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218
Instrument table
Monitor
2
nd
assistant
Aspirator/
irrigator set
OR nurse
Insufflator
1
st
assistant
Electrocautery unit
Surgeon
Fig. 8.5.1 Truncal vagotomy and pyloroplasty. Positioning.
Place the patient supine on the table in a reverse Trendelenburg position
with one arm extended and the legs spread apart.
Fig. 8.5.2 Truncal vagotomy and
pyloroplasty. Position of the operating
team and equipment.
8.5 Anterior and Posterior Truncal Vagotomy and Pyloroplasty
Perforation of the Duodenal Lumen Occurring During Pyloromyotomy
Corrective action: Convert to a Heineke-Mikulicz pyloroplasty
(see Figs. 8.5.10 and 8.5.11).
Injury to the Liver
Corrective action: Minor lesions limited to the capsule without
excessive bleeding can be coagulated with bipolar electrocautery. If necessary, a hemostatic agent and fibrin glue seal
may be applied.
Bleeding
Undetected bleeding may occur from the anterior or posterior
esophageal branch of the left gastric artery, or from a liver le-
sion.
Corrective action: In the presence of a significant decrease in hematocrit and hemoglobin levels and the appropriate clinical
picture, transfuse an adequate amount of packed red cells. Perform diagnostic laparoscopy to identify the source of bleeding
by removing coagulated blood in the operative site with irrigation and suction. If the bleeding cannot be controlled laparoscopically or the findings are uncertain, immediate conversion to
laparotomy is indicated.
Immediate Postoperative Complications
Mediastinitis Due to Esophageal Injury
Corrective action: Immediate laparotomy is indicated if this
complication is suspected.
Peritonitis
Corrective action: Immediate laparotomy is indicated.
T4
Trocar Placement
219
If symptoms persist, follow-up radiologic and endoscopic endoluminal examinations are indicated. Treat a recurrent ulcer
with nonoperative means. If it does not respond to treatment,
conventional surgical intervention is indicated.
Diarrhea
Diarrhea occurs in 20−30% of all patients following truncal
vagotomy.
Corrective action: Dietary and nonoperative treatment.
Persistent or Recurring Ulcer
Corrective action: Treat nonoperatively; if the condition becomes chronic or complications occur, conventional surgical intervention is indicated.
T5
T3
T2
T1
Fig. 8.5.3 Truncal vagotomy and pyloroplasty. Trocar placement.
A total of five ports is required. Insert a 10.5-mm laparoscope/camera trocar (T1) with a trumpet valve into the abdominal cavity about two finger
breadths above the umbilicus after establishing the pneumoperitoneum.
Then insert four working trocars under laparoscopic vision. Ports T3 and
T5 contain 10.5-mm trocars for various dissection instruments. An additional 5.5-mm working trocar at T4 is inserted to permit introducing a retractor to lift the left hepatic lobe. We recommend gastric endoluminal
splinting and transillumination at various landmark levels to facilitate the
different operative steps.
Open trocar placement is an alternative.
Bleeding
Corrective action: Identify the source of bleeding. Locate and
control intraluminal bleeding endoscopically. Bleeding into the
peritoneal cavity must be treated via laparotomy if the patient
requires more than four units of packed cells for stabilization.
Note: Repeat, corrective laparoscopy requires the highest level
of videoendoscopic and surgical expertise.
Late Complications
Recurrent Ulcer with Anterior Perforation
Corrective action: Laparoscopic intervention to suture the ulcer
and postoperative antibiotic treatment are indicated. In the presence of Helicobacter pylorii, appropriate long-term treatment
should be initiated.
Step-by-Step Procedure
I Technical preparations
1. Adjust the electrocautery unit to the required setting.
2. Connect the aspirator/irrigator set.
3. Prepare an endoluminal endoscope.
4. Start the video and recording unit.
II Establishing the pneumoperitoneum
1. Select pressure levels according to patient’s size, age, and
weight (6−8 mm Hg for children; 10−14 mm Hg for adults).
2. Connect all equipment required for surgery.
3. Make a skin incision about two finger breadths above the
umbilicus for the Veress needle and laparoscope/camera tro-
car.
4. Insert the Veress needle.
5. Perform safety tests: injection, aspiration, “slurp,” manometer, and rotation tests.
6. Perform insufflation procedure.
Caution: Insufflate infants at 1 liter/min maximum.
III Laparoscopy
1. Place a nasogastric tube.
2. Insert laparoscope/camera trocar with tapered blunt-tip sty-
let and trumpet valve about two finger breadths above the
umbilicus directly through the linea alba.
