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Technique: laparoscopic distal gastrectomy
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摘要
The description of the technique of laparoscopic distal gastrectomy covers all aspects of the surgical procedure used for the management of chronic gastric ulcers.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: surgical procedure, exploration, dissection of greater curvature, resection of the antrum, gastroduodenal anastomosis, Billroth II anastomosis, complications, intraoperative complications, postoperative complications, functional complications.
Consequently, this operating technique is well standardized for the management of this condition.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: surgical procedure, exploration, dissection of greater curvature, resection of the antrum, gastroduodenal anastomosis, Billroth II anastomosis, complications, intraoperative complications, postoperative complications, functional complications.
Consequently, this operating technique is well standardized for the management of this condition.
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媒體類型
 刊物
2001-07
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普通的
最愛
 音訊
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數位出版
WeBSurg.com, Jul 2001;1(07).
URL: http://www.websurg.com/doi-ot02en171a.htm
URL: http://www.websurg.com/doi-ot02en171a.htm
Technique: laparoscopic distal gastrectomy
1. Introduction
The first laparoscopic gastrectomy, performed in 1992, was a Billroth II gastrectomy for the treatment of chronic gastric ulcers. It reproduced the basic principles of open surgery using videoscopy.
Billroth I gastrectomy and total gastrectomy for cancer have since been described.
Available data in the literature seem to indicate that the laparoscopic approach to gastric resections offers significant advantages in terms of postoperative comfort, despite higher costs and longer operative times as compared to the open approach.
2. General anatomy
• Anatomical description
• Landmarks
The stomach is a J-shaped mobile sac located between two fixed anatomical landmarks:1. The cardia, junction between the abdominal esophagus and the stomach,
2. The pylorus, junction between the stomach and the duodenum.
• Division
The stomach is divided into 2 parts:3. The vertical part projects over the spine to the left; it is composed of both the fundus and the body of the stomach,
4. The horizontal part heads to the right beyond the linea alba, composed primarily of the antrum of the stomach.
• Duodenal bulb
5. The duodenal bulb, often resected during gastrectomies due to its proximity to the stomach, is the first mobile segment of duodenum. It is separated from the pancreas by the omental bursa, which extends to the level of the gastroduodenal artery.• Physiological description
From a physiological standpoint, the stomach divided into the:6. Antrum: acid-stimulating,
7. Fundus: acid-producing.
The limit between the 2 functional regions does not correspond to the junction between the horizontal and vertical regions of the stomach.
3. Vascular anatomy
• Pedicles
Gastric arterial blood supply originates from the celiac trunk and supplies the stomach via 4 major pedicles:- 2 at the level of the lesser curvature,
- 2 at the level of the greater curvature.
The stomach is endowed with a rich submucosal anastomotic network that ensures adequate blood supply in the event one of the main trunks is either obstructed or ligated.
• Celiac trunk
The celiac trunk, representing the main blood supply of the stomach, originates from the anterior aspect of the aorta above the superior aspect of the pancreas.The trunk is 1 to 3 cm long and divides into 3 branches:
1. The left gastric artery;
2. The common hepatic artery;
3. The splenic artery.
• Gastroduodenal junction
The first portion of the duodenum is supplied by branches of the gastroduodenal artery.4. Lesser curvature
• Left gastric artery
• Origin
The left gastric artery originates from the celiac trunk in 90% of cases.• Variations
In some patients, it may originate:1. Directly from the aorta;
2. From the inferior phrenic artery;
3. From the gastrosplenic trunk;
4. From the gastrohepatic trunk.
• Division
It completes an arch before joining and running along the lesser curvature 2 fingerbreadths below the cardia. It then divides into anterior (1) and posterior (2) branches that run down along the lesser curvature to join the terminal branches of the right gastric artery.• Other branches
The left gastric artery gives off several branches:1. Accessory left hepatic artery; there is frequently an accessory left hepatic artery, which is of no clinical significance,
2. Anterior and posterior cardioesophageal arteries (supplying the cardia and abdominal esophagus).
• Right gastric artery
• Normal
The right gastric artery usually originates from the common hepatic artery.• Variations
In some patients, it originates directly from the:1. Gastroduodenal artery;
2. Left hepatic artery, or;
3. Proper hepatic artery.
• Vascular arch
The right gastric artery joins the stomach at the level of the pylorus. It then divides into anterior and posterior gastric branches that run along the lesser curvature to join the left gastric artery network at the level of the incissura, junction between the horizontal and vertical regions of the stomach. The right and left gastric arteries compose the vascular arch of the lesser curvature.
