Background: Laparoscopic gastrojejunostomy allows effective palliation and rapid recovery for the patient with limited survival due to advanced pancreatic cancer presenting with gastric outlet obstruction. Transumbilical single-incision laparoscopic surgery (SILS) offers excellent cosmetic results and may be associated with decreased postoperative pain, reduced need for analgesia, and thus accelerated recovery. The authors report the first transumbilical single-incision laparoscopic intracorporeal anastomosis for gastrojejunostomy. Methods: Preliminary experience with transumbilical single-incision, intracorporeal anastomosis for gastrojejunostomy for a patient with gastric outlet obstruction caused by advanced pancreatic cancer is reported. Results: Transumbilical single-incision laparoscopic intracorporeal anastomosis for gastrojejunostomy was performed with a linear endoscopic stapler using an omega loop. The operative time was 117min. No intra- or postoperative complications were recorded. Conclusion: Transumbilical single-incision laparoscopic intracorporeal anastomoses are feasible using the endoscopic linear stapler. Transumbilical single-incision gastrojejunostomy for gastric outlet obstruction may improve cosmetic results and allow accelerated recovery for patients with limited survival. This anastomosis technique of single-incision laparoscopic surgery for other digestive tract procedures needs further evaluatio

Bucher, Pascal

Morel, Philippe

Pugin, François

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TECHNIQUESTransumbilical single-incision laparoscopic intracorporealanastomosis for gastrojejunostomy: case reportPascal Bucher Æ Franc¸ois Pugin Æ Philippe MorelReceived: 14 October 2008 / Accepted: 19 April 2009 / Published online: 23 May 2009 Springer Science+Business Media, LLC 2009AbstractBackground Laparoscopic gastrojejunostomy allowseffective palliation and rapid recovery for the patient withlimited survival due to advanced pancreatic cancer pre-senting with gastric outlet obstruction. Transumbilicalsingle-incision laparoscopic surgery (SILS) offers excellentcosmetic results and may be associated with decreasedpostoperative pain, reduced need for analgesia, and thusaccelerated recovery. The authors report the first tran-sumbilical single-incision laparoscopic intracorporealanastomosis for gastrojejunostomy.Methods Preliminary experience with transumbilicalsingle-incision, intracorporeal anastomosis for gastrojeju-nostomy for a patient with gastric outlet obstruction causedby advanced pancreatic cancer is reported.Results Transumbilical single-incision laparoscopicintracorporeal anastomosis for gastrojejunostomy wasperformed with a linear endoscopic stapler using an omegaloop. The operative time was 117 min. No intra- or post-operative complications were recorded.Conclusion Transumbilical single-incision laparoscopicintracorporeal anastomoses are feasible using the endo-scopic linear stapler. Transumbilical single-incision gas-trojejunostomy for gastric outlet obstruction may improvecosmetic results and allow accelerated recovery for patientswith limited survival. This anastomosis technique of sin-gle-incision laparoscopic surgery for other digestive tractprocedures needs further evaluation.Keywords E-NOTES  Gastric  Gastrojejunal Intracorporeal anastomosis  Laparoscopy  NOTES Scarless surgery  Single-incision laparoscopic surgery Single port  Single-port access  TransumbilicalLaparoscopic gastrojejunostomy for palliation of gastricoutlet obstruction caused by advanced cancer is shown tobe safe and effective [1–3]. This approach allows rapidrecovery for patients with very limited survival [1, 3, 4].Single-incision laparoscopic surgery (SILS) is a rapidlyevolving field [5, 6]. The SILS procedure offers excellentcosmetic results compared with standard multiport lapa-roscopy and may improve patients recovery because ofpossible decreased parietal trauma [7, 8].Recently, digestive tract (i.e., colorectal and gastric)procedures using this approach with success have beendescribed [9–15]. However, intracorporeal anastomosesthrough SILS have never been described because of diffi-culties with tissue exposition in complex maneuvers evenfor advanced laparoscopic surgeons [8, 11, 16–18]. How-ever, mechanical laparoscopic anastomosis using theendoscopic stapler