Task Analysis of Laparoscopic Procedures

Task Analysis of Laparoscopic Jejunostomy
General Surgery / Apr 3rd, 2018 12:29 pm     A+ | a-
Task Analysis of Laparoscopic Jejunostomy

Dr Ismail Alnjadat
Feeding jejunostomy is done when nutritional support is needed in cases such as gastric outlet obstruction and gastric trauma.
 
Procedural steps:
1. Patient preparation
2. Abdominal access and port placement
3. Identifying the proper jejunostomy site
4. Transabdominal sutures insertion
5. Jejunostomy tube insertion
6. Jejunum and jejunostomy tube fixation
7. Ending the procedure
 
 
Patient preparation:
1. Patient is put on supine position
2. Prophylactic antibiotics are given 
3. Antithrombotic measures are provided according to the protocol
4. scrubbing with antiseptic solution and toweling
 
 
Abdominal access and port placement:
1. Veress needle is inserted in Palmer's point
2. Checking the position of Veress needle with suction, irrigation and drop test
3. Insufflation of the abdomen at rate 1L/minute to a pressure of 14mmHg
4. A 10 mm trocar is inserted at a point of crossing between the level of umbilicus and right anterior clavicular line
5. A 5 mm trocar is inserted 7 cm above the 10 mm trocar at same vertical line
6. A 5 mm trocar is inserted 7 cm below the 10 mm trocar at same vertical line
 
 
Identifying the proper jejunostomy site:
1. Identify Treitz ligament
2. Follow the jejunum distally for 30 cm
3. Mark the antimesentric border at this site(30 cm) with small stitch or methylene blue
 
 Transabdominal sutures insertion:
1. Mark a point at abdominal wall that located at left midclavicular line
at level of umbilicus. This point will be the exit of jejunostomy Tube.
2. Using No. 11 blade put 4 small skin stab incisions at 3, 6, 9 and 12 o’clock positions in relation to the proposed jejunostomy tube exit site.
3. PDS 2.0 on a straight needle is passed from the stab wound to the abdominal cavity the take a seromuscular bite from jejuna wall at the corresponding site around the mark on jejunal wall.
4. The suture then exit the abdomen from the stab wound and both ends held in hemostat (but not tied).
5. This step is repeated for all the 4 sutures at 3, 6, 9 and 12 positions.
 
 
Jejunostomy tube insertion:
1. A small stab incision is made on the skin at the mark in the middle of sutures
2. NO. 15 Cystocath with its introducer is inserted through this stab incision into abdominal cavity
3. The introducer pierces the jejunal wall at the marked area on the antimesenteric side
4. The Cystocth is advanced for 30 cm in jejunal lumen distally with the help of atraumatic grasper and pushing of the tube
5. The introducer is withdrawn from abdominal cavity 
 
 
Jejunum and jejunostomy tube fixation:
1. The previously untied 4 sutures are now tied in a way that the knots will be buried in the subcutaneous tissue
2. Two additional PDS 2.0 sutures are used to fix the jejunal wall to the surface of peritoneum 4 and 8 cm distal to jejunostomy opening
3. One stitch of PDS 2.0 is used to fix Cystocath at its exit on the surface of the abdomen 
 
 
Ending the procedure:
1. 20 cc of normal saline or diluted methylene blue is irrigated in the cystocath to check patency of the tube
2. 5 mm telescope is inserted in one of 5mm trocars and the 10mm camera port is closed under vision using suture passer
3. Ports are checked for bleeding
4. Abdomen desufflated
5. Stab incisions are closed with suture, skin stapler or glue
6. Small pieces of Airstrip are used for dressing
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