3. Insert the working trocars under laparoscopic vision.
4. Explore the peritoneal cavity.
5. Retract the antrum and body of the stomach caudally.
6. Identify and incise the gastrophrenic ligament, and expose
the lower esophagus.
7. Identify the anterior vagal trunk and excise a 10−20 mm seg-
ment.
8. Expose the posterior vagal trunk by rotating the esophagus.
9. Dissect the posterior vagal trunk and excise a 1−2 cm seg-
ment.
10. Perform a Heineke-Mikulicz pyloroplasty (Figs. 8.5.10 and
8.5.11).
11. Close the pyloromyotomy with a transverse suture.
12. Remove the working trocars under laparoscopic vision.
Caution: Residual bleeding from the trocar incisions may occur.
220
8.5 Anterior and Posterior Truncal Vagotomy and Pyloroplasty
Operative Technique
T5
T3
1
2
3
4
Fig. 8.5.4 Truncal vagotomy and pyloroplasty. Schematic diagram.
Complete abdominal truncal vagotomy.
1 Anterior vagal trunk
2 Posterior vagal trunk
3 Hepatic branches
4 Celiac branch
5 Fundic branch
.
.
5
.
.
.
Fig. 8.5.5 Truncal vagotomy and pyloroplasty. Exposure of the anterior
vagal trunk.
After incising and dissecting the gastrophrenic ligament, the terminal
esophagus is completely exposed by blunt dissection (see Fig. 8.5.3 for
key to instrument numbers).
T5
T5
T2
Fig. 8.5.6 Truncal vagotomy and pyloroplasty. Transection of the anterior vagal trunk with bipolar electrocautery.
Normally one can identify the anterior vagal trunk while bluntly dissecting
the anterior aspect of the esophagus. Complete exposure of the anterior
vagal trunk is achieved with a grasper, lifting it off the esophagus (see
Fig. 8.5.3 for key to instrument numbers).
T2
Fig. 8.5.7 Truncal vagotomy and pyloroplasty. Transection of the anterior vagal trunk with bipolar electrocautery.
The exposed vagal trunk is lifted off the esophagus with the bipolar electrocautery forceps and coagulated for a distance of about 5−7 mm. When
coagulating, hold the nerve away from the esophagus to eliminate the
risk of thermal injury or perforation.
After coagulating the nerve, resect the entire coagulated length of the
nerve (approximately 1−2 cm; see Fig. 8.5.3 for key to instrument numbers).
Trocar Placement
221
T5
T3
T2
Fig. 8.5.8 Truncal vagotomy and pyloroplasty. Rotating the esophagus.
The posterior vagal trunk runs far posterior to the esophagus and often
lies on the abdominal aorta. The exposed vagal trunk is lifted off the
muscular coat with the bipolar electrocautery forceps (port T2) and
coagulated. Resect about 1−2 cm of the nerve, dividing all visible
branches. If it is not possible to expose the posterior vagal trunk simply by
rotating the esophagus with a blunt dissector (port T3), then expose the
nerve as shown in Fig. 8.5.9 (see Fig. 8.5.3 for key to instrument numbers).
T4
T3
T5
Fig. 8.5.9 Truncal vagotomy and pyloroplasty. Exposing the posterior
vagal trunk.
To improve exposure at the operative site, the medial leaf of the right crus
of the diaphragm must be exposed where it forms the border of the hiatus. Use a laparoscopic retractor to elevate it and retract it to the right.
Now one can visualize much of the proximal esophagus. Careful dissection with a mini dissection swab exposes the abdominal aorta. Rotating
the esophagus a bit further with a second mini dissection swab (port T4)
rotates the posterior vagal trunk anteriorly, where it can be safely identified and dissected.
Fig. 8.5.10 Truncal vagotomy and pyloroplasty. Longitudinal pyloromyotomy (Heineke-Mikulicz pyloroplasty).
Truncal vagotomy is always followed by a pyloroplasty unless antrectomy
is indicated. Make a midline longitudinal incision in the anterior distal
stomach and duodenum about 8−10 cm long with its midpoint at the pyloric ring. Incise down to the submucosa. Close with transverse interrupted sutures running through all tissue layers.
In the presence of a slight stenosis, the longitudinal serosal incision need
only extend as deep as the muscular coat of the pyloric region (Weber and
Ramstedt). The length of the incision is about 3−4 cm. It can be made
with a special laparoscopic scalpel (as shown here) or with dissection scissors, and it should remain open. Control bleeding directly using bipolar
electrocautery in short bursts at a medium power setting (see Fig. 8.5.3
for key to instrument numbers).
