Laparoscopic vagotomy and antrectomy

This video demonstrates the technique of vagotomy and antrectomy with Billroth I anastomosis for complicated duodenal ulcer disease. The surgeon uses a hand-sewn anastomosis between body of the stomach and the duodenum. The performance of vagotomy is controversial, but in this case the surgeon performs a bilateral vagotomy before the antrectomy.

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Laparoscopic   vagotomy   and   antrectomy

Authors
J Leroy, D Mutter, M Smith-Savu
Abstract
This video demonstrates the technique of vagotomy and antrectomy with Billroth I anastomosis for complicated duodenal ulcer disease. The surgeon uses a hand-sewn anastomosis between body of the stomach and the duodenum. The performance of vagotomy is controversial, but in this case the surgeon performs a bilateral vagotomy before the antrectomy.
Catégorie
complex cases
Mots-clés
operation,vagotomy, antrectomy, Billroth I, chronic duodenal ulcer
Type de vidéo
Durée
10'00''
Publication
2001-11
Popularité
Favoris
Favorites Media
Audio
en
Sous-titres
en
E-publication
WeBSurg.com, Nov 2001;1(11).
URL: http://www.websurg.com/doi-vd01en1140e.htm

Laparoscopic   vagotomy   and   antrectomy

1. Case presentation 00'17''
In this film, we will show a vagotomy and antrectomy performed by laparoscopy for benign ulcer disease. The placement of the trocars are as such: one 5mm port is placed in the subxiphoid position with two 5mm ports placed in the paramedian subcostal position. A 10-12mm port is placed between the umbilicus and the xiphoid and another 10mm port is placed in a sub-umbilical position. Two paramedian ports are also placed lateral to the umbilicus. The dissection will be started medial to the esophagus by opening the pars flaccida using scissors with electrocautery. We do this in order to locate the posterior aspect of the esophagus as we see here and now to identify the posterior vagus, which is easily identified. At this point, we will section the posterior vagus using the Harmonic scalpels. Alternatively, one can place the clips and section the vagus using scissors. We will now make a dissection along the esophagus to locate the anterior vagus, which is well located here, which will also be sectioned with the ultrasonic scissors. To delineate the dissection of our antrum, we will place a line on the anterior aspect of the stomach between the vertical and horizontal areas of the stomach to delineate the area of the antrum. Using our 2 graspers, we will now elevate the stomach and begin our dissection between the greater curvature and the greater omentum. We again are using our Harmonic scalpel in order to avoid any unnecessary bleeding. During this dissection, it is important to stay close to the greater curvature of the stomach to keep as much of the blood supply to the stomach as possible. Of course, it is also possible to perform this dissection using scissors with coagulation. As we approach the pylorus and the 1st part of the duodenum, we will see progressively that there is more fibrosis and scarring due to the ulcer disease. It is therefore imperative to continue this dissection in a slow controlled manner in order to avoid any unnecessary damage to the duodenal wall. Progressively we make our dissection past the pylorus continuing with the Harmonic scalpel. There you can see that we have completely opened the lesser sac and we will continue the dissection on the posterior aspect of our stomach to the level that we have pre-determined on the anterior aspect. This will free the posterior aspect of the antrum completely so that we may place our staplers. It is imperative to have good grasping of the stomach by the assistant to elevate the stomach at this point and have a good vision. At this point, we change our optic to the supra-umbilical port and we introduce the stapler, green cartridge size through the sub-umbilical port to section the stomach at the previously dissected area of the antrum. This can take 2 to 3 staple recharges. The green stapler is used due to the thickness of the stomach itself. We can see that we have freely liberated the antrum and easily placed the stapler. Once we have sectioned the stomach, we continue to dissect down towards the fibrotic area of the duodenum and we can lift up the stomach toward the posterior aspect to continue the posterior dissection under direct vision. We progressively go the 1st part of the duodenum. As you can see, the stomach is lifted up and retracted laterally. We are now going to place a stitch past the ulcerated area to close off the stomach and the 1st part of the duodenum before we make our resection in the duodenum. This is a monofilament PDS stitch and we perform an extracorporeal knot using a knot pusher as you can see here. This will suffice to keep the contents of the stomach in the 1st part of the duodenum from falling into the field as we make our section of the duodenum. Distal to the previously placed stitch, which will close off the stomach and its contents, we now section the duodenum at the first part past the ulcer using the Harmonic scalpel, which avoids unnecessary bleeding. Once we finish this dissection, the specimen is completely free. The antrectomy is finished and the specimen can be placed in an Endo-catch bag. We will now perform a hand-sewn anastomosis using monofilament absorbable suture of PDS. We start with the posterior aspect of the stomach and we approximate it to the duodenum. We use a hand-sewn anastomosis secondary to the fact that the duodenum is fixed at this point and difficult to re-approximate. Extracorporeal knots are performed using a push knot device. Now on the anterior aspect of the stomach, we continue to close the anastomosis. We perform a one-layered anastomosis, hand-sewn. Intracorporeal knotting can also be performed as seen here. Careful placement of suture individual throughout anastomosis will ensure a watertight anastomosis. At the conclusion, the specimen is removed through the sub-umbilical port using a wound protector.