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188
Fig. 7.4.4 Gastrostomy. Placing the gastrostomy tube. 컄
Insert the gastrostomy tube into the peritoneal cavity through a 0.5-cm
stab incision in the abdominal wall between the anchoring sutures. Insert
a 3-mm metal rod into the tube to splint it. This makes it easier to manipulate the tube.
Now introduce the tube into the gastric lumen. Inflate the balloon with
20 ml of saline solution. The gastrostomy should be small enough to be
sealed by the tube and the balloon against the abdominal wall. If this is
not the case, place a Z suture (with an intracorporeal or extracorporeal
knot) through the right trocar to pursestring the gastrostomy site. Next,
reduce the intraperitoneal pressure to about 5 mm Hg and draw the anterior wall of the stomach against the anterior abdominal wall by pulling on
both the tube and the anchoring sutures. Unter laparoscopic visualiza-
tion, verify that the anterior wall of the stomach is pressed tightly against
the abdominal wall in the proper alignment.
Finally, pass the four ends of the anchoring sutures through the holes in
the retention disk and tie them (see insert). This immobilizes the tube sys-
tem and maintains the required contact pressure.
7.5 Endoscopic Intraluminal Gastroduodeno-Pancreatic Cystostomy
Bibliography
Edelman DS, Arroyo PJ, Unger SW. Laparoscopic gastrostomy versus percu-
taneous endoscopic gastrotomy. Surg. Endosc. 1994; 8:47.
Edelman DS, Unger SW, Russin DR. Laparoscopic Gastrostomy. Surg. La-
parosc. & Endosc. 1991; 1:251.
Fletcher DR, Jones RM. Laparoscopic cholecyst-jejunostomy as palliation for
obstructive jaundice in inoperable carcinoma of the pancreas. Surg. Endosc. 1992; 6:147.
Modesto VL, Harkins B, Calton jr. WC, Martindale RG. Laparoscopic
gastrostomy using four-point fixation. Amer. J. Surg. 1994; 167:273.
Sunnerfield JA. Biliary obstruction is the best managed by endoscopist. Gut
1988; 29:714.
7.5 Endoscopic Intraluminal Gastroduodeno-Pancreatic Cystostomy
N. Soehendra
Objectives and Methods
Pseudocysts of the pancreas are approached by intraluminal en-
doscopy using a transmural cystostomy and drained in the same
manner. This is the procedure of first choice.
Operative Technique
Operative Technique
189
a
Fig. 7.5.1 a−e Technique of transmural cyst drainage. Pseudocysts in direct contact with the gastric or duodenal walls can be drained endoscopically.
a The protrusion of the duodenal wall is clearly visible. You make the first
puncture with an injection needle in order to visualize the cyst by
means of contrast medium. In this way, wrongly placed punctures or
puncture of a larger blood vessel can be avoided.
b
b and c Open the selected position with a needle papillotome, from the
duodenal or gastric lumen into the pseudocyst.
c
d Widen the opening with a papillotome. However, this is associated
with a higher risk of bleeding.
190
7.6 Combined Endoluminal and Open Gastric Operation
e It is easier and safer to insert a pig-tail prosthesis (10 Fr). Fig. 7.5.2 Technique of transductal cyst drainage. Cysts communicating
with the main pancreatic duct can be diverted via a transpapillary route
into the duodenum. However, the connection from cyst into duct is often
so small that the inadequate spontaneous drainage must be usefully increased by means of a catheter placed through the papilla and duct of
Wirsung into the pseudocyst.
7.6 Combined Endoluminal and Open Gastric Operation
L. U. Jung, S. D. Potter, H. Rajdeo, K. Bhuta, L. R. M. Del Guercio
Objectives and Methods
Endoluminal endoscopy is widely used for the preoperative
assessment of gastrointestinal disease, to identify location and
nature of the disease process. This useful technique of intralum-
inal evaluation has not been widely utilized as an intraoperative
tool. There are many occasions when the fiberoptic gastroin-
testinal endoscope or colonoscope could guide the open or la-
paroscopic dissection of severely scarred or matted intestine,
facilitate the localization of fistulae, and help in the definition of
anastomotic variations used after previous resections of the
stomach, small and large bowel, especially in the absence of re-
liable records.