5. Greater curvature
• Definition
The greater curvature of the stomach is bordered by the greater omentum and gastrosplenic ligament. The peritoneal covering of each of these 2 structures is in direct contact with the gastric visceral peritoneum. The greater omentum spreads over the transverse colon and extends beyond it inferiorly at the level of the body and horizontal region of the stomach. At the level of the fundus, the greater omentum becomes the gastrosplenic ligament. The right and left gastroomental arteries and the short gastric vessels form the vascular arch that runs through the anterior layer of the greater omentum. • Right gastroomental artery
1. The right gastroomental artery originates from the division of the gastroduodenal artery at the inferior aspect of the duodenum.2. It runs along the greater curvature of the stomach from right to left at an average distance of 1 cm.
3. The branches originating from the right gastroomental artery supply the anterior and posterior aspects of the stomach and the omentum.
• Left gastroomental artery
The left gastroomental artery originates from the splenic artery. It supplies the middle portion of the greater curvature and runs through the gastrocolic ligament to join the terminal branches of the right gastroomental artery.The right and left gastroomental arteries thus form the vascular arch of the greater curvature.
• Short gastric vessels
The short gastric vessels originate from the terminal branches of the splenic artery.Alternatively, they originate either directly from the trunk of the splenic artery or from its terminal branches.
They are composed generally of 2 to 6 vessels that run from the splenic hilum to the stomach via the gastrosplenic omentum.
The largest vessel (the posterior gastric artery) joins the posterior aspect of the stomach and divides to supply the fundus and the cardia.
• Avascular window
An avascular window of only 2 peritoneal layers is situated between the last short gastric vessel and the origin of the left gastroomental artery. The 2 layers of peritoneum split to form the omental bursa opposite the splenic artery.6. Indications
• Generalities
Gastric surgery may be performed laparoscopically:1. Functional surgery:
- treatment of gastro-esophageal reflux disease;
- treatment of hiatal hernias;
- pyloroplasty.
2. Gastric resection:
- for benign tumors,
- for malignant tumors.
7. Operating room set-up
• Patient
- general anesthesia;- nasogastric tube;
- supine position;
- arms at a right angle and legs apart (arms alongside the body for certain authors);
- reverse Trendelenburg position with a 10° or 30° tilt;
- dual-lumen gastric tube (used to totally empty the stomach);
- urinary catheter (used in case of prolonged procedure, optional);
- antibiotic prophylaxis.
• Team
There must be ample space for the anesthetic equipment, as well as a perfectly adapted operating table. For optimal safety conditions and comfort, the operating room should be ergonomic.1. The surgeon stands between the patient’s legs.
2. The first assistant stands on the patient’s left.
3. The second assistant stands on the patient’s right.
4. The scrub nurse stands on the surgeon’s right.
• Equipment
1. Laparoscopic unit (3-chip camera if possible, light source, insufflator)2. Two additional high-quality monitors
3. Anesthetic unit
4. Arm-holders
8. Instruments
• Positioning
A: 0° laparoscopeB C: Atraumatic grasper, monopolar and bipolar diathermy scissors, suction-irrigation device
D: Dissecting hook, monopolar and bipolar diathermy scissors, linear stapler, suction-irrigation device, needle holder
E: Liver retractor
F: Grasper
• Optical
A: Most procedures are performed using a 0° laparoscope, but a 30° laparoscope can be useful when visualization is poor.• Operating
D: Dissecting hook, monopolar and bipolar diathermy scissors, linear stapler, suction-irrigation device, needle holderF: Grasper
• Retractors
B C: Atraumatic grasper, monopolar and bipolar diathermy scissors, suction-irrigation deviceE: We prefer to use an atraumatic liver retractor, however, a fan-like liver retractor can be used.
9. Trocar placement
• Landmarks
1. Xiphoid process2. Costal margin
3. Linea alba
4. Midclavicular lines (mamillary lines)
5. Anterior axillary lines
5 or 7 trocars are used in the procedure. Most authors use 10/12 mm trocars exclusively in order to be able to apply clips or to introduce a linear stapler at all trocar sites.
Trocars must always be placed in such a way as to avoid contact between instruments.
