Operative procedure
Gastrostomy tube placement
Gastrostomy tubes can be placed percutaneously with endoscopic guidance or can be placed at the time of laparotomy. The stomach should be mobile enough to reach the anterior abdominal wall. At laparotomy, a specialized gastrotomy tube, or a Malecot, self-retaining flanged rubber urologic tube can be placed into the abdominal cavity via a left upper quadrant stab incision in the midclavicular line.
Figure 17
Place traction suture midway
Two concentric purse-string sutures of delayed absorbable material are placed in the anterior stomach seromuscular wall approximately 1 cm apart. Electrocautery is used to create an opening in the wall through which the Malecot tube is placed into the stomach. The inner purse-string suture is tied first, then the outer one, creating an inverted tunnel (Figure 24). Three or four interrupted 2-0 delayed absorbable sutures are placed to approximate the stomach to the anterior abdominal wall. After the abdomen is closed, the tube is secured to the skin with a nylon suture. If the tube is subsequently dislodged, it can often be immediately replaced through the gastrocutaneous fistula.
Needle jejunostomy
Needle jejunostomy is a useful method of providing enteral nutrition postoperatively. The technique entails creating an intramural tunnel in the jejunal wall, through which a catheter is placed into the lumen of the bowel. A purse-string suture 1 cm in diameter is placed but not tied in the antimesenteric side of the jejunum at least 12 cm from the ligament of Trietz. A mobile loop of jejunum that easily reaches the abdominal wall is chosen. A 5 cm long 14 gauge needle is inserted through the purse-string into the seromuscular layer for the entire length of the needle. The needle is then directed into the bowel lumen, and the feeding catheter and stylet are threaded through the needle. The needle is then removed. The catheter is advanced into the bowel for 20-25 cm and the stylet is removed. The purse-string suture is tied. Another 14 G needle is placed through the skin at an oblique angle similar to the angle of the catheter exiting from the bowel. The catheter is then pulled through the needle. The jejunum is fixed to the anterior abdominal wall with 2-0 silk suture to prevent dislodgement of the catheter. Similarly, the catheter is fixed to the skin to prevent kinking. Catheter position may be confirmed intraoperatively by injecting 10 ml of air and observing its passage into the jejunum. Radiographic confirmation of intraluminal tube placement can be achieved using water-based contrast. A low-viscosity elemental amino acid diet is used to prevent clogging of the needle jejunostomy tube. When jejunal feeding is no longer necessary the tube is removed percutaneously.
Figure 18
Excise redundant tissue after stapling
Figure 19
Completed reanastomosis
Baker tube jejunostomy
A tube jejunostomy can be utilized for intraoperative small bowel decompression as well as postoperative small bowel stenting to prevent obstruction. A Baker (International Hospital Products, Little Silver, NJ) tube jejunostomy is inserted at laparotomy using a modified Stamm technique similar to that used for gastrostomy tube placement. The Baker tube is placed in the abdominal cavity through a stab wound in the
Figure 20
Ideal sites for stomas abdominal wall. Two concentric purse-string sutures are placed in the antimesenteric edge of a mobile loop of jejunum. The balloon is inflated, and the tube is manually passed into the distal small bowel, through the ileocecal valve and into the ascending colon. The small bowel is then situated in the peritoneal cavity to prevent obstruction. The purse-string sutures are tied to create an inverted tunnel. The bowel is secured to the parietal peritoneum with a suture. If a Baker tube is used for decompression, making extra holes in the tube will facilitate drainage.
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