This chapter discusses a situation in which a complicated
abdominal procedure was enhanced by the use of intraopera-
tive fiberoptic endoscopy (ILE).
쐌 History of multiple operations with or without intestinal re-
sections; no clear description is available.
쐌 Primary gastric or esophageal resections, to aid in the inter-
nal definition of landmarks and margins.
쐌 Pedunculated colon lesions.
Contraindications
쐌 Active intraluminal bleeding can interfere with visualization
and slow the operative procedure when expeditious action is
most needed.
쐌 Severe, acute inflammation which can lead to perforation.
Instruments
Indications
쐌 Complicated fistulae not clearly identified radioscopically or
clinically.
쐌 Fiberoptic gastroscope and colonoscope.
쐌 Various videoendoscopic or traditional instruments.
Operative Procedure
191
Position
The patient is generally in the supine position for abdominal
procedures, but this may vary depending on the operation.
Position of Surgeon and Equipment
The surgeon is positioned in the usual place required for the
procedure to be performed. The endoscopist is either at the
head for upper endoscopy or between abducted legs (lithotomy
position) for colonoscopy. The monitors can be placed either on
the right and the left side of the patient, near the shoulders. For
the combined endoluminal and intracavitary videoendoscopic
procedure, one monitor is dedicated to each one of the pro-
cedures.
Complications
Operative Complications
The same risks present during endoluminal endoscopy are present during intraoperative endoscopy. These risks include perforation and bleeding. Given the complicated nature of the
operation that requires intraoperative endoluminal endoscopy,
the occurrence of these complications tends to be higher unless
extreme care is taken. The patient should be made aware of the
risks, however, he or she should also be aware that the compli-
cations can usually be managed satisfactorily if noted in-
traoperatively. While the risk of injury can be higher, the overall
operative risk and successful outcome may be improved with
the use of intraoperative endoluminal endoscopy.
Operative Procedure
Figures 7.6.1 to 7.6.4 represent a young patient with multiple
previous abdominal procedures for cholecystitis, peptic ulcer
disease, and severe pancreatitis. She presented with a small
bowel obstruction that did not resolve with non-operative therapy. During exploratory laparotomy, the small bowel was mobilized. A gastroscope was advanced into the stomach in order to
identify, the duodenum, a duodenojejunostomy (Roux-en-Y),
and a pancreatojejunostomy (all accomplished during previous
operations). Once the anatomy was delineated, an antrectomy
was performed for persistent ulcer seen on endoscopy and a
Baker tube Nobel style stent was passed along the entire length
of the small bowel, into the cecum to stent the bowel postoperatively.
This case illustrates the effectiveness of intraoperative intraluminal endoscopy in identifying the operatively altered
anatomy more clearly.
Step-by-Step Procedure
1. The patient is placed on the operating table in the supine position if gastroscopy is planned, whereas the lithotomy position
is best for colonoscopy.
2. For gastroscopy, the endoscope is advanced into the
esophagus and into the stomach under visualization either via
the eyepiece or on the video monitor. The pathology or anatomy in question is identified, and the endoscopist communicates this information to the surgeon.
Postoperative Complications
The most serious postoperative complication is a missed intraoperative bowel injury. Although bowel injury is sometimes
difficult to avoid, immediate identification and repair will usually prevent postoperative difficulties and limit operative morbidity. If an injury is not noted during the operation however,
poor recovery, fistulae, severe sepsis, and even death may
ensue. To prevent this disastrous complication, meticulous dis-
section and examination of the bowel intraoperatively are man-
datory.
192
1
A
B
D
C
7.6 Combined Endoluminal and Open Gastric Operation
a
Fig. 7.6.1a Patient with multiple previous abdominal operations for
cholecystitis, peptic ulcer disease and severe pancreatitis. The type of
various previous operations was unknown to the patient and could not be
ascertained. She now presented with a small bowel obstruction. At open
operation the entire small bowel was liberated.
