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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_788_Библиотеки_им_академика_М_И_Перельмана.pdf
178
a b
Fig. 7.2.8a, b A TA 30 stapler is used across the duodenum distal to the transverse incision. When transecting the duodenum proximal to the stapler,
be sure to avoid cutting the suture (“leash”) along the anvil.
7.2 Laparoscopically-Assisted Gastric Resection
Fig. 7.2.9a
c d
b
Operative Procedure
Gastrojejunal Anastomosis
179
Fig. 7.2.10 The final result. Notice the posterior position of the
gastroduodenal anostomosis. It assumes a funnel configuration as food
passes through.
Fig. 7.2.11 The future specimen is developed in a fashion similar to the
Billroth I. No incision is needed in the duodenum as in Fig. 7.2.7
(Billroth I). In muscular and obese patients with a thick abdominal wall, it
would be difficult to deliver the pyloric-duodenal area through a small incision (as in Fig. 7.2.5). In this case, the first portion of the duodenum is
best closed and transected with the Endo-GIA under pneumoperitoneum
with the abdomen still closed.
a b
Fig. 7.2.12a, b In the patients with a flat, thin abdominal wall, the small
midline incision (see Fig. 7.2.5) is performed. The pylorus and first portion
of the duodenum are elevated. The duodenum is closed with a TA-55 ar-
컅 Fig. 7.2.9 a−d Pull the anvil rod through the staple line in the duodenum
and remove the traction suture (leash). Now a transverse incision is made
in the anterior surface of the stomach distal to the initial stay sutures that
mark the level of resection. The cartridge of the EEA is inserted into the
stomach. The trocar guiding the hollow rod of the cartridge, is advanced
through the posterior gastric wall proximal to the planned line of gastric
ticulated stapler and is then transected between this stapler and a Kocher
clamp placed distal to the pylorus.
transection. The trocar is removed after the central rod has cleared the
posterior wall of the stomach. The two portions of the EEA are mated and
the EEA is closed and fired. A TA 90 stapler is then used to close the
stomach distal and anterior to the gastroduodenal anastomosis, including
the anterior gastrotomy in the specimen. The specimen is transected
caudad to the TA 90 and removed.
180
7.2 Laparoscopically-Assisted Gastric Resection
Fig. 7.2.13 Once the duodenum has been transected, the distal portion
of the stomach can be elevated to the left and anteriorly into the midline
incision. A loop of jejunum from beyond the ligament of Treitz is brought
to the posterior aspect of the stomach cephalad to the level of the
planned transection. A gastrotomy and enterotomy are made for the in-
sertion of the GIA stapler with one fork of the instrument advanced into
each viscus. The jejunum and stomach are matched for Welter’s “anasto-
mose-résection intégrée.”
Fig. 7.2.14 After the stapler is fired, gentle traction is exercised on both
limbs of the jejunum, and a TA 90 is placed along the stomach at the line
of resection, including the now single GIA introduction site. When the TA
is fired, the gastrojejunostomy is completed along the greater curvature
and the stomach is closed simultaneously onto the lesser curvature, and
the specimen can be removed.
Distal Gastrectomy and Gastroduodenostomy
2
1
4
Fig. 7.2.15 The proximal gastric remnant with completed gastrojejunos-
tomy.
3
5
Fig. 7.2.16 a 1. Elevate left lobe of liver with fan retractor. 2. Perform
anterior and posterior vagotomy. 3. Divide gastro-colic ligament; secure
gastroepiploic vessels. 4. Place stay sutures to mark level of resection. 5. Perform a 4−5 cm upper midline incision, overlying antrum and
pylorus.
Operative Procedure
181
6
8/9
10
7
Fig. 7.2.16b 6. Dissect lesser curvature. 7. Advance EEA anvil and
“leash,” through duodenotomy into duodenum. 8./9. Close duodenum
proximal to duodenotomy with Kocher clamp and distally with linear stapler. Transect in between, leaving the protruding “leash” intact. 10. In-
troduce EEA cartridge through anterior gastrotomy.