has been widely reported and shown tobe safe [3]. We report the first intracorporeal anastomosisthrough transumbilical SILS for gastrojejunostomy.Patient and methodsCase reportA 64-year-old man presented with gastric outlet obstruc-tion caused by advanced pancreatic cancer. The patient wasP. Bucher (&)  F. Pugin  P. MorelDepartment of Surgery, University Hospital Geneva,Switzerland, 24 rue Micheli-du-Crest, 1211 Geneva, Switzerlande-mail: pascal.bucher@hcuge.ch123Surg Endosc (2009) 23:1667–1670DOI 10.1007/s00464-009-0510-7offered intracorporeal anastomosis through transumbilicalsingle-incision laparoscopic gastrojejunostomy and gavehis informed consent for this approach. The procedure wasperformed successfully using a side-to-side anastomosiswith a jejunal omega loop. The total operative time was117 min. No intra- or postoperative complications wererecorded.A normal low-residue diet was started on day 4. At thiswriting, the patient is doing well 6 months after surgerywithout umbilical incisional hernia and receiving a normaldiet.Surgical techniqueThe reported transumbilical single-incision laparoscopicgastrojejunostomy was performed using a surgical tech-nique similar to the standard multiport laparoscopicapproach except that it was conducted through a singleumbilical incision (Fig. 1). A 12-mm umbilical port (En-dopath Xcel Trocar; Ethicon Endo-surgery, Spreitenbach,Switzerland) was placed using an open approach, and aparallel 5-mm port was placed in the same 2-cm circularumbilical incision (Fig. 2). A 10-mm laparoscope with a 6-mm working channel and a 5-mm 308 laparoscope wereused alternatively (Richard Wolf GmbH, Knittlingen,Germany).Under laparoscopic vision, an adequate position wasobtained by tilting the operation table to achieve correctexposition for the procedure. Gastric and then jejunal loopsuspension and exposition were achieved by placing atransparietal sling suture in the left hypochondrium. Theywere passed in the gastric or small bowel wall, with greatcare taken not to be intralumenal, using a modified skineedle as described earlier [10, 11].After the mobility of the jejunal loop had been chosenand controlled, a side-to-side gastrojejunal anastomosiswas performed using a linear endoscopic stapler (Endo-path endoscopic linear stapler; Ethicon Endo-surgery,Spreitenbach, Switzerland). A large gastrojejunal anasto-mosis was created using two 45-mm stapler cartridges.The gastrotomy and jejunotomy used for stapler insertionwere closed with the linear endoscopic stapler. The gas-trostomy and jejunostomy border were resected duringtheir closure.For completion of the anastomosis, the 5-mm lapa-roscope was placed in a 5-mm trocar positioned in theumbilical incision parallel to the 12-mm trocar. Thisallowed use of the 12-mm trocar for the stapler. Expo-sition and mobilization were achieved during anastomo-sis completion by transparietal sling suture placed beforestapler insertion. The anastomosis was tested intraoper-atively for leak using an air test through a nasogastrictube.DiscussionWe describe the first intracorporeal digestive anastomosisthrough transumbilical SILS. The SILS intracorporealgastrojejunostomy was feasible using an endoscopic linearFig. 1 Intraoperative view of single-incision laparoscopic gastroje-junostomy. A Gastric exposition with transparietal sling suture. BJejunal loop mobilized and exposed with transparietal sling suturepassed in the subserosal space of the jejunal wall. C Gastrotomyperformed with laparoscopic scissors to allow endoscopic linearplacement in the stomach for side-to-side gastrojejunostomy (anenterotomy is performed on the jejunum with the same technique). DSide-to-side endoscopic linear stapler gastrojejunostomy viewedthrough the gastrotomy and jejunotomy. E Suspension of thegastrotomy and jejunotomy border after completion of gastrojejunos-tomy, with transparietal suture to facilitate their closure with theendoscopic linear stapler. F Closure of gastrotomy and jejunotomywith the endoscopic linear stapler. G Gastrotomy and jejunotomyresected during closure with the endoscopic linear stapler. H Finalview of the side-to-side gastrojejunostomy (posterior view)1668 Surg Endosc (2009) 23:1667–1670123stapler. This surgical procedure reproduced standard mul-tiport laparoscopic gastrojejunostomy, with the adjunctionof some artifacts, and