Next the status of the upper GI tract was explored with endoluminal
gastro-duodenoscopy: Findings were those of a persistent duodenal ulcer,
a Roux-en-Y duodenojejunostomy and pancreatojejunostomy.
b
Fig. 7.6.1b 1. Endoluminal esophagogastroduodenoscopy. A. Identification of normal GE junction. B. Persistent peptic ulcer. C. Finding
of Roux-en-Y duodenojejunostomy. D. Finding of Roux-en-Y pancreatojejunostomy.
3
2
4
a
Fig. 7.6.2a Following identification of the various operative rearrangements of the upper GI tract, and after lysis of all small bowel adhesions, an
antrectomy was performed to treat the persistent duodenal ulcer, because the status of the vagus nerves was uncertain. The Roux-en-Y jejunal
loop, between duodenojejunostomy and pancreatojejunostomy was used
for the gastrojejunostomy.
b
Fig. 7.6.2b 2. Staple closure and transection of duodenum caudal to the
peptic ulcer (but cranial to stapler). 3. Placement of the circular EEA
anastomosing instrument through pylorus and antrum, for anastomosis
of the greater curvature above the antrum to the jejunal loop. 4. Site
selected on the Roux-en-Y jejunal loop for circular, side-to-side anastomosis.
Bibliography
193
Fig. 7.6.3 Following gastrojejunostomy the antrum is resected caudad
to the linear stapler, placed across the stomach, caudad to the circular
gastrojejunostomy at the level of demarcation of gastric body from antrum.
5
2
7
4
6
Fig. 7.6.4 After accomplishing linear, stapled duodenal closure, circular
gastrojejunostomy, linear stapled gastric closure and antrectomy, a Baker
tube is placed into the small bowel caudad to the gastrojejunostomy. It is
advanced all the way to and beyond the ileocecal valve, to serve as an internal stent and prevent acute bowel kinks by new adhesion formations
(Nobel concept).
Bibliography
Bowden jr. TA. Intraoperative endoscopy of the gastriointestinal tract. In
Dent TL, Strodel WE, Turcotte jr. JG (eds.). Surgical Endoscopy, p. 167−188.
Chicago: Year Book; 1985.
Grisendi A, Lonardo A, Della Casa G et al. Combined endoscopic and surgical
management of Dieulafoy vascular malformation. J. Amer. Coll. Surg.
1994; 179:182−186.
Rajdeo H, Bhuta K. Intraoperative endoscopy for complex problems in
gastrointestinal surgery. Compl. In Surg. Nov. 19; 199:37−41.
Smedh K, Olaison G, Nyström PO, Sjödahl R. Intraoperative endoscopy on
Crohn’s disease. Br. J. Surg. 1993; 80:897−900.
8
Fig. 7.6.5 2. Stapled, linear duodenal closure. 4. Circular gastrojejunostomy. 5. Stapled linear gastric closure and antrectomy. 6. Status
after lysis of small bowel adhesions. 7. Intraluminal Baker-Nobel
stent. 8. Balloon of the Baker tube beyond iliocecal valve in cecum.
Tube will be left until resumption of small bowel contractility is finally established. Balloon was deflated after bowel sounds were first heard, to
prevent reverse intussusception.
194
8. Vagotom y and Drainage Procedures
8.1 Indications for Vago tom y
A. Pier , F . Götz
General Remarks
Gastroduodenal ulcers undergo trials of non-operative treatment.
Current treatment considers the specific pathogenesis, i. e.,
bacterial (Helicobacter pylori), iatrogenic (nonsteroidal anti-inflammatory agents or acetylsalicylic acid), and peptic.
Surgical intervention is only indicated if drug therapy fails,
patient compliance is lacking, or complications occur (Figs. 8.1.1
to 8.1.11).
Goals and Methods
Vagotomy is indicated in the treatment of uncomplicated
duodenal ulcers, distal gastric ulcers in association with antrectomy, and ulcers occurring after gastric operations. The type
of vagotomy is specific to the indication:
− Selective proximal vagotomy.