11
13
1412
Fig. 7.2.16c 11. Elevate distal stomach (future specimen) anteriorly and
to the left. 12. Advance the cartridge trocar and central rod through
posterior gastric wall, proximal to stay sutures marking transection. 13. Advance anvil through duodenal staple line, remove “leash”
and cartridge trocar, mate anvil and cartridge, accomplish the circular
gastro-duodenostomy. 14. Close the stomach distal to this anostomosis
with linear stapler and resect specimen caudal to stapler.
Distal Gastrectomy and Gastrojejunostomy
2
1
3
6
8
5
9
4
7
Fig. 7.2.17a 1. Elevate left lobe of liver with fan retractor. 2. Perform
anterior and posterior vagotomy. 3. Transect duodenum with Endo-GIA
stapler. 4. Divide gastro-colic ligament; secure gastro-epiploic ves-
sels. 5. Place stay sutures to mark level of resection. 6. Dissect lesser
curvature after making a 4−5 cm upper midline incision (7).
10
Fig. 7.2.17b 8. Elevate distal stomach anteriorly and to the left. 9. Perform a side-to-side gastroenterostomy on the posterior wall of the
stomach with the GIA stapler. Close the GIA introduction site and the
stomach with the linear stapler. Resect specimen caudal to the linear stapler. 10. Jejuno-jejunostomy by surgeons’s choice.
182
7.3 Combined Laparoscopic and Endoscopic Gastric Wedge Resections
7.3 Combined Laparoscopic and Endoscopic Gastric Wedge R esections
S. D. Potter , H. K. Yang, C. A. Schneider, R. Karafilian
Objectives and Methods
In the past, surgical treatment of benign gastric lesions (such as
a Dieulafoy ulcer, ectopic pancreatic nodule or a small leiomyoma) required a formal laparotomy with either a partial
gastrectomy or a wedge resection. Often intraoperative localization of the lesion was difficult and usually required an open
gastrotomy. Combined laparoscopic and endoluminal endoscopic wedge resection provides an excellent minimally invasive method for resection of this type of lesions. It eliminates
the need to open the GI tract, provides excellent exposure and
visualization of the stomach and therefore precise localization
of the lesion. Additionally, post-operative pain is decreased,
length of ileus is shorter, and hospital stay is reduced.
Indications
Small benign lesions of the stomach.
Contraindications
Large lesions.
Malignant lesions.
Instrumentation
− General purpose laparoscopic setup,
− Endostitch (United States Surgical Corporation),
− One 11 mm port,
− Two 12 mm Versiports (United States Surgical Corporation),
− Laparoscopic Babcock clamp,
− Laparoscopic Endo GIA-30 (United States Surgical Corporation),
− Laparoscopic Endo GIA-60 (United States Surgical Corporation),
− Laparoscopic liver fan retractor.
Operative Positioning
The patient is placed supine on the operating table. The operation can be performed from either the left or right side of the
table with the first assistant providing retraction from the opposite side.
The intraluminal endoscope can be reinserted to confirm removal of the lesion and the specimen is sent to the department
of pathology for frozen sectioning.
Port Selection and Placement
Fig. 7.3.1 The patient is placed on the table in a supine position and a
pneumoperitoneum is established. The laparoscope is introduced
through an 11 mm port in the 3 periumbilical position. Two additional
ports (12 mm) are placed in the right and the left mid-clavicular lines approximately three centimeters below the costal margin. We prefer to use
Versiports (United States Surgical Corporation) for these ports. Their design allows stay sutures to be brought through them without compromising the pneumoperitoneum.
Operative Procedure
Postoperative Care
183
Fig. 7.3.2 The anterior wall of the stomach is elevated with an endo-Bab-
cock clamps and the gastrocolic ligament is incised and gastroepiploic
vessels are secured with the vascular Endo-GIA stapler.
Anesthesia
General endotracheal anesthesia.
Postoperative Care
A nasogastric tube is placed intraoperatively. This can be re-
moved in the early postoperative period. Diet can be advanced
as tolerated and the patient discharged on the first postoperative day.
Fig. 7.3.3a The lesion, in this case a Dieulafoy ulcer, is located by endoluminal endoscopy and is demonstrated by transillumination and rotation of the greater curvature upwards.
Step-by-Step Procedure
Fig. 7.3.5
Fig. 7.3.3b A fan retractor maintains the upward rotation of the greater
curvature. The lesion, localized by intraluminal, endoscopic transillumination is marked and held by two stay sutures of placed on its periphery.
