What are the steps of laparoscopic (lap) gastrojejunostomy?

From the Guidelines

Laparoscopic gastrojejunostomy involves creating a connection between the stomach and jejunum to bypass gastric obstruction, and the steps include patient positioning, port placement, identification of the jejunal limb, anastomosis creation, and testing for leaks. The procedure begins with patient positioning in reverse Trendelenburg with legs apart, followed by placement of four to five ports: a 10-12mm camera port at the umbilicus, two 5mm working ports in the right and left upper quadrants, and a 5mm assistant port in the left lower quadrant. After establishing pneumoperitoneum, the surgeon identifies the ligament of Treitz and measures 30-40cm distally to select the jejunal limb for anastomosis, as the creation of access to the jejunum through the stomach is a key step in gastrojejunostomy 1. The transverse colon is retracted upward to expose the lesser sac, and the intended site on the posterior wall of the stomach is identified. Both the gastric and jejunal anastomotic sites are marked. The surgeon then creates the anastomosis using either a stapled or hand-sewn technique. For stapled anastomosis, small enterotomies are made in both the stomach and jejunum, a linear stapler is inserted to create the connection, and the common enterotomy is closed with sutures or staples. For hand-sewn technique, the surgeon performs a two-layer anastomosis with inner full-thickness continuous sutures and outer seromuscular interrupted sutures using absorbable material like 3-0 Vicryl. After completing the anastomosis, the surgeon checks for hemostasis, ensures the anastomosis is patent and tension-free, and tests for leaks using air insufflation through a nasogastric tube while the anastomosis is submerged in saline. The procedure concludes with removal of instruments, release of pneumoperitoneum, and closure of port sites. Key considerations in this procedure include minimizing morbidity, mortality, and improving quality of life, and the technique used should prioritize these outcomes.

Some key points to consider in laparoscopic gastrojejunostomy include:

• Patient positioning and port placement to allow for optimal access and visualization
• Identification of the jejunal limb and creation of the anastomosis using either a stapled or hand-sewn technique
• Testing for leaks and ensuring the anastomosis is patent and tension-free
• Use of absorbable materials for sutures and staples to minimize complications
• Prioritizing morbidity, mortality, and quality of life in the choice of technique and management of the patient.

From the Research

Steps of Lap Gastrojejunostomy

• The procedure involves creating a side-to-side gastrojejunostomy, which can be performed using a 30-mm or 45-mm Endo-GIA stapler 2.
• Intracorporeal suture using 2-0 vicryl is performed to repair the gastrotomy and jejunotomy site after gastrojejunostomy 2.
• The procedure can be performed using an antecolic or retrocolic approach, with the antecolic approach being more common 2.
• The steps involved in laparoscopic gastrojejunostomy include:
  • Insertion of four trocars
  • Creation of a gastrojejunostomy using a stapler
  • Intracorporeal suture to repair the gastrotomy and jejunotomy site
  • Closure of the trocar sites
• Various techniques can be used to create the gastrojejunostomy, including hand-sewn anastomosis (HSA), circular-stapled anastomosis (CSA), and linear stapled (LS) anastomosis 3, 4.
• The choice of technique may depend on the surgeon's preference and experience, as well as the patient's individual needs 3, 4.

Complications and Considerations

• Complications of laparoscopic gastrojejunostomy can include anastomotic leaks, marginal ulcers, strictures, and postoperative bleeding 3, 4.
• The use of mechanical circular staplers has been associated with a higher rate of postoperative complications, including marginal ulcers, strictures, and postoperative bleeding 4.
• The procedure should be performed by an experienced surgeon, and the patient should be carefully selected and evaluated for any potential risks or complications 2, 5.
• The patient's nutritional needs and overall health status should be carefully considered when deciding on the best approach for gastrojejunostomy 5, 6.