seems safe. In addition to possiblydecreasing parietal trauma, SILS gastrojejunostomy offersa cosmetic advantage over the standard laparoscopicapproach.Laparoscopic gastrojejunostomy for palliation of gastricoutlet obstruction caused by advanced cancer is shown tobe safe and effective [1–3, 19]. Laparoscopic gastrojejunalderivation may ameliorate patient recovery by decreasingpostoperative pain and thus the analgesia requirementcompared with the open approach [1, 3, 19]. Moreover, thelaparoscopic approach is shown to be associated with alower inflammatory response than laparotomy for patientswith gastric outlet obstruction [3].The laparoscopic approach allows rapid recovery forpatients with very limited survival [1, 3, 4]. Transumbilicalsingle-incision laparoscopic gastrojejunostomy may beadvantageous in this regard because it decreases parietaltrauma and the risk of morbidity associated specificallywith multiport laparoscopy (i.e., port-orifice infections,hemorrhage, incisional hernia) [7].Recently, SILS has been described for gastric procedureincluding gastrostomy placement, gastric banding, andsleeve gastrectomy [13, 14, 20, 21]. However, none of theseincluded gastric anastomosis, and digestive intracorporealanastomoses through SILS have never been reported.The current technique of transumbilical SILS gastroje-junostomy for gastric outlet obstruction is shown to beefficient and associated with rapid recovery. This techniquereproduces the laparoscopic technique for side-to-sideanastomosis using the endoscopic linear stapler [3, 22].The difficulty with the SILS gastrojejunostomy is rep-resented by the need for satisfying exposition of thestomach and jejunal loop during anastomosis completion.This may be achieved using transparietal sling suture, asdescribed earlier for various SILS procedures [10, 11, 23–25]. These sutures should be placed on the mesentery, theomentum, or only the subserosa on the digestive tract,avoiding intralumenal passage to decrease the risk ofcontamination. However, great care should be taken withplacement and manipulation of the transparietal slingsuture to avoid digestive tract wall tears [11]. Futuredevelopment of multiport single-access trocar and angu-lated laparoscopic instruments will facilitate complex SILSin the same manner as the current gastrojejunostomytechnique [7, 8, 10–12, 26].ConclusionTransumbilical single-incision laparoscopic gastrojeju-nostomy is feasible using conventional and clinicallyavailable instrumentation by advanced laparoscopic sur-geons. The current technique seems safe and efficientbecause it merely reproduces the standard technique ofthe multiport laparoscopic approach. Future materialdevelopment, especially multichannel port and bendedinstrumentation, will improve the feasibility of this tech-nique. However, it has to be determined whether thisapproach offers any benefit except for cosmesis comparedwith the standard laparoscopic surgical technique ofgastrojejunostomy for these patients who benefit highlyfrom rapid recovery.Fig. 2 Single-incision laparoscopic gastrojejunostomy. A Generalinstallation with transumbilical access and transparietal sling suture inthe left hypochondrium (surgeon is on the right and assistant on theleft). B Anastomosis performance with the endoscopic linear stapler.Note the use of a 5-mm laparoscope to allow passage of the linearstapler in the larger trocar during this maneuver. C Abdominal viewafter completion of transumbilical single-incision laparoscopic gas-trojejunostomy (note the invisible umbilical scar)Surg Endosc (2009) 23:1667–1670 1669123References1. Bergamaschi R, Marvik R, Thoresen J, Ystgaard B, Johnsen G,Myrvold H (1998) Open versus laparoscopic gastrojejunostomyfor palliation in advanced pancreatic cancer. Surg Laparosc En-dosc Perctan Tech 8:92–962. Denley S, Moug S, Carter C, McKay C (2005) The outcome oflaparoscopic gastrojejunostomy in malignant gastric outletobstruction. Int J Gastrointest Cancer 35:165–1693. 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Transumbilical single-incision laparoscopic intracorporeal anastomosis for gastrojejunostomy: case report

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Transumbilical single-incision laparoscopic intracorporeal anastomosis for gastrojejunostomy: case report

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