Types Of Jejunostomy Sabiston Book

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Figure 19-7 Jejunostomy. A, Open jejunostomy tube placement requires a formal laparotomy, generally performed through an upper midline incision. The ligament of Treitz is located, and a loop of proximal jejunum that will easily reach the anterior abdominal wall is isolated. B, A small incision is made to the left of the midline wound to form the exit site for the jejunostomy tube, and the tube is passed through the abdominal wall, into the abdomen. A pursestring suture is placed at the proposed entry site on the small bowel. A small enterotomy is made with cautery at the center of the pursestring, large enough for passage of the tube. The tube is advanced several centimeters, and the pursestring suture is tied, securing the tube. A serosal tunnel is created, as illustrated, by placing four to six Lembert sutures beginning at the entry site and proceeding proximally. The needles are left on the sutures for use in securing the jejunostomy site to the anterior abdominal wall. C, The jejunostomy tube is carefully withdrawn through the skin incision while the loop ofjejunum is positioned immediately subjacent to the anterior abdominal wall. D, The previously placed sutures are used to secure the loop jejunostomy to the abdominal wall to prevent twisting. When postoperative ileus is expected to be minimal, enteric feedings may be started immediately. (A-D from Grant, J.P.: Witzel jejunostomy. In Sabiston, D.C. [ed.]: Atlas of General Surgery. Philadelphia, WB Saunders, 1994, pp. 240-242, with permission.)

Witzel Sutures

Jejunal loop sutured to

Witzel Jejunostomy

Figure 19-8a Laparoscopic jejunostomyplacement. A, Laparoscopic jejunostomy placement requires three trocars, as illustrated. The surgeon stands to the patient's right side. B, Under laparoscopic visualization, the omentum and transverse colon are reflected superiorly, exposing the ligament of Treitz. The small bowel is then followed distally for 20 to 30 cm in order to select the jejunostomy site. The exit site on the anterior abdominal wall is chosen and is visualized laparoscopically as an indentation corresponding to the surgeon's finger. C, The site of the jejunostomy is fixed to the anterior abdominal wall using T fasteners. Under direct vision, a needle is placed through the abdominal wall and into the loop ofjejunum. The T fastener is passed through the needle and remains in place within the lumen of the jejunum when the needle is withdrawn. D, Four T fasteners are used to affix the loop ofjejunum flush with the inner surface of the abdominal wall. E, After placement of the T fasteners, the jejunum is entered under direct vision using a percutaneously placed needle. A guide wire is placed intraluminally, and the needle is withdrawn. F, A dilator is passed into the lumen of the jejunum with wire guidance. G, The jejunostomy tube is passed through the dilator for a distance of about 30 cm distally. The dilator is withdrawn. The intra-abdominal pressure is dropped, and the T fasteners are drawn up to secure the bowel to the abdominal wall. The Jejunostomy tube is secured externally using a nylon suture. Enteric feedings may be started immediately. (A-G from Grant, J.P.: Laparoscopic jejunostomy. In Sabiston, D.C. [ed.]: Atlas of General Surgery. Philadelphia, WB Saunders, 1994, pp. 247-250, with permission.)

Figure 19-8a Laparoscopic jejunostomyplacement. A, Laparoscopic jejunostomy placement requires three trocars, as illustrated. The surgeon stands to the patient's right side. B, Under laparoscopic visualization, the omentum and transverse colon are reflected superiorly, exposing the ligament of Treitz. The small bowel is then followed distally for 20 to 30 cm in order to select the jejunostomy site. The exit site on the anterior abdominal wall is chosen and is visualized laparoscopically as an indentation corresponding to the surgeon's finger. C, The site of the jejunostomy is fixed to the anterior abdominal wall using T fasteners. Under direct vision, a needle is placed through the abdominal wall and into the loop ofjejunum. The T fastener is passed through the needle and remains in place within the lumen of the jejunum when the needle is withdrawn. D, Four T fasteners are used to affix the loop ofjejunum flush with the inner surface of the abdominal wall. E, After placement of the T fasteners, the jejunum is entered under direct vision using a percutaneously placed needle. A guide wire is placed intraluminally, and the needle is withdrawn. F, A dilator is passed into the lumen of the jejunum with wire guidance. G, The jejunostomy tube is passed through the dilator for a distance of about 30 cm distally. The dilator is withdrawn. The intra-abdominal pressure is dropped, and the T fasteners are drawn up to secure the bowel to the abdominal wall. The Jejunostomy tube is secured externally using a nylon suture. Enteric feedings may be started immediately. (A-G from Grant, J.P.: Laparoscopic jejunostomy. In Sabiston, D.C. [ed.]: Atlas of General Surgery. Philadelphia, WB Saunders, 1994, pp. 247-250, with permission.)

