Laparoscopic Gastrojejunostomy
Laparoscopic gastrojejunostomy is a simple procedure that may be used when palliation of malignant upper gastrointestinal obstruction is required. It has the same drawbacks as the corresponding open procedure but may be of occasional use when a nonresectable pancreatic cancer requires palliation of gastric outlet or duodenal obstruction.
SCORE™, the Surgical Council on Resident Education, did not classify laparoscopic gastrojejunostomy.
STEPS IN PROCEDURE
Obtain laparoscopic access and explore abdomen
Identify loop of proximal jejunum that reaches stomach without tension
Create gastrotomy
Pass one side of endoscopic cutting linear stapler into gastrotomy and gently close
Create similar opening in jejunum and align with stomach
Insert second limb of endoscopic stapler into jejunum
Align stomach and jejunum together within jaws of stapler, close and fire
Inspect staple line for hemostasis (using suction irrigator)
Close gastrotomy and enterotomy with stapler or with sutures
Check for leakage
Close trocar sites greater than 5 mm
HALLMARK ANATOMIC COMPLICATIONS
Injury to bowel or viscera during access
Use of ileum rather than jejunum for anastomosis
LIST OF STRUCTURES
Stomach
Greater curvature
Lesser curvature
Lesser omentum
Pancreas
Left gastric artery
Gastroepiploic artery
Prepyloric vein (of Mayo)
Jejunum
Duodenum
Pylorus
Suspensory ligament of duodenum (ligament of Treitz)
Laparoscopic Gastrojejunostomy—Orientation and Setup (Fig. 63.1)
Technical and Anatomic Points
The usual trocar pattern (Fig. 63.1A) may be modified if both gastrojejunostomy and biliary bypass are to be done (see Chapter 66). Thoroughly explore the abdomen and determine the extent of disease. The initial view is shown in Figure 63.1C. Choose a loop of proximal jejunum that will reach comfortably to the stomach without tension (Fig. 63.1B). Confirm that this is indeed proximal small intestine by tracing the loop to the suspensory ligament of duodenum (ligament of Treitz) as shown in Figure 63.1D.
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