Caution: There is a risk of penetrating into the duodenal lumen.
222
8.6 Laparoscopically Guided Truncal Vagotomy and Assisted Pyloroplasty Using a Circular Stapler
컅 Fig. 8.5.11 Truncal vagotomy and pyloroplasty.
Close the pyloromyotomy with three or four interrupted absorbable sutures (2 × 0, metric 3) about 15 cm long, and secure with a laparoscopic
knot (see Fig. 8.5.3 for key to instrument numbers).
Bibliography
See chapter 8.1.
8.6 Laparoscopically Guided Truncal Vagotomy and Assisted
Pyloroplasty Using a Circular Stapler
S. D. Potter , L. U. Jung, H. Yang
Goals and Methods
Truncal vagotomy and pyloroplasty offers a time honored treatment for patients with peptic ulcer disease that is either complicated or has failed nonoperative management. The introduction of stapling techniques and the ever advancing technology
of laparoscopic surgery have provided a new method for performing this procedure. Laparoscopic truncal vagotomy provides a minimally invasive approach to acid reduction and anterior pylorectomy using a circular stapler offers patients and surgeons a quick, simple and effective drainage procedure.
Indications
− Peptic ulcer disease refractory to nonoperative management.
− Bleeding gastric ulcers.
− Perforated gastric ulcers.
Instrumentation
− General multipurpose open and laparoscopic setup.
− Circular stapler sizers.
− Linear stapler.
− Circular stapler.
− Laparoscopic Clip applier.
− Laparoscopic Babcock clamp.
− Laparoscopic ports,
− Four-10/11 mm.
− Laparoscopic fan retractor.
Patient Positioning
Lithotomy (Fig. 8.6.1).
Anesthesia
Contraindications
− Gastric outlet obstructions (inability to pass the circular stapler through the pylorus).
General endotracheal anesthesia.
Postoperative Care
223
Complications
Incomplete truncal vagotomy.
Esophageal perforation.
Incomplete anterior pylorectomy:
Creation of a patulous plyoric outlet is essential for proper
drainage. The entire anterior two-thirds of the pylorus must be
held within the firing area of the stapler to obtain a complete
muscular disruption.
Fig. 8.6.1 Truncal vagotomy and
pyloroplasty. Position of the operating
team and equipment.
Position of patient.
Monitor
Postoperative Care
A nasogastric tube is placed in the operating room. This is removed when the patient has bowel sounds. Diet can be advanced as tolerated. The patient can be discharged when tolerating a regular diet.
Insufflator
st
assistant
1
Electrocautery unit
Surgeon
nd
2
assistant
Instrument table
Aspirator/
irrigator set
OR nurse
224
8.6 Laparoscopically Guided Truncal Vagotomy and Assisted Pyloroplasty Using a Circular Stapler
Step-by-Step Procedure
1. The patient is placed on the operating room table in supine
position with the entire abdomen in the operative field
(Fig. 8.6.1).
2. Five 10/11 mm ports are placed. One each to the right and left
of the xyphoid, another in the midline just below the umbili-
cus and the last two in a line two fingerbreaths above the
umbilicus and to the left and right of the rectus muscules
(Fig. 8.6.2).
3. The laparoscope is inserted through the umbilical port.
4. A fan retractor is placed through the xyphoid port to expose
the esophagogastric junction by retracting the left lobe of the
liver superiorly and to the right (Fig. 8.6.3a).
5. A Babcock clamp is placed through the left port to retract the
stomach inferiorly (Fig. 8.6.3a).
6. Through the right port scissors are used to open the peritoneum overlying the esophagus. This will expose the ante-
rior (left) vagus (Fig. 8.6.3a).
7. The anterior vagus is dissected free of surrounding structures
and then divided between endoclips. A segment of nerve is
sent for histological confirmation (Fig. 8.6.3a).
8. The Babcock clamp then retracts the esophagus to the left ex-
posing the posterior (right) vagus. This is also divided be-
tween endoclips and a piece of nerve sent for histological
confirmation.
9. All instruments and ports are removed. A 4−5 centimeter
midline incision is made and the stomach is then delivered
into the operative field (Fig. 8.6.3b).
10. Using electrocautery a transverse gastrotomy is made six centimeters from the pylorus on the ventral surface of the
stomach. This should be just large enough to accept the head
of the circular stapler (Fig. 8.6.4).
11. Circular stapler sizers are used to size the pylorus.
12. The corresponding circular stapler is chosen and inserted
closed through the gastrotomy (Fig. 8.6.5).
