I IO

Surgicol Procedures lncluding Minimol Access Procedures

Goslrointestinol Surgery

oIII

sulure. Methylene blue dye may be instilled into the stomach via nasogastric tube to verify integrity of the gastric repair. A fibrin sealant (e.g., Tisucol) may be applied to the tissue line. A variant of the procedure is to distract a seromuscular strip (in lieu of seromyotomy), excising it using a multifire linear stapler, thus interrupting the intramural vagal branches. After the vagotomy is complete, a congo red test may be performed. In addition to histologic confirmation
that the nervous tissue was removed, testing for gastric acidity may be done intraoperatively. Pentagastrin (to stimulate gastric acid production) 6 pg/kg is given subcutaneously. Twenty minutes prior to the testing, the stomach is lavaged through the laparascope with sodium bicarbonate solution to remove residual acid. Congo red dye is instilled into the stomach to coat the
gastric mucosa. If vagotomy is complete, the red dye remains unchanged.' If even partial innervation remains, the affected area will turn black as seen via the scope and additional nerve transection may be done. Hemostasis is assured. The pneumoperitoneum is released. Ports are closed in the usual manner.

)roping
Folded towels and a laparoscopy sheet [amera cab]e cover (with ties, plastic)

lquipment
Sriction
ElLectrosurgical unit Light source (e.g., Xenon 300 W)
(2)
.

lideo monitors
CR (optional)
rl0.-,

Mavigraph (optional)

insufflator

Prelsure bag to facilitate irigation S-lastic and suction tubing

Sequential compression device

-n':rres

rsrumentotion lhjor tray (open)

needle i-n-.son trocar

Preporotion of the Potient

The patient is supine; arms may be padded and tucked in at the patient's sides unless the patient is obese, and then the right arm may be placed on an armboard. Sequential compression stockings may be put on both legs to avoid pooling of blood in the lower extremeties. A nasogastric tube is placed by the anesthetist. A Foley catheter may be inserted. Apply electrosurgical dispersive pad. The table is placed in a Trendelenburg 5 to 10" to establish pneumoperitoneum and then in reverse Trendelenburg 10 to 20" to allow the abdominal viScera

Tlrrars 10 to 11 mm (2) Tscars 5 mm (2 or 3) !;ducer caps ]r.sector clamps, endoscopic ]'.sector hook, endo scopic
,-4":aspirrg

(2)

lrrock clamp 5 mm (atraumatic), endoscopic -4--- clamp, endoscopic

S:-:sors (3) (hook, straight, micro), endoscopic

"*1mk tip, endoscopic farcock clamp 10 mm (atraumatic), endoscopic

clamps (4) (2 trar.rmatic, locking; atraumatic), ;ndoscopic -:rgation, suction, electrosurgical device, endoscopic

to gravitate inferiorly. The table may be

ach. Skin Preporotion

rotated

slightly to the right to increase exposure of the stom-

il:r applier, endoscopic --,ereroscope(s) and camera(s) *.pling device (e.g., endo GIA) endoscopic, available Trraudable fan retractor, endoscopic

i
Begin at the midline extending from axilla to the pubic symphysis and down to the table at the sides.

rclies

I,u reduction agent

:*,ra.v stopcock)

*-.=.ric tubing (straight. 1000-mL bag normal saline,