Laparoscopic Access Procedures

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.

All patients requiring an enteral route for nutritional rehabilitation.

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.

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.

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.