• Pneumoperitoneum/exposure
The pneumoperitoneum is preferably obtained by introducing the first trocar under direct visual control. This trocar is placed in the umbilicus.The peritoneal cavity is insufflated with carbon dioxide at a pressure of 12 mm Hg.
The exposure is aided by the 10° to 30° tilt of the operating table (the patient’s head higher than the feet).
• Trocars
The remaining trocars are introduced under visual control. The first trocar (A) is introduced in the umbilicus. Two trocars are positioned below the right costal margin (B) and the left costal margin (C) on the midclavicular line. A fourth trocar (D) and a fifth trocar (F) are positioned on the midclavicular line at umbilicus level. A sixth trocar (E) is introduced at the level of the xiphoid process.
• Size and position
Trocar A: 10 to 12mm in size, accommodates a laparoscope, located subumbilically.Trocar B: 10 to 12mm in size, accommodates a grasper, located on the right midclavicular line just below the costal margin.
Trocar C: 10 to 12mm in size, accommodates a grasper, located on the left midclavicular line just below the costal margin.
Trocar D: 10 to 12mm in size, accommodates the dissecting instruments and sutures, located on the left midclavicular line below the umbilicus.
Trocar E: 10 to 12mm in size, accommodates the liver retractor, located at the level of the xiphoid process.
Trocar F: 10 to 12mm in size, accommodates the atraumatic grasper, located on the right midclavicular line below the umbilicus.
10. Surgical procedure
• Four steps
The procedure can be broken down into 4 main operative steps:- exploration of the abdominal cavity and stomach and determination of the extent of resection;
- mobilization and division of the stomach;
- anastomosis;
- minilaparotomy for the extraction of the specimen.
• Principles
Principles of gastrectomy:1. Dissection of the greater curvature
2. Dissection of the duodenum:
- Billroth II (closed duodenal stump)
- Billroth I (opened duodenal stump)
3. Dissection of the lesser curvature
4. Division of the stomach
5. Reconstruction:
- Billroth II
- Billroth I
11. Exploration
The exploration of the abdominal cavity determines the feasibility of the laparoscopic approach (absence of adhesions, good visualization).The exploration of the stomach and its topographical anatomy makes it possible to determine the extent of the intended resection and delimit various regions using marker threads, clips or electrocautery.
12. Dissection/greater curvature
• Principles
The mobilization of the stomach is performed directly through the lesser sac.• Ligature and dissection
• Omentum identification
The omentum is identified and retracted with the grasper introduced via the trocar situated in left subcostal position (via C).The surgeon uses the trocar situated in the right flank (via F) and the left latero-umbilical trocar (via D).
• Vessel division
The direct vascular branches from the gastroomental vessels are divided sequentially. The dissection is continued to the right after division of the gastroomental vein down to the duodenum.• Vessel dissection
The vessels are progressively dissected and then controlled using clips, monopolar or bipolar coagulation or an ultrasonic scalpel.• Variation
• Staplers
The use of staplers with vascular cartridges has been suggested for this operative step, but the high cost of such devices must be taken into consideration.• Ultrasonic scalpel
The ultrasonic scalpel is currently the most suitable instrument for this stage of dissection.• Right gastric artery
The right gastric artery is dissected, controlled, and clipped.The gastro-hepatic ligament is exposed and opened following retraction of the left lobe of the liver.
This retraction can be performed with an atraumatic retractor placed in the left subcostal trocar (via C). However, this forces the surgeon to pull back the grasper to expose the stomach. We favour placing the retractor through the fifth epigastric trocar (trocar E) in the xiphoid position.
13. Resection of the antrum
• Division of stomach
Once the dissection of the antrum is complete, it is divided proximally.The specimen is held by graspers introduced through the trocars placed in the right and left subcostal positions (via B and C) to facilitate this step.
• Stapler use
The stapler is introduced via the left latero-umbilical trocar (via D). Two to three firings of the stapler (4.8 mm staples, 60 mm cartridges) are necessary to perform total transection of the stomach.• Division of duodenum
The duodenum is circumferentially dissected at this stage of the procedure. It is divided: - without staples in preparation for gastroduodenal anastomosis (Billroth I),
- with a linear stapling device in preparation for a Billroth II gastro-jejunostomy . One or two cartridges are necessary to completely transect the duodenum. We do not feel it is necessary to oversee the staple line since endoscopic staplers apply 3 rows of staples.
