How I Do It

Novel cost-effective method of laparoscopic feeding- jejunostomy

Rajesh C Mistry, Sanket S Mehta, George Karimundackal, C S Pramesh Department of Thoracic Surgery, Tata Memorial Hospital, Mumbai, India

Address for correspondence: Dr. R C. Mistry, Department of Thoracic Surgery, Tata Memorial Hospital, E Borges Marg, Parel, Mumbai - 400 012, India. E-mail: [email protected]

Abstract available.[4–6] We describe an indigenous method for totally laparoscopic feeding jejunostomy tube A feeding jejunostomy tube placement is required placement using simple laparoscopic instruments and for entral feeding in a variety of clinical scenarios. It offers an advantage over gastrostomies by an inexpensive, readily available feeding tube. eliminating the risk of aspiration. Standard described laparoscopic methods require special METHOD instrumentation and expensive custom-made tubes. We describe a simple cost-effective method No specific pre-operative preparation of the patient is of feeding jejunostomy using regular laparoscopic required for this procedure. The operating room (OR) instruments and an inexpensive readily available tube. The average operating time was 35 min. We setup is as shown in the illustration in Figure 1. The had no intra-operative complications and only one patient is placed in the supine position and the port post-operative complication in the form of extra- sites are as shown in the illustration in Figure 2. The peritoneal leakage of feeds due to a damaged additional monitor for the assistant is optional. The tube. No complications were encountered while procedure was conceptualized as an adjunct to surgery pulling out the tubes after an average period of 5–6 weeks. for cancer of the oesophagus for which laparoscopic stomach mobilization and stomach tube preparation are

Key words: Laparoscopic, feeding-jejunostomy, done. Hence, the position of the patient, the operating minimal-access, feeding procedure room setup and the port positions are as would be required for laparoscopic mobilization of the stomach. DOI: 10.4103/0972-9941.55108 However, we found that the same port positions provided an advantage while doing a laparoscopic feeding jejunostomy. Introduction We prefer to get intraperitoneal access by the open Enteral feeding has several advantages over method at the umbilical port site. We insert the parenteral feeding. A feeding jejunostomy tube remaining ports under vision, and the left-sided port placement is required for enteral feeding in a variety site also serves later as the exit of the feeding tube. of clinical scenarios. It offers an advantage over We find it easier to initially identify the duodenojejunal gastrostomies by eliminating the risk of aspiration. flexure and the proximal jejunum with the camera in Minimal access methods have been described for the umbilical port. A bowel grasper introduced through the placement of feeding jejunal tubes, but they the left paramedian port helps to lift the colon; bowel often require special equipment not routinely graspers introduced through the two right-sided ports available in all operation theatres.[1–3] Also, most are then used to identify the duodenojejunal flexure. of these methods require specially designed Once the loop is identified, a point approximately 40 feeding tubes which are expensive and not easily cm from the duodenojejunal flexure is selected as the

43 Journal of Minimal Access Surgery | April-June 2009 | Volume 5 | Issue 2 Mistry, et al.: Laparoscopic feeding jejunostomy

Figure 2: Port sites

to 4-cm length each, as the feeding tube. The choice of this tube was based on our experiences with the other custom-made feeding tubes that were expensive, not easily available and difficult to introduce and hitch. Also, they are of a smaller calibre making them liable to blockage with regular feeds.[7] The simple T-tube is Figure 1: The operating room set-up easily available, inexpensive, of adequate calibre, easy jejunostomy site. We then pass a grasping forceps from to introduce and because of its T-joint, is self-retaining the right lower paramedian port to the left-sided port and easy to hitch laparoscopically. Once the horizontal and through the port outside. Once the grasper has limb of the T-tube is within the peritoneal cavity, the passed through the port outside, the left paramedian camera is then shifted to the right lower paramedian port is removed. The grasper is then used to hold the port, and the umbilical and the right upper paramedian feeding tube and deliver it into the peritoneal cavity. We ports are used for instrumentation. An opening is use a simple 12-Fr T-tube, with the horizontal limbs cut then made at the selected site of the proximal jejunal

Figure 4: Completed insertion of the horizontal limbs of the T-tube in the Figure 3: Insertion of T-tube in the jejunal opening jejunum and the sero-muscular purse-string stitch

Journal of Minimal Access Surgery | April-June 2009 | Volume 5 | Issue 2 44 Mistry, et al.: Laparoscopic feeding jejunostomy loop using monopolar diathermy attached to a closed before creating the jejunal opening and tied once the Maryland grasper. The two horizontal limbs of the tube is in place [Figure 6]. The integrity of this stitch is T-tube are then introduced into the jejunum one after checked by pushing a dilute betadine solution through the other [Figure 3]. As the limbs are equal in length, there is no worry as to the direction of introduction or the orientation of the afferent and the efferent loops during the introduction of the tube. Also, as the T-joint is the site of exit of the tube from the intestine, there is no concern regarding the adequacy of the intra-intestinal length of the tube, in contrast to the other custom-made tubes that need measuring the intrajejunal length and introduction specifically in the efferent direction for proper placement. After the two limbs are in position, a seromuscular purse-string suture is placed at the exit site of the tube using an absorbable suture material, as shown in the illustration in Figures