13. The stapler is advanced distally so that the tip of the anvil lies
against the gastric side of the pylorus.
14. The cartridge of the stapler is held firmly in place in the pyloric
outlet. Countertraction is applied to the body of the stomach
close to the pylorus as the stapler is opened, advancing the
anvil across the pylorus (Fig. 8.6.6).
15. A “popping” sensation is felt as the sphincter falls into the sta-
pler firing area. Proper placement of the stapler is then con-
firmed by palpating the entire pyloric sphincter within the sta-
pler’s firing area (Fig. 8.6.6).
16. A No. 0 suture is placed transversely across the pylorus de-
pressing the anterior circumference of the sphincter into the
firing area of the stapler (Fig. 8.6.7).
17. Pressure on the suture is maintained as the stapler is closed,
fired and withdrawn.
18. A half moon specimen removed from the stapler’s firing area
confirms proper execution. Additionally, the patulous gastric
outlet can be verified by palpation (Fig. 8.6.8).
19. The gastrotomy is then closed using a linear stapler
(Fig. 8.6.9).
Port Placement
Fig. 8.6.2 After insertion of the umbilical trocar, the abdomen is insuf-
flated and the 0° scope is inserted. Four other trocars are then placed. The
two lateral ports are placed lateral to the rectus muscles. The middle
ports are placed on either side of the xiphoid, cephalad to the lateral
ports.
The trocar to the right of the xyphoid accomodates the fan retractor. The
Babcock clamp is placed through the left lateral port. The right lateral and
the left paraxyphoid ports receive the working trocars.
Operative Technique
Fig. 8.6.3a Before pyloroplasty an anterior and posterior truncal
vagotomy is performed. The left lobe of the liver is retracted anteriorly
and to the right. A Babcock is used to retract the stomach inferiorly, grasp-
ing its anterior surface in order to avoid unnecessary bleeding.
The peritoneum overlying the esophagus is incised to expose the anterior
vagus, which is then dissected and ligated with endoclips. The esophagus
is then retracted to the left to expose the posterior vagus for ligation in
the same fashion. Segments of both vagi are sent for histologic confirmation. The anterior surface is cleared of all small vagal branches.
Postoperative Care
6 cm
Fig. 8.6.4 Using electrocautery a transverse gastrotomy if performed
through the ventral surface of the stomach. This gastrotomy should be
large enough to accommodate the cartridge and anvil of the circular stapler and should be placed approximately six centimeters proximal to the
pyloric sphincter.
225
Fig. 8.6.3b Now a small (4−5 cm) midline incision is made in the upper
abdomen exposing the antrum and pylorus. This should be large enough
to bring the stomach into the wound. Surgeon and assistants assume the
usual. Positions for laparotomy.
the pyloric outlet as the stapler is fully opened advancing the anvil across
the pyloric sphincter. A “popping” sensation is felt when the anvil is in
proper position on the distal side of the sphincter in the first portion of
the duodenum. This maneuver is helped by exerting countertraction on
the body of the stomach. Proper placement can be confirmed by palpat-
ing the entire sphincter within the firing area of the stapler.
Fig. 8.6.5 The pyloric sphincter is then sized using the circular stapler
sizers. The proper stapler is chosen and inserted through the gastrotomy.
The closed stapler is advanced distally so that the anvil portion lies up
against the gastric side of the pyloric sphincter.
컄Fig. 8.6.6 The cartridge portion of the stapler is held firmly in place in
226
8.6 Laparoscopically Guided Truncal Vagotomy and Assisted Pyloroplasty Using a Circular Stapler
Fig. 8.6.7 A No. 0 suture is then placed transversely across the pylorus
depressing the anterior two thirds of the sphincter into the stapler’s firing
area. While maintaining down pressure on the suture the stapler is closed,
fired and withdrawn.
Fig. 8.6.9 Once proper performance of the anterior pylorectomy is
verified the gastrotomy can be closed using a linear stapler.
1
4
5
3
Fig. 8.6.8 The procedure is properly performed if a half-mooned piece
of pylorus can be retrieved from the stapler’s firing area. This specimen
can be sent for histologic examination, which should confirm both gastric
and duodenal tissue with the pyloric musculature. The patulous gastric
outlet can be verified through palpation.
2
Fig. 8.6.10
1 Anterior and posterior tunnel vagotomy.
2 Four to five centimeter upper midline incision.
3 Gastrotomy and placement of appropriately sized circular stapler down to
pylorus.
4 Separation of stapler anvil from cartridge across pylorus. Closure of stapler
and anterior pylorectomy.
