Correspondence Address: Dr. Marco Lotti Advanced Surgical Oncology Unit, Ospedale Papa Giovanni XXIII, Piazza OMS, 1, 24127 Bergamo Italy
Source of Support: None, Conflict of Interest: None
The placement of a feeding jejunostomy can be indicated in malnourished patients with gastric and oesophagogastric junction cancer to allow for enteral nutritional support. In these patients, the jejunostomy tube can be suitably placed at the time of staging laparoscopy. Several techniques of laparoscopic jejunostomy (LJ) have been described, yet the Witzel approach remains neglected, due to the perceived difficulty of suturing the bowel around the tube and securing them to the abdominal wall. Here, we describe a novel technique for LJ, using a single barbed suture for securing the bowel and tunnelling the jejunostomy catheter according to the Witzel approach.
The placement of a feeding jejunostomy can be indicated in malnourished patients with foregut malignancy to allow for enteral nutritional support during neoadjuvant therapy and in the perioperative period. In these patients, feeding jejunostomy is suitably placed at the time of explorative laparoscopy, which is usually performed for proper staging of gastric and oesophagogastric junction cancers.
Several techniques of laparoscopic jejunostomy (LJ) have been described, yet the Witzel approach remains neglected due to the perceived difficulty of suturing the bowel around the tube and securing them to the abdominal wall. Direct access to the bowel, the use of T tubes, the simultaneous placement of multiple holding sutures, the use of peel-away introducers, sealing the entry site with barbed sutures: all these technical variations testify to the complexity of this operation, which is quite often underestimated.,,,,,,,,
Here, we present our original technique for LJ, using a single barbed suture for securing the bowel and tunnelling the jejunostomy catheter according to the Witzel approach [Video 1].
¤ Preoperative Preparation
A single absorbable polyglyconate knotless wound closure device (V-Loc™ 180, Medtronic, USA) with a taper point needle and a 14 Fr jejunostomy catheter is required. The proposed jejunostomy site is located preoperatively with the patient in the supine, sitting and standing positions and drawn on the skin with a permanent marker.
¤ Positioning of Patient and Ports
Positioning of the patient
The patient is placed supine, with the right arm at the side [Figure 1]a.
Figure 1: (a) Positioning of patient, (b) ports and (c) instruments
The surgeon is on the patient's right side; the assistant stays on the surgeon's left side; the monitor stays behind the patient's left shoulder.
Port site placement
A 10-mm trocar (U-T) is placed in the midline just above the umbilicus. A 10-mm trocar (RIF-T) is placed in the right iliac fossa, 2 cm below the McBurney's point. Then, a 5-mm trocar is placed in the hypogastric midline (HYP-T) [Figure 1]b.
Step 1: Selection of the jejunal loop
The patient is placed in the reverse Trendelenburg position, the left side inclined upward. The laparoscope is inserted through the RIF-T. The U-T and the HYP-T are used by the surgeon [Figure 1]c.
The greater omentum is placed in the supramesocolic space; the small bowel is displaced to the right and inferiorly, and the duodeno-jejunal junction is identified.
A loop of jejunum is chosen 30–40 cm from the ligament of Treitz and marked with a clip [Figure 1]d.
Step 2: Preparation of the jejunostomy site
A 5-mm trocar is inserted at the jejunostomy site (J-T), with the tip placed just below the peritoneal plane [Figure 2]a. The suture begins 1.5 cm cranial to the tip of the J-T, where the needle is passed clockwise through the abdominal wall [Figure 2]b and then through the anchoring hole of the barbed suture [Figure 2]c. Finally, the needle is passed again through the abdominal wall 5 mm below to bring the suture to the left side of the J-T [Figure 2]d.
Figure 2: Preparation of the jejunostomy site. (a) Insertion of the trocar, (b) first bite, (c) anchorage of the suture, (d) second bite
Step 3: Anchoring the selected jejunal loop to the abdominal wall
The needle is passed clockwise through the seromuscular layer of the selected jejunal loop and then through the abdominal wall 5 mm before the tip of the J-T [Figure 3]a and [Figure 3]b. The jejunal loop is gently brought toward the abdominal wall and the suture is secured. This passage is repeated, with the needle going through the seromuscular layer of the bowel and finally through the abdominal wall, just before the tip of the J-T [Figure 3]c. The suture is secured again [Figure 3]d.
Figure 3: Anchoring the selected jejunal loop to the abdominal wall. (a) First bite through the bowel, (b) first bite through the abdominal wall, (c) second bite, (d) securing the suture
A small incision is made with the monopolar hook on the antimesenteric border of the jejunum, 4.5 cm caudal to the anchorage site [Figure 4]a. The feeding tube is inserted in the J-T, and the J-T is pushed forward to guide the tube through the hole of the bowel [Figure 4]b and [Figure 4]c. Finally, the feeding tube is pulled and guided into its final position [Figure 4]d.
Figure 4: Placement of the feeding tube. (a) Bowel incision, (b) inserting the tube through the trocar, (c) placing the tube and (d) guiding it into position
The J-T is retrieved. The needle is passed clockwise through the bowel wall, then over the feeding tube, then again through the bowel wall and finally through the abdominal wall just below the entry point of the tube [Figure 5]a, [Figure 5]b, [Figure 5]c. The suture is secured, thus creating the conditions to start with the tunnellisation of the jejunostomy [Figure 5]d.
Figure 5: Starting with the tunnellisation. (a) Driving the needle through the bowel, (b) over the tube, (c) through the abdominal wall and (d) securing the suture
Step 6: Getting out of the tunnel and securing the bowel
The tunnel is created as per the procedure described in Step 5, the only difference being that the abdominal wall is pierced only once, halfway between the beginning and the end of the tunnel [Figure 6]a and [Figure 6]b. This trick allows for a better compliance of the bowel wall and facilitates the control over the suturing to warrant the complete covering of the catheter without tension [Figure 6]c. When the tunnel is finished, the abdominal wall is pierced two times and the suture is finally secured [Figure 6]d. When securing the bowel to the abdominal wall, a cranio-caudal direction is maintained [Figure 7].
Figure 6: (a and b) proceeding with the tunnel, (c) completing the covering of the tube and (d) securing the bowel to the abdominal wall
The feeding tube is flushed with saline to check for easy flow and then it is secured to the skin. The jejunostomy can be used since the 1st postoperative day.
The Witzel approach is often the preferred one during open surgery for several reasons. Placing the exit to the skin far from the entrance of the tube into the bowel is a way to reduce the occurrence of reflux of the bowel contents from the skin orifice, which usually causes inflammation, granulation and infection. Moreover, the complete covering of the entrance of the tube into the bowel by the seromuscular suture, and the wider contact of the bowel with the abdominal wall, can reduce the risk of detachment, dislodgement and peritonitis. Finally, compared to the needle catheter techniques, the Witzel approach allows for the use of larger catheters, reducing the risk of clogging and obstruction.
We developed our LJ technique to reproduce laparoscopically the Witzel approach as in open surgery, since the several techniques of LJ we found available in the literature are compromises that do not allow for the same effectiveness in the tunnellisation of the jejunostomy catheter. We did not observe intraoperative complications, and our average operative time is 45 min. This technique is minimal-equipment and cheap; moreover, the J-T can be used also for the explorative laparoscopy, before being the entry site of the catheter.
Siow SL, Mahendran HA, Wong CM, Milaksh NK, Nyunt M. Laparoscopic T-tube feeding jejunostomy as an adjunct to staging laparoscopy for upper gastrointestinal malignancies: The technique and review of outcomes. BMC Surg 2017;17:25.