Wietzel Sutures JejeunostomyTypes Jejunostomy

Figure 19-9a Resection of Meckel's diverticulum. A, Meckel's diverticulum is the most common development anomaly of the small bowel, occurring in 1 to 2% of the population.1 ' Meckel's diverticulum may be encountered incidentally during abdominal surgery for unrelated processes, of during exploration of the abdomen for acute inflammatory processes or acute gastrointestinal bleeding in patients presenting with [5]

symptoms. 1 ' Options for treatment of patients with symptoms include diverticulectomy and segmental small bowel resection. In patients with bleeding or acute Meckel's diverticulitis, segmental resection of a small portion of surrounding small intestine with primary anastomosis is recommended. B, A wedge-shaped portion of small bowel mesentery, including the diverticulum and surrounding ileum, should be removed. A primary ileal anastomosis, as outlined previously, can be performed.

Figure 19-9b C, When acute inflammation and bleeding are absent, resection of the diverticulum with a small portion of the ileum can be performed in a wedge configuration. D, The resulting ileal defect can be closed with interrupted Lembert sutures. E, A TA-type stapler can also be used to control the base of the diverticulum. F, The diverticulectomy is completed by sharp transection after firing of the stapler. G, When a Meckel's diverticulum is discovered during laparoscopic exploration, excision can be performed using a laparoscopic bowel stampling device. (A from Rossi, R.L.: small bowel resection. In Braasch, J.W., Sedgwick, C.E., Veidenheimer, M.C., et al. [eds.]: Atlas of Abdominal Surgery. Philadelphia, WB Saunders, 1991, p. 99, with permission: B-F from Pappas, T.N.: Meckel's diverticulectomy. In Sabiston, D.C. [ed.]: Atlas of General Surgery. Philadelphia, WB Saunders, 1994, pp. 374-375, with permission: G from Martin, D.T., Pitcher, D.E., and Zucker, K.A: Laparoscopic small bowel surgery. In Arregui, M.E., Fitzgibbons, R.J., Katkhouda, N., et al. [eds.]: Principles of Laparoscopic Surgery. New York, Springer-Verlag, 1995, p. 278, with permission.)

Strictureplasty

Figure 19-10 Strictureplasty. A, Strictureplasty is a useful adjunctive technique for treating segments of small bowel narrowing as a result of chronic inflammation. Stricturoplasty is most commonly employed in the treatment of patients with Crohn's disease. When chronic scarring has caused obstruction secondary to a short-segment stricture, a stricturoplasty analogous to a Heineke-Mikulicz pyloroplasty may be used. Sutures are placed, and a longitudinal incision is made through the full thickness of the bowel wall. B, Tension on traction sutures converts the longitudinal incision into a transverse opening. The stricturoplasty is closed in a single layer using interrupted nonabsorbable seromuscular sutures (see inset). C, If the stricture is longer than 1 to 2 cm in length, a stricturoplasty analogous to a Finney pyloroplasty may be used. Seromuscular sutures approximating the bowel wall in the area of the stricture are placed. An incision traversing the stricture (dashed line) is performed. D, A common lumen encompassing the small bowel both proximally and distally is thus created. E, Interrupted sutures are used to close the anterior portion of the enteroenterostomy. (A and B from Fazio, V.W., Galanduik, S., Jagelman, D.G., et al.: Stricuroplasty in Crohn's disease. Ann. Surg., 210:623, 1989, with permission; Inset B from Fazio, V.W., and Tjandra, J.J.: Stricturoplasty for Crohn's disease with multiple long strictures. Dis. Colon Rectum, 36:72, 1993, with permission; C-E from M.W. Zelenock, G.B. and Michelassi, F.: Atlas of small intestinal surgery. In Bell, R.H. Rikkers, L.F. and Mulholland, M.W. [eds.]: Digestive Tract Surgery. Philadelphia, Lippincott-Raven, 1996, p. 1305, with permission.)