− Posterior truncal and anterior selective proximal vagotomy
by seromyotomy.
− Total vagotomy.
Selective proximal vagotomy with denervation of the fundus
and body of the stomach depresses acid secretion by the gastric
mucosa. The procedure leaves the hepatic, anterior and posterior antral, and celiac branches of the vagus nerves intact.
The posterior truncal and anterior selective proximal vagotomy
by seromyotomy achieves a similar depression of acid secretion.
It also interrupts the celiac branch of the vagus nerve and partially interrupts the motor nerve supply to the antrum.
Total vagotomy reduces acid secretion and interrupts the motor
nerve supply to the antrum, necessitating pyloroplasty (see
Figs. 8.1.8 to 8.1.11). Truncal (total) vagotomy can also be performed through a left transthoracic approach.
All of these laparoscopic procedures are subject to the restriction that circular clearing of the distal esophagus, which may be
performed in open operation to further reduce acid secretion, is
not currently practiced in laparoscopic vagotomy.
Requirements
Vagotomy requires the diagnosis of ulcer confirmed by biopsy
obtained by esophagogastroduodenoscopy. Extragastric sources
of increased acid secretion must be excluded.
1
2
8
4
7
3
6
5
Fig. 8.1.1 Vagotomy. Branches of the vagus nerve supplying the
stomach.
1 Anterior and posterior vagal trunk
2 Fundal branches
3 Antral branches
4 Celiac ganglion
5 Right gastroepiploic branch (Rosati)
6 Duodenal branches
7 Choledochal branches
8 Hepatic branches
Indications
− Selective proximal vagotomy or posterior truncal and anterior selective proximal vagotomy via seromyotomy are indicated for treating an uncomplicated duodenal ulcer and as
an associated procedure in the repair of a perforated
duodenal ulcer in the absence of peritonitis.
− Double (total) truncal vagotomy is indicated in the presence
of an ulcer occurring after gastric operation for treatment of
the original ulcer.
Indications
195
Fig. 8.1.2 Vagotomy.
Prominent posterior vagal trunk.
Fig. 8.1.5 Vagotomy.
Fan-shaped anterior vagal trunk.
Fig. 8.1.3 Vagotomy.
Right anterior vagal trunk.
Fig. 8.1.6 Vagotomy.
Anterior vagal trunk with hepatic branches
and without fundal branches.
Fig. 8.1.4 Vagotomy.
Double anterior vagal trunk.
Fig. 8.1.7 Vagotomy.
Possible intraoperative complications.
1 Injury to the spleen
10
11
2
3
12
5
9
4
6
8
7
2 Injury to the esophagus
3 Injury to the liver
4 Injury to the stomach
5 Injury to the hepatic branches of the vagus nerve
6 Injury to the celiac branch of the vagus ner ve
7 Injury to the antral nerves
8 Vagal nerve fibers left in place
9 Injury to the anterior vagal trunk
10 Fundal branches left in place.
11 Injury to the parietal pleura.
12 Pyloric stenosis left in place.
1
196
1
8.1 Indications for Vagotomy
6
.
.
2
3
4
.
.
.
.
5
Fig. 8.1.8 Vagotomy.
Complete abdominal truncal vagotomy.
1 Anterior vagal trunk
2 Posterior vagal trunk
3 Hepatic branches of the anterior vagal trunk
4 Celiac branch of the posterior vagal trunk
5 Anterior and posterior main gastric branches
6 Fundal branches
Fig. 8.1.11 Vagotomy.
Thoracic total truncal vagotomy.
.
Fig. 8.1.9 Vagotomy.
Principle of selective proximal vagotomy.
Contraindications
− Anesthetic risks.
− Coagulating disorders that do not respond to treatment.
− Difficult anatomy due to previous upper abdominal surgery.
− Cancer, sarcoma, or malignant lymphoma.