These sutures are brought through one of the ports and will be used as
traction to create a wedge of posterior gastric wall, containing the lesion.
184
7.3 Combined Laparoscopic and Endoscopic Gastric Wedge Resections
3
1
2
Fig. 7.3.4 Traction is placed on the sutures. The Endo GIA-60 stapler is
then positioned to resect a gastric wedge that encompasses the lesion.
This usually takes two to three applications of the stapler. The lesion can
then be placed in an Endo-Catch (United States Surgical Corporation) and
removed through one of the 12 mm ports.
45
Fig. 7.3.5 1. Incise gastrocolic ligament and secure gastro-epiploic vessels with vascular Endo-GIA. 2. Rotate greater curvature of stomach superiorly and maintain position of posterior gastric wall and entry into
lesser sac with fan retractor. 3. The intraluminal gastroscope is advanced through the esophagus and the lesion is identified. 4. By transillumination the area of the lesion is delineated and signaled to the laparoscopic surgeon. Stay sutures are placed. 5. With traction on the stay, sutures a wedge of gastric wall containing the lesion is formed. This wedge
is resected with one or several applications of the Endo-GIA stapler.
7.4 Gastrostom y
K. Schönleben
185
Goals and Methods
The goal of gastrostomy is to establish access into the gastrointestinal tract for the purpose of enteral nutrition or decompres-
sion, or both alternatively. To do so, a large tube is placed
through the abdominal and gastric walls into the stomach. The
laparoscopic variant of this operation can be performed as an
alternative to a conventional Witzel’s gastrostomy. Patients
with incurable cancer in poor general health benefit from the
laparoscopic approach.
Indications
The procedure is indicated in the palliative or adjuvant radioand/or chemotherapy of malignant esophageal and proximal
gastric obstructions, with intent to reestablish an endoluminal
G.E. passage. Gastrostomy represents a substitute for a tem-
porary feeding nasogastric tube or an endoluminal prosthesis
that would not be appropriate or tolerated over a prolonged pe-
riod of time.
Contraindications
The laparoscopic variant is contraindicated if an extensive previous operation could make dissection difficult and increase the
risk of organ injury and prolong the duration of the operation.
Patient Positioning
Position the patient supine with both arms abducted. The hips
should be slightly flexed with the legs abducted and individually supported. Place the operating table in a 30° reverse Trendelenburg position with the patient rolled into a slight right
lateral position.
Position of the Operating Team
(Fig. 7.4.1).
Trocar Placement
Establish a pneumoperitoneum up to 14 mm Hg through a
Veress needle placed in the inferior rim of the umbilical fossa.
Introduce a 10-mm trocar for the 0-degree or 25-degree laparoscope. Insert two additional 10-mm trocars in pararectal positions in the same transverse plane or slightly inferior to it, depending on the specific anatomy (Fig. 7.4.2). Place the working
trocars under laparoscopic control. Both working trocars should
be equipped with adapters or reducing sleeves to accommodate
instruments of different sizes. Open laparoscopy is an alternative.
Complications
Surgical Risks and Patient Information
The risks involved are essentially the same as in laparoscopic
gastroenterostomy (see p. 172). One should specifically inform
the patient of the risk of dislocation or obstruction of the
gastrostomy tube which will necessitate replacing it. Such com-
plications must in general be managed by conventional open
operation.
Special Preparations
No special surgical instruments are required. Special
gastrostomy catheters with retention disks may be used. Balloon catheters have proven particularly effective due to their superior retention effect.
Anesthesia
General anesthesia.
Intraoperative Complications
Aside from the complications associated with establishing the
pneumoperitoneum and inserting the trocars, the operation involves few intraoperative risks because the gastric stage affects
few vascular structures. While bleeding from the incised wall of
the stomach may occur, this can generally be controlled with
electrocautery or by ligation.
Note: The anterior gastric and abdominal wall incisions must
line up exactly and continue to be aligned after the
pneumoperitoneum is let down.
Poor alignment can dislocate or damage the gastrostomy tube.
Corrective action: Reposition the gastrostomy tube under laparoscopic control, and test for tube patency and surrounding
tissue sealing with a dilute methylene blue solution.