14. Gastroduodenal anastomosis
• Principles
The anastomosis can be performed laparoscopically with either a hand-sewn technique or a circular stapling device. At this stage of the procedure, the anastomosis can be performed by either of the following methods:1. The procedure can be continued laparoscopically and the anastomosis performed prior to the extraction of the specimen.
2. A minilaparotomy can be performed right away (an incision will eventually be required to extract the specimen) to allow performance of the gastroduodenal anastomosis.
• Manual suture
• Posterior surface
The staple line is opened over 4 cm and a running suture is used to create the posterior suture line of the gastroduodenal anastomosis. The needle holder is introduced via D.
• Anterior surface
Interrupted sutures are applied to complete the anterior suture line. • Circular stapler
• Anvil introduction
Billroth I reconstruction can be achieved laparoscopically using equipment that is well suited for the introduction of circular staplers. A 33 mm trocar is placed in left lateral umbilical position (via D), allowing for the introduction of the anvil of a circular stapler into the abdominal cavity. The duodenal stump is opened. The head of the anvil is introduced into the duodenum and a purse string suture is secured around the anvil. A pre-formed loop can also be used to close the duodenal stump on the anvil.• Anastomosis
A gastrotomy is then performed on the anterior aspect of the gastric remnant. An EEA stapler is introduced through the 33 mm trocar into the stomach. The distal stomach is pulled up. The tip of the stapling device perforates the posterior aspect of the stomach and docks with the anvil to create the gastroduodenal anastomosis. Interrupted sutures, continuous sutures or a final row of linear staples are then applied to close the gastrotomy. • Extraction of specimen
The specimen is placed in a bag and extracted via the 33 mm trocar site.Intracorporeal anastomosis is lengthy, adding to the already lengthy total operative time of this procedure (4-6 hours). The benefits of an incision of 33 mm (trocar size) over a 4-8 cm minilaparotomy that would allow for specimen extraction and performance of the anastomosis are limited, in our opinion.
15. Billroth II anastomosis
• Anastomosis
The stomach is fixed to the anterior abdominal wall with 2 sutures.These sutures are introduced with a straight needle through the abdominal wall, and then passed through the anterior gastric wall to suspend the stomach to the anterior abdominal wall. This manoeuvre effectively exposes the posterior aspect of the stomach where the anastomosis is to be performed.
• Selection of loop
• Passage of jejunal loop
The laparoscope is placed in the umbilical port to facilitate the location and selection of the jejunal limb to be used for the reconstruction. The ligament of Treitz is identified (via D) and a jejunal segment 40 cm from the ligament of Treitz is selected. The jejunal loop is then passed in an antecolic (simpler and more commonly used option) or retrocolic fashion. • Anisoperistaltic anastomosis
The anastomosis is performed in anisoperistaltic fashion.An incision is made using scissors or hook at the left end of the region intended for the anastomosis. An isoperistaltic anastomosis is preferred after a limited antrectomy.
• Stapling device introduction
The stapling device is introduced via the left latero-umbilical trocar (via D). Two successive rows of linear staples (blue cartridge) make it possible to achieve an anastomosis of a sufficient length.• Testing the anastomosis
The stapler introduction site is then closed with endoscopic, running or interrupted sutures. The sutures used for suspension of the stomach are removed. The integrity of the anastomosis can be tested by gastroscopy or intragastric methylene blue injection.16. Complications
It is generally accepted that the intraoperative risks for laparoscopic and open gastric resection are comparable. On the other hand, comparative studies published in the literature report a lower incidence of postoperative complications following the laparoscopic approach (ileus). Postoperative recovery and quality of life appear to be equivalent if not superior to the open results (Kitano et al., 2002a, 2002b; Mochiki et al., 2002; Uyama et al., 1999). Theoretically, the laparoscopic approach to gastric surgery should offer the same advantages of any laparoscopic approach, namely a faster recovery, reduced postoperative pain, and a lowered incidence of pulmonary complications.
