sutures placed
anterior gastric wall surrounding the gastrostomy site is
then sutured to the anterior abdominal wall with four
sutures. Each suture is placed in one of the quadrants
surrounding the gastrostomy tube in the stomach and
placed correspondingly around the exit site of the
gastrostomy tube in the anterior abdominal wall (5).
Once all four sutures are placed, the anterior gastric
wall is approximated to the anterior abdominal wall
by gently pulling the Foley catheter out onto the ante-
rior abdominal wall. All four sutures are then secured
(6 and 7). The gastrostomy tube is secured to the skin
with two 4-0 stainless steel wire sutures wrapped spiral-
ly around the gastrostomy tube (7).
Anterior
gastric wall
Anterior
abdominal
wall
5
Foley
balloon
Wire sutures
Abdominal wall
Gastric wall
6
7
Alternate
catheters
Operative Gastrostomy 137
8 9
Extra side holes
in Foley catheter
This type of gastrostomy is very effective for feed-
ing. However, if it is to be used for decompression,
during creation of the gastrostomy, the Foley
catheter should have extra side holes cut into it and
be advanced into the gastric lumen for approximate-
Malecot
catheter
ly 8 to 10 cm (8). In this configuration, it is very
effective in decompressing the stomach. In this
instance the Foley balloon should not be inflated
because peristalsis will tend to carry it into the
pylorus and cause obstruction. A variety of other
tubes can also be used for the gastrostomy (9). The
abdomen is irrigated with an antibiotic containing
solution and closed in layers.
10
Percutaneous Endoscopic Gastrostomy (PEG)
Operative Indications
Percutaneous endoscopic gastrostomy (PEG) provides a non-operative method of obtaining direct access to the stomach
for gastric decompression and enternal feeding. The advantages over operative gastrostomy are: (1) the avoidance of laparo-
tomy for operative placement of gastrostomy, and (2) the procedure can be performed easily under local anesthesia with
intravenous sedation. The indications are generally the same as for the open gastrostomy. In most series, patients with neu-
rologic disabilities or head and neck cancers predominate. Contraindications include the inability to pass a gastroscope
through an upper aerodigestive tract tumor or a benign or malignant esophageal stricture. Relative contraindications include
previous gastric surgery or prior abdominal surgery, which might be associated with extensive upper abdominal adhesions.
Operative Technique
Presently two techniques of PEG are commonly used: the “push” technique and the “introducer ” technique. In all cases
the patient has fasted and the procedure is performed in an operating room, endoscopy suite, or intensive care unit.
Although an anesthesiologist is not necessary for all cases, absolute attention to airway management is required. The
abdomen is prepped and the patient’s mouth is swabbed with cleansing solution to minimize oral bacteria. Prophylactic
antibiotics should be administered before the procedure. The posterior pharynx is anesthetized with topical spray, and intra-
venous sedation is given.
Typically, two experienced operators are necessary, a surgical endoscopist and an assistant to perform the abdominal
part of the procedure. The gastroscope is passed into the stomach, and a complete endoscopic examination is carried out.
The stomach is fully insufflated with air, and the room lights are dimmed. The assistant identifies the site where the light of
the gastroscope most clearly transilluminates the anterior abdominal wall. Although this site is typically in the left upper
quadrant, it may be in the midepigastrium near the midline. Finger pressure at this site should produce an unmistakable
indentation of the gastric lumen seen by the endoscopist. Care should be taken to avoid placement at a site in the distal
stomach, near the pylorus, where the pyloric channel may be obstructed.
“Push” Technique
Percutaneous Endoscopic Gastrostomy 139
Once the site is identified, the assistant infiltrates the skin in the area with
a local anesthetic. A long metal needle is then passed through the abdom-
inal wall at this site into the lumen of the stomach (1, 2). The
endoscopist can see the needle in the gastric lumen (3).
The assistant’s fingertip should be kept over the needle
to avoid leakage of air (4), which would allow the
stomach to decompress and thus fall away from the
abdominal wall (4). A knife blade is then passed
along the edge of the needle to divide the fascia
adjacent to the needle to allow for the subsequent
passage of the gastrostomy tube (5).
Scope
Needle
Abdominal wall
Colon
Scope
1
Pancreas
Gastric lumen
2
Blade
Needle
Gastric lumen
3
Scope view
4
Fascia
5
140 Atlas of Gastrointestinal Surgery: The Stomach
7
Polypectomy
snare
Scope
Guidewire
introduced
through
needle
Next, a coated guidewire is passed through the needle into the stomach (6).
When the guidewire is visualized in the gastric lumen, it is retrieved by a
6
polypectomy snare passed through the endoscope (6 and 7). The gas-
troscope is removed from the stomach, pulling the wire out of the
patient’s mouth (8). The needle is also extracted from the gas-
tric lumen and anterior abdominal wall.
Guidewire
Abdominal wall
Needle
Gastric lumen
8
Gastrostomy tube
passed over
guidewire
Percutaneous Endoscopic Gastrostomy 141
Tapered dilator
Gastrostomy tube
Guidewire
9
Guidewire
A specially designed gastrostomy
tube fitted with a long dilator-like end is
then passed over the guidewire and intro-
duced through the patient’s mouth (9).
Both ends of the guidewire must be held
taut as the lubricated gastrostomy tube is
directed over the wire and pushed into the
10
stomach and out the abdominal wall (10).
Once the tube emerges from the abdominal
wall, the assistant may grasp and pull it the
rest of the way out.
Tapered dilator
Guidewire
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