4,5. Alternatively, the purse-string suture can be taken Figure 6: Sero-muscular purse-string stitch taken prior to insertion of the T-tube

Figure 5: Sero-muscular purse-string stitch (illustration) Figure 8: Stitches taken to hitch the jejunostomy exit site to the anterior abdominal wall (distal stitch)

Figure 7: Stitches taken to hitch the jejunostomy exit site to the anterior Figure 9: Stitches taken to hitch the jejunostomy exit site to the anterior abdominal wall (proximal stitch) abdominal wall (completed final picture)

45 Journal of Minimal Access Surgery | April-June 2009 | Volume 5 | Issue 2 Mistry, et al.: Laparoscopic feeding jejunostomy the T-tube and looking for any leak. A gentle tug on pliable. We did not have any difficulty in removing the the tube from the outside then gets the loop up to the tube thereafter. site of exit from the abdominal wall. After confirming the orientation of the afferent and the efferent loops, CONCLUSION two seromuscular sutures are taken and hitched to the abdominal wall, one on the proximal and one on the Feeding jejunostomy is frequently performed either distal side of the purse-string stitch to decrease the as an isolated procedure by itself or as an adjunct tension at the site of exit of the tube [Figures 7–9]. A to specialized surgery like oesophageal and gastric third stitch is taken on the skin exit site to hitch the tube resections and after pancreaticoduodenectomy. in slight traction. The port sites are then closed taking Conventionally performed laparoscopic jejunal tube adequate precaution to close the sheath for the 11-mm placement requires special equipment, feeding tubes ports. Feeding through the tube can start after 12 h. and specially formulated feed solutions. Our innovative method of totally laparoscopic jejunal tube placement RESULTS is easy, inexpensive, does not require specialized equipment or feeding tubes and is a simple alternative We performed the procedure in 19 patients undergoing to conventional laparoscopic feeding tube placement. oesophageal resection from May to November 2008. Using this method, we had no intra-operative References complications related to the procedure. The average time required for the procedure was 35 min. Post- 1. Duh QY, Way LW. Laparoscopic jejunostomy using T-fasteners as retractors and anchors. Arch Surg 1993;128:105-8. operatively, we had no port-site complications, and 2. Rosser JC Jr, Rodas EB, Blancaflor J, Prosst RL, Rosser LE, Salem RR. A feeding was started for all patients on the first post- Simplified Technique for Laparoscopic Jejunostomy and Gastrostomy operative day. The only complication encountered Tube Placement. Am J Surg 1999;177:61-5. 3. Shike M, Latkany L, Gerdes H, Bloch AS. Direct percutaneous endoscopic was extraperitoneal leakage of feeds in one patient. jejunostomies for enteral feeding. Gastrointest Endosc 1996;44:536-40. There was no intraperitoneal leak as confirmed by a 4. Senkal M, Koch J, Hummel T, Zumtobel V. Laparoscopic needle catheter fluoroscopic conray study. Damage to the vertical limb jejunostomy: modification of technique and outcome results. Surg Endosc 2004:18:307-9. of the T-tube was the probable cause. The tube was 5. Sica GS, Sujendran V, Wheeler J, Soin B, Maynard N. Needle catheter removed on the fifth post-operative day without any jejunostomy at esophagectomy for cancer. J Surg Oncol 2005:91:276-9. further complications. There were no complications 6. Jenkinson, A, Lim, J, Agrawal, N, Menzies, D. Laparoscopic feeding jejunostomy in esophagogastric cancer Surg Endosc 2007:21:299-302. faced while removing the tubes after an average period 7. Wolfsen HC, Kozarek RA, Ball TJ, Patterson DJ, Botoman VA. Tube of 5-6 weeks. During the first few cases, we had used dysfunction following percutaneous endoscopic gastrostomy and the portex T-tube that tends to become stiff with time. jejunostomy. Gastrointest Endosc 1990;36:261-3. Although we had no complications while removing Cite this article as: Mistry RC, Mehta SS, Karimundackal G, Pramesh CS. this tube, we did face difficulty in pulling out the tube Novel cost-effective method of laparoscopic feeding-jejunostomy. J Min Access in one of the cases that required the tube to be kept Surg 2009;5:43-6. for a longer time for feeding purposes. This made us Date of submission: 12/04/09, Date of acceptance: 13/07/09 switch over to the latex T-tube that is softer and more Source of Support: Nil, Conflict of Interest: None declared.

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Journal of Minimal Access Surgery | April-June 2009 | Volume 5 | Issue 2 46