17. Intraoperative complications
1. Intraoperative hemorrhage can occur due to several factors:- loosening of a surgical knot or suture: this can be controlled by direct compression and resuturing;
- minor oozing: usually easily controlled by monopolar or bipolar coagulation;
- venous injuries: difficult to control, may require en masse suturing of the tissues;
- hepatic or splenic injuries with parenchymal hemorrhage: these can be controlled using direct compression, Argon Beam coagulation, fibrin glue or collagen based hemostatic aid application, splenectomy if indicated (the ligature of the splenic vessels deprives the stomach of some of its collateral blood supply and may mandate a completion total gastrectomy in some situations);
- bleeding from the staple lines: this can be controlled with a hemostatic suture application;
- biliary and pancreatic injuries can cause bleeding. A gallbladder injury or inadvertent ligature of the cystic artery frequently requires cholecystectomy. An injury to the common bile duct or main pancreatic duct requires drainage or a primary protected repair; while a small lateral injury to the CBD can be repaired primarily, a more complex biliary injury or complete division of the CBD requires either primary end-to-end repair over a T-tube or a Roux-en-Y choledocho- or hepatico-jejunostomy.
2. Gastric ischemia in the course of a subtotal gastrectomy, secondary to simultaneous ligature of the left and right gastric arterial trunks as well as the short gastric vessels (or an emergent splenectomy for control of hemorrhage) mandates conversion to a total gastrectomy.
Ischemia of the transverse colon secondary to sacrifice of the middle colic artery in an elderly patient with poor collateral blood supply requires a segmental colectomy of the ischemic segment.
Ischemia of the Roux limb is handled by resection of the ischemic segment and reconstruction of a new Roux limb.
18. Postoperative complications
Early postoperative complications are defined as those complications occurring within 30 to 60 days of surgery, depending on the author. They are observed in 10% to 30% of patients (Bozzetti et al., 1997; Hayes et al., 1999). These complications are generally significant and often result in prolonged hospitalizations, added costs, and an elevated mortality rate. The most common complications include postoperative hemorrhage, fistulas, and abscesses (Bozzetti et al., 1997). Of 121 total gastrectomies with lymphadenectomy, 9% had anastomotic leak, 0.15% duodenal stump leak, and 10% other fistulas (Hayes et al., 1999). The management of these complications has evolved rapidly due to our improved understanding of the pathophysiology of such injuries, improved imaging as well as interventional radiological abilities and an understanding of the high morbidity associated with surgical re-explorations. While most such complications can be treated conservatively, reoperative surgery remains of value in rapidly addressing some acute complications. Other postoperative complications seen following laparoscopic gastric surgery include acute pancreatitis, motility disorders, and lymphorrhea.1. Intraperitoneal hemorrhage can occur secondary to a delayed loosening of a vascular suture, or a delayed rupture of a subcapsular splenic hematoma. This usually mandates a rapid re-exploration of the patient to identify and correct the etiology of the bleeding (re-suturing, splenectomy) and evacuate the hematoma.
2. Gastro-intestinal hemorrhages following gastrectomies are reported in 1% to 2.5% of cases (Bozzetti et al., 1992; Kyser et al., 1997). They are most commonly due to a recurrent ulcer or suture line bleeding. The management of recurrent ulcer bleeding may require reoperative surgery, medical therapy of Helicobacter pylori, endoscopic measures for hemorrhage control (local injections of epinephrine or fibrin/cyanoacrylate glue) or selective embolization of the gastroduodenal artery. Suture line bleeding is generally managed conservatively, initially with nasogastric suction and appropriate resuscitation. If the above management fails then reoperation may be indicated to oversee the bleeding site via a vertical gastrotomy.
3. An enteric fistula is defined as leakage of intestinal contents outside of the gastro-intestinal tract. This includes leakage of intestinal contents, bile or pancreatic juice. The severity and morbidity of such leaks is determined by the patient’s clinical course. A small, contained leak often remains asymptomatic or leads to a delayed anastomotic stricture. It may lead to a local inflammatory reaction with localized peritonitis with an entero-cutaneous or entero-enteral fistula. The reported rate of anastomotic leaks following gastric surgery is 4% for esophageal anastomoses (Fahn et al., 1997) and 2.7% for gastric suture lines. A major anastomotic disruption occurring early in the postoperative course leads to generalized peritonitis, with a mortality rate of 50%.
4. Postoperative abscesses are diagnosed clinically (fever and abdominal pain in the postoperative setting) coupled with imaging (CT scanning). These can often be managed with percutaneous image guided aspiration and drainage.
19. Functional complications
1. Motility disordersEarly postoperative vomiting may occur secondary to anastomotic edema. It is often self-limiting and is usually managed via continued nasogastric aspiration.
