Step 2: Preoperative Considerations
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The procedure may be performed under local infiltration or block in patients that will not tolerate general anesthesia, if exploration of the abdomen is not required. If the patient’s medical condition allows general anesthesia or the abdomen needs to be explored these approaches are suitable.
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Jejunostomy tubes should typically be reserved for patients with contraindications to a gastrostomy tube, as jejunostomy tubes are associated with a higher morbidity rate.
Step 3: Operative Steps
1.
Witzel Technique
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A vertical left paramedian or rectus incision is made. The incision is typically 5 to 6 cm long and begins immediately below the costal margin and one half centimeter posterior to the anterior axillary line. ( Figure 24-1A ) The incision is carried to the peritoneum through the external oblique, internal oblique, and transversalis muscles. The peritoneum is opened for 3 cm. A high loop of jejunum typically presents itself 20 to 25 cm distal from the duodenojejunal flexure. If this loop is not apparent, the initial part of the jejunum at the duodenojejunal angle is palpated under the transverse colon and mesocolon at the left of the spine. The first bowel loop is gently grasped with a Babcock forcep or finger and withdrawn through the abdominal wound. Ideally, the site selected should be 20 to 40 cm from the duodenojejunal angle.
Figure 24-1
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An enterotomy is then made in the antimesenteric aspect of the bowel, and the catheter is passed distally at least 7.5 cm into the distal lumen.
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The tube is anchored to the lumen by a single absorbable stitch, which passes through the walls of the intestinal incision and into, not through, the wall of the tube.
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The catheter is then bent back over the bowel and is made to depress the bowel wall slightly, while the outer coats of the intestine are suture-folded over the rubber tube by interrupted seromuscular stitches. This is performed until the tube is completely buried in the jejunal wall. ( Figure 24-1BCD, parts 1 and 2 ) Just enough intestinal wall is used to fit snugly around the tube to prevent significant narrowing of the lumen of the bowel. ( Figure 24-1E, parts 1, 2, and 3 )
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If there is omentum available, the free end of the tube is passed through the omentum. The omentum is fixed over the suture line with 2 to 3 absorbable sutures. The free end of the catheter is then brought out a separate small stab wound in the abdominal wall. The bowel is then sutured to the abdominal wall over a broad area. ( Figure 24-1F, parts 1 and 2 )
2.
Stamm-Kader Technique
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This procedure is generally reserved for patients who have a distended jejunum or insufficient length for a Witzel.
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An enterotomy is made in exposed jejunum on the antimesenteric side between two concentric purse-string sutures. The first bite of the purse-string should be backhand and the remainder forehand. The first purse-string should be of catgut and should include a bite made tangentially in the wall of the rubber tube. The subsequent purse-string sutures may be of absorbable or nonabsorbable suture, and all should be seromuscular only, not penetrating the lumen.
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The catheter is inserted through the two purse-string sutures.
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The catheter is fixed to the abdominal wall. ( Figure 24-2ABCD )
