Laparoscopically assisted transgastric endoscopy is a well-accepted
strategy to access the papilla of Vater in patients with a bypassed duodenum,
as after Roux-en-Y gastric bypass [1]
[2]
[3]. In this technique the endoscope
is introduced into the abdomen through a trocar and is advanced to the duodenum
via a gastrotomy. Using this technique however, gastric fluid and endoscopic
insufflated air might escape from the gastrotomy during manipulation of the
endoscope. The presence of gastric contents inside the peritoneal cavity might
cause peritonitis or abscess formation. The presence of insufflated room air in
the peritoneal cavity could cause dangerous gas embolisms [4]
[5].
We present a modification of laparoscopically assisted transgastric
endoscopy that reduces the risk of these complications. The patient is placed
in supine position. Four trocars are introduced as in routine foregut surgery.
An additional 15 mm trocar is placed at the left upper quadrant. The
first modification is to achieve mobilization of the greater curve of the
antrum ([Fig. 1 a]) until it can reach the
anterior abdominal wall during pneumoperitoneum ([Fig. 1 c]).
Fig. 1 a Mobilization of the
antral remnant. b Trocar (arrow in the middle) is guided
through the gastrotomy into the mobilized antrum (arrow on the left).
Purse-string with needle (arrow on the right). c Antral
pouch lifted up to the anterior abdominal wall.
Next, as in the original technique, a purse-string is fashioned
about 5 cm proximal to the pylorus and a gastrotomy is performed. In
second modification, the 15 mm trocar itself is guided into the gastric
remnant instead of introducing the naked scope into the remnant. This can only
be achieved if the remnant has been sufficiently mobilized ([Fig. 1 b]). Afterwards the purse-string is
tightened. Next, an endoscope, covered in a sterile camera bag, is inserted
through the 15 mm trocar. At the end of the procedure the gastrostomy is
closed using a stapling device. These two alterations of the original technique
allow proper control of the site of insertion, which is important to prevent
soiling by gastric contents and to reduce insufflated gas leakage.
Endoscopy_UCTN_Code_TTT_1AT_2AF