Figure 19-10 Strictureplasty. A, Strictureplasty is a useful adjunctive technique for treating segments of small bowel narrowing as a result of chronic inflammation. Stricturoplasty is most commonly employed in the treatment of patients with Crohn's disease. When chronic scarring has caused obstruction secondary to a short-segment stricture, a stricturoplasty analogous to a Heineke-Mikulicz pyloroplasty may be used. Sutures are placed, and a longitudinal incision is made through the full thickness of the bowel wall. B, Tension on traction sutures converts the longitudinal incision into a transverse opening. The stricturoplasty is closed in a single layer using interrupted nonabsorbable seromuscular sutures (see inset). C, If the stricture is longer than 1 to 2 cm in length, a stricturoplasty analogous to a Finney pyloroplasty may be used. Seromuscular sutures approximating the bowel wall in the area of the stricture are placed. An incision traversing the stricture (dashed line) is performed. D, A common lumen encompassing the small bowel both proximally and distally is thus created. E, Interrupted sutures are used to close the anterior portion of the enteroenterostomy. (A and B from Fazio, V.W., Galanduik, S., Jagelman, D.G., et al.: Stricuroplasty in Crohn's disease. Ann. Surg., 210:623, 1989, with permission; Inset B from Fazio, V.W., and Tjandra, J.J.: Stricturoplasty for Crohn's disease with multiple long strictures. Dis. Colon Rectum, 36:72, 1993, with permission; C-E from M.W. Zelenock, G.B. and Michelassi, F.: Atlas of small intestinal surgery. In Bell, R.H. Rikkers, L.F. and Mulholland, M.W. [eds.]: Digestive Tract Surgery. Philadelphia, Lippincott-Raven, 1996, p. 1305, with permission.)

Stricturoplasty MichelassiMedial Visceral Rotation

Figure 19-11a Small intestinal revascularization. A, Small intestinal revascularization can be performed through a number of standard abdominal incisions, including midline and subcostal incisions. Exposure of the retroperitoneal aorta is facilitated by a large subcostal incision extending onto the left flank. The patient should be positioned with the left flank supported. Rotation of the operating table also aids exposure. B, The retroperitoneal aorta is exposed through medial visceral rotation. This exposure involves incisions along the left lateral peritoneal reflection of the colon, mobilizing the entire left colon, spleen, pancreas, and stomach toward the patient's right upper quadrant. C, The medial visceral rotation proceeds anterior to the left kidney and renal vasculature. This exposure provides visualization of the celiac axis and the superior mesenteric artery. Additional aortic exposure can be obtained by mobilizing the left kidney in the direction previously used for medial visceral rotation. D, Diagrammatic representation of medial visceral rotation. The figure illustrates exposure of the retroperitoneal aorta through the left flank.

Figure 19-11a Small intestinal revascularization. A, Small intestinal revascularization can be performed through a number of standard abdominal incisions, including midline and subcostal incisions. Exposure of the retroperitoneal aorta is facilitated by a large subcostal incision extending onto the left flank. The patient should be positioned with the left flank supported. Rotation of the operating table also aids exposure. B, The retroperitoneal aorta is exposed through medial visceral rotation. This exposure involves incisions along the left lateral peritoneal reflection of the colon, mobilizing the entire left colon, spleen, pancreas, and stomach toward the patient's right upper quadrant. C, The medial visceral rotation proceeds anterior to the left kidney and renal vasculature. This exposure provides visualization of the celiac axis and the superior mesenteric artery. Additional aortic exposure can be obtained by mobilizing the left kidney in the direction previously used for medial visceral rotation. D, Diagrammatic representation of medial visceral rotation. The figure illustrates exposure of the retroperitoneal aorta through the left flank.

Medial Visceral Rotation Medial Visceral Rotation

Figure 19-11b E, The area surrounding the major visceral arteries contains a dense aggregation of ganglionic tissue. Aortic exposure is facilitated by resection of this ganglionic material. F, The major visceral arteries, as well as the intracostal branches, are controlled before aortotomy. An incision in the aorta on the left lateral wall is placed between the superior mesenteric artery orifice and the left renal artery. Care is taken to provide an adequate margin of aortic tissue for later closure. G, Endarterectomy commences on the left lateral wall of the aorta and proceeds cephalad around the origin of the visceral vessels. H, Intussusception of the arterial vessels by gentle pressure on the visceral artery clamps, combined with traction on the plaque, helps with eversion endarterectomy. I, The aortotomy is closed with continuous monofilament suture.

Figure 19-11b E, The area surrounding the major visceral arteries contains a dense aggregation of ganglionic tissue. Aortic exposure is facilitated by resection of this ganglionic material. F, The major visceral arteries, as well as the intracostal branches, are controlled before aortotomy. An incision in the aorta on the left lateral wall is placed between the superior mesenteric artery orifice and the left renal artery. Care is taken to provide an adequate margin of aortic tissue for later closure. G, Endarterectomy commences on the left lateral wall of the aorta and proceeds cephalad around the origin of the visceral vessels. H, Intussusception of the arterial vessels by gentle pressure on the visceral artery clamps, combined with traction on the plaque, helps with eversion endarterectomy. I, The aortotomy is closed with continuous monofilament suture.