Surgical Risks and Patient Information
The patient must be made aware of the current lack of longterm experience. This also makes it difficult to judge the risk of
recurring ulcers. Intraoperative complications can force the surgeon to convert to an open procedure (see the specific chapters
in this volume). Available studies report a morbidity of up to 7%
and mortality ranging from 0−0.5%.
Special Preparations
− Nasogastric tube.
− Indwelling urinary catheter.
Fig. 8.1.10 Vagotomy.
Posterior truncal vagotomy with anterior
seromyotomy. The posterior truncal
vagotomy may be combined with an anterior
selective proximal vagotomy.
Bibliography
Anvari M, Park A. Laparoscopic-assisted vagotomy and distal gastrectomy.
Surg. Endosc. 1994; 8:1312.
Aust BA. New techniques for pyloroplasty. Surgery 1953; 53:309.
Burge H. Vagotomy. London: Arnold; 1964.
Burge HW, Hutchinson JSF, Longland CJ, McLennan I et al. Selective nerve
section in the prevention of post-vagotomy diarrhea. Lancet 1964; 1:577.
Craig PI, Gillespie PE. Through the endoscope balloon dilatation of benign
gastric outlet obstruction. Birt. Med. J. 1988; 297:396.
Daniel EE, Sarnasa SK. Distribution of excitatory vagal fibres in canine gastric
wall to central motility. Gastroenterology 1976; 71:608.
Delmas J, Laux G. Système nerveux sympathique, vol. 1. Paris: Masson; 1952.
Desmond AM. Selektive proximale Vagotomie. In Burge H, Farthmann EH,
Grassi G, Hedensted SB, Hollender LF, Schreiber HW, Tanner NC. Vago-
tomie, p. 101. Stuttgart: Thieme; 1976.
Dragstedt LR. Section of the vagus nerves to the stomach in the treatment of
peptic ulcer. Ann. Surg. 1947; 126:687.
Dubois F. Vagotomie sélective avec conservation des vaisseaux coronaires.
Nouv. Presse Me d. 1976; 5:2322.
Franckson C. Selective abdominal vagotomy. Acta Chir. Scand. 1948; 96:409.
Helms B, Czametzki HD, Krause N, Jantschulev M, Scharlau U. Technik und
Ergebnisse der laparoskopischen selektiv proximalen Vagotomie. Ver-
dauungskrankheiten 1993; 11:145.
Hill GL, Barker MCJ. Anterior highly selective vagotomy with posterior trun-
cal vagotomy: a simple technique for denervating the parietal cell mass.
Brit. J. Surg. 1978; 65:702.
Holle F, Anderson S. Vagotomy. Berlin: Springer; 1974.
Hollender LF. Pyloroplastik. In Bunge H, Farthmann EH, Grassi G, Hedenstedt
SB, Hollender LF, Schreiber HW, Tanner NC. Vagotomie, p. 49. Stuttgart:
Thieme; 1976.
Hollender LF, Marrie A. Die selektiv proximale Vagotomie. Berlin: Springer;
1978.
Hollender LF, Marrie A. Highly selective vagotomy, vol. 1. Paris: Masson;
1979.
Jackson RC. Anatomic study of vagus nerves with a technique of trans-
abdominal selective resection. Arch. Surg. 1948; 57:333.
Johnston D. Selektive Vagotomie mit Ulkusexzision beim Ulcus ventriculi. In
Becker HD, Lierse W, Schreiber HW. Magenchirurgie, S.167. Berlin:
Springer; 1986.
Johnston D, Wilkonson AR. Higher selective vagotomy without a drainage
procedure in the treatment of duodenal ulcer. Brit. J. Surg. 1970; 57:289.
Kahwaji F, Grange D. Ulcère duodénal chronique: Traitement par séromyo-
tomie fundique antérieure avec vagotomie tronculaire postérieure. Presse
Med. 1987; 16:28.
Katkhouda N, Mouïel J. A new surgial technique of treatment of chronic
duodenal ulcer without laparotomy by videocoelioscopy. Amer. J. Surg.
