Segmental resection of duodenojejunal junction

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Segmental resection of duodenojejunal junction

Authors

J Leroy, J Marescaux

Keywords

operation,segmental resection,duodenojejunal junction

Media type

Surgical video

Duration

09'00''

Publication

2002-11

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E-publication

WeBSurg.com, Nov 2002;2(11).
URL: http://www.websurg.com/doi-vd01en1371e.htm

Segmental resection of duodenojejunal junction

1. Case presentation 00'14''

This patient is a 70-year-old male who recently had cardiac bypass surgery and he was anticoagulated postoperatively. He presented with bleeding from the gastrointestinal tract and on further investigation with radiology and endoscopy, no cause was seen in the stomach or duodenum but this submucosal tumor with ulceration was seen in the first part of the small bowel just after the duodenum.

2. Trocar placement and exposure 00'54''

In this case, the port position is very different as the operating team is on the left and the right of the patient and the table will be tilted to both sides to position the small bowel for better exposure of the area that we are interested in. The duodenojejunal flexure is found by following the small bowel proximally after full exposure with the retractors and here just after the DJ flexure, a subserosal mass is found. Of note is that a pacemaker was fitted to this patient 3 weeks ago and we will therefore use the ultrasonic dissector and not bipolar diathermy.

3. Dissection of duodenojejunal junction 01'42''

And eventually our aim will be to free the duodenojejunal angle. A window is opened posterior to the bowel through the mesentery. And one can see the posterior view here through the mesentery. For this purpose, the ultrasonic scissors is used. Tissues are inflamed and easily damaged and good hemostasis is imperative also because of the cardia condition and the anticoagulation. Here one can see the color difference in the devascularized bowel.

4. Proximal and distal division 03'24''

The division will be on the duodenum quite close here. Again the ultrasonic scissors are used and there is no bleeding. Here’s the duodenum then and it appears to be well below the tumor. And now for the final posterior dissection of the duodenum. And there we go: it is finished. Shortly the other end will be divided. Mechanical anastomosis is also possible. The anvil of a circular stapler can be placed in the duodenum and the stapler itself in the distal small bowel to perform an end-to-side anastomosis. The open end of the small bowel can then be closed with a linear stapler. The segment of small bowel is pushed into this plastic bag. Another 12mm trocar is now introduced to the left of the midline allowing a closer view of the operating field. Mobilization of the proximal small bowel is now completed.

5. Anastomosis 06'10''

I can now take the circular stapler. We have prepared the proximal bowel. It is well mobilized for the anastomosis and we can introduce the anvil of the circular stapler. It is introduced here laterally. Now it may be a problem as it can be difficult to introduce the circular anvil into the duodenum. But no, it fits easily without difficulty. Now an assistant pulls upwards on the anvil and this makes sure that the anvil is closed. I shall finish securing the anvil with a loop. The stapler is now introduced into the abdominal cavity. It goes through the same site and this can be difficult. The difficulty is finding the lumen. There we go. The protective plastic sheath is held tight against the stapler on the outside to prevent loss of the pneumoperitoneum. It looks like a 25mm circular stapler. It’s a good choice as it can be introduced with no difficulty. The anastomosis should be performed about 2cm or more from the end of the bowel to prevent ischemia. Now we have to lock the anvil onto the stapler. There is a lot of tissue around the duodenal side but this will be pushed out by the stapler. There we go. It should always be done under vision to make sure that no tissue is trapped in the jaws of the stapler. Now we must verify the donuts. Here’s the distal one and here the somewhat thicker proximal. Next resection of the mesentery using a linear stapler like this and it might need 1, 2 or 3 applications. Now the bowel is also transected using the blue cartridge. The tumor may be a bit too big for this orifice. No there it goes. We will inspect it now and it is clear that the tumor has been removed in total. This is a contrast study done 3 days after surgery illustrating a good result with no leak.