5 Closure of gastrotomy with linear stapler.
Trocar Placement
227
Bibliography
Adams JT. Technique for anterior hemi-pylorectomy. Surg. Gyn. Ob. 1978;
147:421−422.
Kuster GGR. Anterior pylorectomy (pyloroplasty) with the circular stapling
instrument. In Ravitch, Steichen, Welter, eds. Current Practice of Surgical
Stapling. Philadelphia: Lea & Febiger; 1991.
8.7 Gastrojejunostomy
K. Schönleben
Goals and Methods
Gastrojejunostomy without gastrectomy is a palliative operation. Its purpose is to alleviate problems in stomach emptying
due to gastroduodenal obstructions. The laparoscopic procedure is recommended in cases in which gastrojejunostomy is
the only procedure indicated. This applies most often to
patients with incurable cancer (cancer of the distal stomach,
pancreas, common bile duct, papilla of Vater, or primary
duodenal carcinoma). Obstructive jaundice, due to extrahepatic
malignant blockage, should be alleviated by endoluminal endoscopic drainage or external transhepatic drainage.
Specific diagnostic studies are not required for the laparoscopic
procedure. The customary endoluminal endoscopic and imaging studies required to diagnose the underlying condition and
determine that the cancer is incurable are generally suf ficient.
Gastroscopy and endosonography should demonstrate that the
stomach wall intended for the anastomosis is free of tumor.
The simplest technique for laparoscopic surgery is an antecolic
anterior isoperistaltic gastrojejunostomy with the first jejunal
coil. A side-to-side anastomosis is not mandatory.
Indications
Definitive Indications
Inoperable malignant occlusion of the pylorus or duodenum.
Transitory Indications
Pier A, Götz F. Vagotomie − Indikationen. In Kremer K, Lierse W, Platzer W,
Schreiber HW, Weller S, eds. Chirurgische Operationslehre: Minimal-Invasive Chirurgie, p. 175. Stuttgart: G. Thieme-Verlag; 1995.
Potter SD, Spiro SA, Nance FC. An Alternative Method to Traditional Pyloro-
plasty Using a Circular Stapler. Jr. Am. Col. Surg. 1995; 180:742−744.
Steichen FM. Vordere hemizirkuläre Pylorektomie. In Kremer K, Lierse W,
Platzer W, Schreiber HV, Weller S, eds. Chirurgische Operationslehre,
p. 194. Stuttgart: G. Thieme-Verlag; 1987.
Surgical Risks and Patient Information
(See Chapter 10.5).
Special Preparations
Gastric lavage is indicated in the presence of occlusion of the
pylorus. Place a nasogastric tube and indwelling urinary catheter.
Anesthesia
General anesthesia.
Patient Positioning and Position of the
Operating Team
Position the patient supine in a reverse Trendelenburg position
with both arms abducted. The hips should be slightly flexed
with the legs abducted and individually supported. The surgeon
stands on the right side of the patient, the assistant holding the
laparoscope stands between the patient’s legs, and the other assistant stands on the patient’s left. The monitor and video recorder and light source are placed at the patient’s left shoulder;
the operating room nurse stands to the surgeon’s right with the
laparoscopy equipment (Fig. 8.7.1).
Temporary bypass gastrojejunostomy in an emaciated con-
valescing patient, for example in the presence of inflammatory
occlusion of the pylorus (complications of duodenal diverticula,
stenoses from Crohn’s disease, stenoses from annular pancreas,
or stricture from an ulcer).
Contraindications
− Gastrojejunostomy as a permanent solution for benign disease, since chronic duodenal reflux increases the risk of gastric cancer.
− As a palliative procedure in the presence of obstructive jaundice requiring surgical correction.
− After previous operations in the upper abdomen since the
adhesions and operative changes in anatomy may lengthen
and complicate the procedure and endanger the patient.
Trocar Placement
In patients who have not had a previous operation, establish the
pneumoperitoneum and insert the 1-cm trocar (T1) for the 0degree forward-viewing laparoscope in the inferior umbilical
fossa. Four instrument trocars are required, two (T4, T5) in the
left upper to middle abdomen and two (T2, T3) in the right
upper to middle abdomen. The precise placement of these trocars depends on the individual anatomy and the requirements
of the specific surgical procedure.
We recommend using 10 to 12-mm instrument trocars, which
can be fitted with various adapters to accommodate a variety of
instrument sizes. Trocar T2 should be 15 mm in diameter to accommodate the linear stapler (Fig. 8.7.2).
Open trocar placement is an alternative.