Figure 19-11c J, Superior mesenteric artery emboli usually lodge distal to the orifice of the superior mesenteric artery, often at the origin of the middle colic artery. The superior mesenteric artery is exposed immediately medial to the ligament of Treitz by retracting the small intestine to the right upper quadrant. A length of the superior mesenteric artery is exposed. Small jejunal branches may be controlled with fine vessel clamps. A transverse arterial incision is used. Fine Fogarty catheters are passed proximally and distally to retrieve embolic material. K, Vigorous forward and back bleeding from the superior mesenteric artery should be observed before arterial closure. L, When visceral revascularization requires graft placement, proximal and distal control of the supraceliac aorta and clamping of the celiac axis is required. A small elliptical aortotomy is made for the proximal anastomosis. M The left limb of the bifurcated vascular prosthesis is anastomosed to the suprapancreatic portion of the celiac axis. A spatulated suture technique is used to avoid anastomotic narrowing. The superior mesenteric artery is exposed by inferior traction on the body of the pancreas. The right limb of the prosthesis is anastomosed to the superior mesenteric artery. N, Diagrammatic representation of completed celiac axis and superior mesenteric artery revascularization using prosthetic graft. (A-C and E-I from Hansen, K.J., and Deitch, J.S.: Transaortic mesenteric endarterectomy. Surg. Clin. North Am., 77:401, 1997, with permission; D, L, and M from Cunningham, C.G., Reilly, L.M., Rapp, J.H., et al.: Chronic visceral ischemia: Three decades of progress. Ann. Surg., 214:279, 1991, with permission; J and K from McKinsey, J.F., and Gewertz, B.L.: Acute mesenteric ischemia. Surg. Clin. North Am., 77:316, 1997, with permission; N from Shanley, C.J., Ozaki, C.K., and Zelenock G.B.: Bypass grafting for chronic mesenteric ischemia. Surg. Clin. North Am. 77: 389, 1997, with permission.)

Figure 19-11c J, Superior mesenteric artery emboli usually lodge distal to the orifice of the superior mesenteric artery, often at the origin of the middle colic artery. The superior mesenteric artery is exposed immediately medial to the ligament of Treitz by retracting the small intestine to the right upper quadrant. A length of the superior mesenteric artery is exposed. Small jejunal branches may be controlled with fine vessel clamps. A transverse arterial incision is used. Fine Fogarty catheters are passed proximally and distally to retrieve embolic material. K, Vigorous forward and back bleeding from the superior mesenteric artery should be observed before arterial closure. L, When visceral revascularization requires graft placement, proximal and distal control of the supraceliac aorta and clamping of the celiac axis is required. A small elliptical aortotomy is made for the proximal anastomosis. M The left limb of the bifurcated vascular prosthesis is anastomosed to the suprapancreatic portion of the celiac axis. A spatulated suture technique is used to avoid anastomotic narrowing. The superior mesenteric artery is exposed by inferior traction on the body of the pancreas. The right limb of the prosthesis is anastomosed to the superior mesenteric artery. N, Diagrammatic representation of completed celiac axis and superior mesenteric artery revascularization using prosthetic graft. (A-C and E-I from Hansen, K.J., and Deitch, J.S.: Transaortic mesenteric endarterectomy. Surg. Clin. North Am., 77:401, 1997, with permission; D, L, and M from Cunningham, C.G., Reilly, L.M., Rapp, J.H., et al.: Chronic visceral ischemia: Three decades of progress. Ann. Surg., 214:279, 1991, with permission; J and K from McKinsey, J.F., and Gewertz, B.L.: Acute mesenteric ischemia. Surg. Clin. North Am., 77:316, 1997, with permission; N from Shanley, C.J., Ozaki, C.K., and Zelenock G.B.: Bypass grafting for chronic mesenteric ischemia. Surg. Clin. North Am. 77: 389, 1997, with permission.)

References

1. Bohnen, J.M.A.: Antimicrobial prophylaxis in general surgery. Can. J. Surg., 84:548-550, 1991.

2. Ehrmantraut, W., and Sardi, A.: Laparoscopy-assisted small bowel resection. Am. Surg., 68:996-1001, 1997.

3. Koltun, W.A., and Pappas, T.N.: Anatomy and physiology of the small intestine. In Greenfield, L.J., Mulholland, M.W., Oldham, K.T., et al. (eds.): Surgery: Scientific Principles and Practice, 2nd ed. Philadelphia, Lippincott-Raven, 1997, pp. 806-807.

4. Nichols, R.L.: Surgical antibiotic prophylaxis. Med. Clin. North Am., 79:509-522, 19 9 5.

5. Peoples, J.B., Lichtenberger, E.J., and Dunn, M.M.: Incidental Meckel's diverticulectomy in adults. Surgery, 118649-652, 1995.

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