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INDICATIONS

Whenever possible, nutrition should be delivered through enteral routes. The past two decades have seen a shift in treatment approaches from open techniques to a predominance of laparoscopically and endoscopically placed feeding tubes. Beginning in the early 1990s, the technique for laparoscopic feeding jejunostomy tube (J-tube) placement has undergone numerous revisions and refinements, providing a safe and expedient form of enteral access.

Patients with complex surgical and medical problems benefit greatly from adequate nutritional support. Enteral feeding is often required for patients with significant recurrent aspiration, intraabdominal trauma, long-term ventilatory support, esophageal or gastric dysmotility, and complications following abdominal operations that render the upper GI tract undesirable or inaccessible for enteral access. In addition to patients with long-term enteral feeding requirements, the surgeon anticipating a delay in oral intake after complex abdominal procedures may elect to place a jejunostomy tube for early postoperative feeding.

PATIENT POSITIONING

The patient should be placed in the supine position. General anesthesia with a naso- or orogastric tube for stomach decompression is required. All pressure points are carefully protected. The operating surgeon stands on the patient’s right with the assistant on the patient’s left. The primary monitor should be over the patient’s left shoulder, with an additional monitor for the assistant at the right shoulder (Figure 1).

DETAILS OF PROCEDURE

The future tube position is chosen and marked in the left midabdomen, near the lateral edge of the rectus muscle. The site should be at least 4 cm from the costal margin and well above the patient’s usual belt line. A pneumoperitoneum to 15 mm Hg pressure with CO2 is obtained through the umbilicus with a Veress needle. If the jejunostomy is to be performed as a stand-alone procedure, the first port is a 5-mm camera port placed to the right of the umbilicus, approximately 15 cm from the jejunostomy tube entrance site. Two other ports are placed in the right abdomen above and below the primary port (Figure 2). Both secondary ports should be 5-mm. Care is exhibited to place all trocars lateral to the right epigastric artery. If the J-tube is performed as a complementary procedure to a more involved laparoscopic procedure, the port positions chosen for that procedure may be used for the jejunostomy tube placement. However, if visualization of the ligament of Treitz or bowel manipulation is difficult, additional trocars should be placed to improve the safety and ease of the operation.

Several techniques have been used successfully to allow laparoscopic J-tube placement. The T-fastener method to attach the jejunum to the abdominal wall is essentially a combination percutaneous Seldinger technique with laparoscopic guidance.

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