2. Surgically induced motility disorders
Anastomotic strictures are rare, occurring in less than 1% of cases (Johannson et al., 2000), and are almost never reported when the diameter of the stapled anastomosis is greater than 28 mm. Such strictures manifest themselves within the first 3 postoperative months and may resolve spontaneously or following endoscopic dilatation in the majority of cases.
3. Motility disorders following Billroth II gastro-jejunostomy
a. Afferent limb obstruction
The afferent limb is composed of the remaining duodenum as well as proximal jejunum. Afferent limb obstruction can occur if the limb is too short and stretched out over the colon or too long, leading to intermittent volvulus. A surgical bypass of the obstructed limb proximal to the site of obstruction or fixation of the afferent limb in case it is too floppy may be indicated.
b. The afferent loop syndrome is caused by a partial high-grade obstruction of the afferent limb leading to duodenal distention associated with abdominal pain and relieved by copious projectile bilious vomiting. The afferent limb obstruction can occur secondary to acute angulation of a short limb, afferent limb torsion, adhesions, mesocolic window stricture, anastomotic stricture or invagination of the afferent limb into the anastomosis. Treatment of this condition is difficult and often requires remedial surgery.
c. The blind loop syndrome occurs secondary to bacterial overgrowth in a partially obstructed afferent limb. This limb empties occasionally in a sudden and massive fashion, dumping its septic contents in the gastrointestinal tract, leading to diarrhea. The treatment of this entity may require re-establishment of intestinal continuity to the duodenum by conversion of a gastro-jejunostomy to a gastro-duodenostomy.
d. Afferent limb internal hernia occurs most commonly secondary to incarceration of a small bowel loop into the mesocolic window. This may also be accompanied by herniation of the anastomosis into the lesser sac. Treatment is surgical with reduction of the internal hernia.
e. Gastric outlet obstruction can occur secondary to anastomotic stricturing or to invagination of the jejunal limb into the anastomosis. Revision of the anastomosis is often necessary.
4. Motility disorders following Billroth I reconstruction
a. Acute gastric dilatation is usually treated by naso-gastric suction coupled with parenteral nutritional support or a decompressive gastrostomy.
b. Acute peptic esophagitis can be mechanical in nature due to a pre-existing hiatal hernia, indwelling naso-gastric tube or stretching of the angle of His. It may also be secondary to bilious reflux following proximal gastrectomy encompassing the cardia or due to damage to the lower esophageal sphincter sustained in the course of an antrectomy-vagotomy. However, it can often be successfully managed medically; operative hiatal repair or duodenal diversion may be indicated.
5. Other functional complications
The “dumping syndrome”: it manifests in 2% to 88% of cases according to the chosen definition (Behrns and Sarr, 1994). It occurs in 2 forms, early or delayed:
- early dumping (within 5 minutes to an hour)
- delayed dumping (within 2-3 hours of meals, relieved by food intake): this is due to rapid absorption of carbohydrates in the afferent limb with reactive hyperinsulinemia leading to secondary hypoglycemia.
Diarrhea: a non-specific complication observed in 5% to 20% of cases.
Anastomotic stricture: the small gastric stump syndrome is due to a combination of gastric atony and acute reduction in gastric volume. It resolves spontaneously.
A bezoar requires endoscopy and re-exploration.
Ulcer-type pair or postprandial heartburn can be observed.
20. Conclusion
• Management
Postoperative management and follow-up are similar to the conventional approach. The use of a drain remains a topic for debate and is decided upon depending on the preference of the surgeon.
The nasogastric tube is placed under tactile control opposite the anastomosis. It is maintained for 2 to 5 days with a low aspiration (less than 30 mm Hg) before removal.
Food intake is usually resumed after testing the anastomosis with a gastrograffin swallow.
• Vagotomy
When the indication for the antrectomy is acid-dependant ulcer disease, a vagotomy can be added.• Advantage
The advantage of the laparoscopic approach to gastrectomies lies in the fact that it makes possible a complete abdominal exploration before a large laparotomy and, for well-trained surgical teams, a dissection comparable to that performed in open surgery. Early findings in the literature do not report complications specifically related to this approach. While the operative time may be considerably longer, the patient’s postoperative comfort is improved. Recovery of bowel function, the amount of food ingested, the performance index, and the patient’s satisfaction are better after a video-assisted procedure than after a conventional procedure.Performing anastomoses entirely via endoscopy does not seem to offer obvious advantages. The anastomosis can often be safely performed through the incision required to extract the specimen.