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Objectives and Methods
197
Latarjet MA. Résection des nerfs de l’estomac. Bull. Acad. Med. 1922; 87:681.
Mikulicz J. Zur operativen Behandlung des stenosierenden Magen-
geschwürs. Arch. klin. Chir. 1888; 37:79.
Mouïel J. Actualités digestives médico-chirurgicales, 10
Masson; 1989.
Mouïel J. Katkhouda N. Laparoscopic truncal and selective vagotomy. In
Zucker KA. Surgical Laparoscopy, p. 263. St. Louis: Quality Medical Publishing; 1991.
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116:546.
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Sakuramachi S, Kimura T, Harada Y. Experimental study of laparoscopic
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th
ed., p. 861. Boston: Little, Brown & Co.; 1986.
th
ed., p. 20. Paris:
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Chirurgie für die Praxis, Bd. II/2, S. 77. Stuttgart: Thieme; 1969.
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Chirurgische Gastroenterologie, Bd. 1, S. 460. Berlin: Springer; 1981.
Smith GK, Farris JM. Some observations upon selective gastric vagotomy.
Arch. Surg. 1963; 86:716.
Steele RJ, Munro A. Successful treatment of gastric stasis following proximal
vagotomy. Endoscopy 1989; 21:120.
Taylor TV. Lesser curve superficial seromyotomy. An operation for chronic
duodenal ulcer. Brit. J. Surg. 1979; 66:733.
Taylor TV, Gunn AA. MacLeod DAD et al. Morbidity and mortality after ante-
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Taylor TV, Lythgoe JP, McFarland JB, Gilmore IT et al. Anterior lesser curve
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Triboulet JP. Progrès dans le traitement de l’ulcère duodénal: la séromyo-
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8.2 P osterior Truncal V agot om y and Denervating Anterior Linear Strip Gastrectomy
G. Meyer, T.P. Hüttl, F.W. Schildberg
Objectives and Methods (Fig. 8.2.1)
Three processes, combining a posterior truncal vagotomy with a
selective denervation of the anterior stomach have been
developed with the idea of simplifying the technique and thus
reducing the rate of recurrences by avoiding the technically
demanding, complete selective denervation of the anterior wall
of the stomach. These are:
쐌 Anterior selective proximal vagotomy (conventional: Hill
and Barker 1978, laparoscopic: Bailey et al. 1991).
쐌 Anterior seromyotomy (conventional: Taylor et al. 1982, la-
paroscopic: Katkhouda and Mouiel 1991).
쐌 Linear sleeve resection of the anterior wall of the stomach
(conventional: Gomez-Ferrer 1986, laparoscopic: Hannon et
al. 1992).
As a result of the separation of the rami gastrici antrales anteriores and the ramus ad fornicem (socalled ‘R. criminalis’) as well
as the posterior truncal vagotomy, all procedures lead to a suppression of gastric acid secretion by parietal cells, interrupt the
ramus coeliacus, and effect a lower motoric denervation of the
antrum. The pylorus function remains intact because the an-
terior nerve supply of the antrum (nerve of Latarjet) is preserved; this ensures that normal gastric emptying is possible. It
is known from conventional surgery that the occurrence of
postoperative diarrhea as well as of a dumping syndrome is ex-
tremely rare.
For laparoscopic use, the combination of posterior truncal
vagotomy with linear resection of the anterior wall of the
stomach has proved to be advantageous over other procedures
and is easy to perform with endoscopic stapling-cutting instruments. This reduces the duration of operation and almost
completely avoids bleeding from the wall of the stomach and
mucosal openings. With use of the stapler, the stomach is not
open at any time. Thus, this procedure is also highly suitable for
the special conditions of laparoscopic surgery. In addition, this
procedure presumably leads to an effective separation of the
intramural nerve fibers; it also prevents intramural nerve regeneration and the resulting redevelopment of acid secretion
(Gomez-Ferrer et al. 1993; Mulholland and Debas 1989).
Anesthesia
General endotracheal anesthesia.
Patient Positioning (Fig.8.2.2)