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Laparoscopic Placement of Jejunostomy Tube
Laparoscopic Placement of A Jejunostomy Tube
 

The laparoscopic jejunostomy can be a very helpful procedure in the management of patients requiring intensive nutritional rehabilitation. It eliminates the risk of aspiration associated with gastrostomy feedings. In addition, this is the preferred enteral administration route in patients whom may require a future procedure requiring gastric integrity such as a patient with an adenocarcinoma of the esophagus.

This procedure can be performed safely using various methods. Some authors have described techniques using Cope suture anchors or T anchors. We personally prefer a simpler technique using traditional laparoscopic instruments as described herein. Our technique is not necessarily better, but we have had consistently good results with the use of this technique.

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Indications

All patients requiring an enteral route for nutritional rehabilitation.

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Operating Room Set-up

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The Instruments

 

LAPAROSCOPIC HARDWARE
Telescope Stryker 5 mm - 30 Deg.
Insufflator High Flow
Video out NA
Suction Irrigation No

 

ESSENTIAL LAPAROSCOPIC INSTRUMENTS

QQTY Instrument Website
1 MIC Jenunostomy Tube Medical Innovations Corp.
1 USSC Versaport V2 Trocar 5 mm www.autosuture.com
2 USSC Versaport  5-11mm www.autosuture.com
1 Storz Dolphin Nose 5 mm Grasper  
1 USSC SURGINEEDLE www.autosuture.com
1 USSC EndoStich 10 mm www.autosuture.com

 

The MIC™ Jejunostomy Tube

Although originally designed to be inserted via a minilaparotomy incision, in our procedure and in this laparoscopic setting, this tube has become the optimal jejunostomy tube to use. Surgeons attempting this procedure should become familiar with this device.

A. Female adapter for standard solution infusion tubing
B. Dacron Cuff
C. Length of tubing to cross transversely in the subcutaneous tissue
D. Proximal Wings with embedded Dacron Mesh (to suture on anterior abdominal wall)
E. Tube between the wings
F. Distal Wings inserted via standard Jejunostomy
G. Distal Feeding Tube
H. Luer Cap

 

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Trocars Placement

 

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The Technique

 

 Step 1  Finding the Ligament of Trietz

Using two atraumatic graspers, the jejunum is run to the ligament of Trietz. Once identified, it is run forward (1 foot). An appropriate location for the jejunostomy is identified and marked. The surgeon should simultaneously chose the entry site of the jejunostomy tube on the abdominal wall ( preferably in the left upper quadrant).

It should be verified there is no tension on the selected jejunal loop when brought up to the anterior abdominal wall.

 Step 2  Inserting the Jejunostomy Tube

A 5 mm trocar is inserted at an angle at the exact location chosen on the anterior wall. A grasper is inserted via the lower midline trocar into the newly inserted VERSAPORT* 5mm Trocar. The VERSAPORT* 5 mm Trocar is removed over the ENDO DISSECT* Instrument.

The distal end of the MIC Jejunostomy tube is grasped outside the intra-abdominal cavity with the ENDO DISSECT* instrument and pulled into the intra-abdominal cavity.

The Dacron ring is positioned at the level of the abdominal fascia. The jejunostomy tube is now clamped outside the intra-abdominal cavity to prevent a major air leak.

 Step 3  Insertion into the Jejunal Lumen

The Jejunum is grasped with an atraumatic grasper right proximal to the site of the enterostomy. An enterostomy is made on the antimesenteric aspect using the ENDO SHEARS* instrument. The enterostomy should be 3 mm in size.The tip of the jejunostomy tube is grasped with an ENDO DISSECT* instrument and inserted into the jejunal lumen. The surgeon should be very careful to insert the catheter into the lumen. A submucosal tunnel should not be created.

The distal wings of the jejunostomy catheter should then be inserted into the lumen forcefully. They will secure the catheter when deployed in intraluminal position.

 Step 4  Securing the Jejunostomy Tube

 

The ENDOSTITCH* instrument is inserted via the lower midline trocar. The ENDOSTITCH* is loaded with a 7 inch, 2.0 SOFSILK** suture. A purse string suture is inserted/sewn around the insertion site of the catheter into the jejunum using the ENDOSTITCH* instrument. The suturing should always be started anteriorly. At one point, the ENDOSTITCH* Instrument's Needle will have to be passed from one side of the catheter to the other side. This is done by closing the ENDOSTITCH* instrument around the catheter (the catheter is between the jaws of the ENDOSTITCH* instrument - refer to picture). Once this is done, the needle can be passed to the other side of the catheter to complete the purse string suture.

The purse string suture is tied. Using the same suture, the purse string is now sewn on the anterior abdominal wall, 3 cm inferior to the entry site of the jejunostomy catheter.

Using the ENDOSTITCH* instrument, sutures are placed from the jejunum (3 cm from the jejunum insertion site), into the proximal wing (hole in wing) and into the anterior abdominal wall.

The jejunostomy catheter is now held between the jejunum and the anterior abdominal wall. In most cases, two additional sutures are placed to further secure the catheter onto the abdominal wall [using the "wings of the tube"].

Alternate Method to Secure the Jejunum to the Anterior Abdominal Wall : The sutures used in this setting are PolySorb Sutures 2.0 (Absorbable). Once the purse string suture has been placed around the catheter entry site into the duodenum using a 7 inch or 12 inch Polysorb suture. The purse string is tied and cut as closely as possible to the ENDOSTITCH* Needle. Again, the ENDOSTITCH* instrument is used to suture the proximal wings of the MCI Jejunostomy Tube to the antimesenteric border of the jejunum, going through the suture hole in the wings themselves. The sutures are left long and cut as close as possible to the ENDOSTITCH* needle.

An ENDO CLOSE* instrument is then inserted and each limb of silk suture is grasped at its tip and pulled through the anterior abdominal wall (a total of six suture limbs). The sutures are pulled tight (check with the telescope) and tied on the anterior abdominal wall (outside). This maneuver will attach the jejunum against the anterior abdominal wall securely. The suture will be closed at skin level on the seventh postoperative day.

In all cases, a Blake Drain is left in intraabdominal position, next to the jejunostomy site.

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