Laparoscopy.com

Surgeon: Mark Pleatman, MD

The patient is a 75 year-old man with a one year history of early satiety and epigastric discomfort. He was treated initially with antacids. He lost 16 pounds and was referred for further evaluation. Endoscopy demonstrated a malignant ulcerated tumor along the greater curvature of the body of the stomach. CT scan was negative except for thickening of the stomach and a small amount of free fluid in the pelvis. He was taken to surgery for possible resection, but laparoscopy was done first to rule out metastatic disease that would make resection unwise.

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Laparoscopy demonstrated obvious diffuse carcinomatosis, with implants on all peritoneal surfaces. Here are some on the abdominal wall.

Gastric Bypass enterotomy

This image shows implants on the surface of the liver.

gastric bypass division of the mesentery

Close-up view showing peritoneal implants, as well as abnormal feeding blood vessels.

gastric bypass entero enterostomy closure

A punch biopsy is taken to confirm the diagnosis.

gastric bypass entero enterostomy closure

At this point a decision was made to abandon plans for resection. We decided to place a feeding jejunostomy to facilitate nutritional support. The proximal jejunum is being located.

gastric bypass entero enterostomy closure

The proximal jejunum has been located and grasped with an instrument. An examining finger is palpating the abdominal wall in preparation for making a small incision to deliver the jejunum.

gastric bypass entero enterostomy closure

The jejunum is exteriorized. A jejunostomy tube is placed, and the bowel is then returned to the abdomen and sutured to the abdominal wall at the site of the incision. The feeding tube is tunnelled to another site and brought out, completing the procedure.