If difficulties are encountered, conversion to laparotomy is indicated.
Late Complications
Specific complications include obstruction of the tube due to
coarse food or dislocation of the tube from the surrounding tissues or malfunction of the tube anchoring mechanism. If this results in leakage of gastric contents into the peritoneum, localized abscesses or generalized peritonitis may result. Published
results regarding replacement of laparoscopically placed catheters are not yet available; a complication of this nature would
most likely have to be managed by laparotomy.
186
Fig. 7.4.1 Gastrostomy. Position of the surgeon,
assistants, OR nurse, and equipment.
7.4 Gastrostomy
Monitor
Surgeon
Assistant
Fig. 7.4.2 Gastrostomy. Trocar placement. Positioning of the laparo-
scope bearing trocar (T1) and the instrument trocars (T2) and T3). If an
additional instrument is required to improve exposure, another trocar
(T4) can be placed inferior to the left costal arch.
OR nurse
Assistant
holding
the laparoscope
Instrument table
Equipment
T2
T4
T3
T1
Conversion to Laparotomy
187
Conversion to Laparotomy
Conversion to laparotomy is indicated if:
− Primary laparoscopic exploration reveals that an extended
procedure such as anastomosis is required.
− The anatomy is not favorable to a prompt laparoscopic procedure (i. e., in the presence of adhesions from a previous
operation).
− The operation does not appear feasible for other technical
reasons.
− The patient’s general health or cardiopulmonary condition
does not permit maintaining the pneumoperitoneum for 60
to 90 minutes.
Step-by-Step Procedure
1. Place the patient in a 30° reverse Trendelenburg position.
2. Establish the pneumoperitoneum and introduce the 10-mm laparoscope/camera trocar below the inferior umbilical fossa.
Place one instrument trocar each in a pararectus position on
the left and right side; select their transverse plane according
to the specific anatomy.
3. Expose the anterior wall of the stomach. Choose an appropriate placement for the tube corresponding to the point of attachment to the anterior abdominal wall.
4. Place the anchoring sutures at this site directly through the
abdominal wall, pass them through the anterior wall of the fundus, and lead them out of the abdomen.
5. Insufflate the stomach with CO
approach.
6. Incise the stomach wall between the two anchoring sutures
sufficiently to advance the gastrostomy tube through the stab
incision in the abdominal wall.
7. If a balloon-equipped tube is used, inflate the balloon with
20 ml of saline solution and reduce the intraperitoneal pressure 50% (i. e., to 5−6 mm Hg). Draw the wall of the stomach
toward the anterior abdominal wall with the anchoring sutures.
8. Fix the retention disk of the catheter to the outer wall of the
stomach with the two anchoring sutures.
9. Let down the pneumoperitoneum completely and close the
wound.
gas via a direct percutaneous
2
Operative Technique
Fig. 7.4.3 Gastrostomy. Placing the anchoring sutures and insufflate the
stomach with CO
After elevating the left hepatic lobe and applying tension to the anterior
wall of the stomach with a grasper advanced from the right, mark the site
chosen for gastrostomy with electrocautery. The anchoring sutures (2−0
nonabsorbable atraumatic suture material) on straight needles are passed
directly into the abdomen through corresponding sites in the left anterior
superior abdominal wall. Using the needle holder introduced from the
right, pass the needle through the anterior gastric wall medial to the
planned gastrostomy site, and return it to the outside through the
abdominal wall. Now pass the needle back out of the gastric wall about 1−
1.5 cm from the point of entry. Repeat this procedure, placing the second
anchoring suture about 2.5 cm to the left of and lateral to the first anchoring suture (i. e., 1 cm lateral to the planned gastrostomy site). After inserting a Veress needle through the abdominal wall, aspirate the stomach
between the anchoring sutures and insufflate it with CO
Then use monopolar electrocautery (a hooked electrode inserted from
the left) to make an incision no longer than 3−5 mm through the serosa
and muscularis. With a right-angle or other laparoscopic clamp, puncture
and spread the mucosa to gain access to the gastric lumen. Control bleeding from the stomach wall with a laparoscopic clamp and electrocautery.
1
1 Body of the stomach
.
2
2
(see insert).