21. Reference
Abercrombie JF, McAnena OJ, Rogers J, Williams NS. Laparoscopic resection of a bleeding gastric tumour. Br J Surg 1993;80:373.Adachi Y, Suematsu T, Shiraishi N, Katsuta T, Morimoto A, Kitano S et al. Quality of life after laparoscopy-assisted Billroth I gastrectomy. Ann Surg 1999;229:49-54.
Azagra JS, Goergen M, De Simone P, Ibanez-Aguirre J. Minimally invasive surgery for gastric cancer. Surg Endosc 1999;13:351-7.
Buyske J, McDonald M, Fernandez C, Munson JL, Sanders LE, Tsao J et al. Minimally invasive management of low-grade and benign gastric tumors. Surg Endosc 1997;11:1084-7.
Fowler DL, White SA. Laparoscopic resection of a submucosal gastric lipoma: a case report. J Laparoendosc Surg 1991;1:303-6.
Goh P, Tekant Y, Kum CK, Isaac J, Shang NS. Totally intra-abdominal laparoscopic Billroth II gastrectomy. Surg Endosc 1992;6:160.
Goh PM, Alponat A, Mak K, Kum CK. Early international results of laparoscopic gastrectomies. Surg Endosc 1997;11:650-2.
Gurbuz AT, Peetz ME. Resection of a gastric leiomyoma using combined laparoscopic and gastroscopic approach. Surg Endosc 1997;11:285-6.
Ibrahim IM, Silvestri F, Zingler B. Laparoscopic resection of posterior gastric leiomyoma. Surg Endosc 1997;11:277-9.
Kitano S, Shimoda K, Miyahara M, Shiraishi N, Bandoh T, Yoshida T et al. Laparoscopic approaches in the management of patients with early gastric carcinomas. Surg Laparosc Endosc 1995;5:359-62.
Llorente J. Laparoscopic gastric resection for gastric leiomyoma. Surg Endosc 1994;8:887-9.
Martinez-Serna T, Filipi CJ. Endoluminal surgery. World J Surg 1999;23:368-77.
Mayers TM, Orebaugh MG. Totally laparoscopic Billroth I gastrectomy. J Am Coll Surg 1998;186:100-3.
Naitoh T, Gagner M. Laparoscopically assisted gastric surgery using Dexterity Pneumo Sleeve. Surg Endosc 1997;11:830-3.
Ohgami M, Otani Y, Kumai K, Kubota T, Kim YI, Kitajima M. Curative laparoscopic surgery for early gastric cancer: five years experience. World J Surg 1999;23:187-92; discussion 192-3.
Seelig MH, Hinder RA, Floch NR, Klingler PJ, Seelig SK, Branton SA et al. Endo-organ and laparoscopic management of gastric leiomyomas. Surg Laparosc Endosc 1999;9:78-81.
Seshadri PA, Mamazza J, Poulin EC, Schlachta CM. Technique for laparoscopic gastric surgery. Surg Laparosc Endosc Percutan Tech 1999;9:248-52.
Shiraishi N, Adachi Y, Kitano S, Bandoh T, Katsuta T, Morimoto A. Indication for and outcome of laparoscopy-assisted Billroth I gastrectomy. Br J Surg 1999;86:541-4.
Taniguchi E, Kamiike W, Yamanishi H, Ito T, Nezu R, Nishida T et al. Laparoscopic intragastric surgery for gastric leiomyoma. Surg Endosc 1997;11:287-9.
Taniguchi S, Koga K, Ibusuki K, Sugio K, Uchimura Y. Laparoscopic pylorus-preserving gastrectomy with intracorporeal hand- sewn anastomosis. Surg Laparosc Endosc 1997;7:354-6.
Trias M, Targarona EM, Balague C, Bordas JM, Cirera I. Endoscopically-assisted laparoscopic partial gastric resection for treatment of a large benign gastric adenoma. Surg Endosc 1996;10:344-6.
Yamashita Y, Maekawa T, Sakai T, Shirakusa T. Transgastrostomal endoscopic surgery for early gastric carcinoma and submucosal tumor. Surg Endosc 1999;13:361-4.
Yoshida M, Otani Y, Ohgami M, Kubota T, Kumai K, Mukai M et al. Surgical management of gastric leiomyosarcoma: evaluation of the propriety of laparoscopic wedge resection. World J Surg 1997;21:440-3.