Step

Alternatives to open cystogastrostomy include either a totally endoscopic approach to cystogastrostomy or a less-well standardized, percutaneous, radiologic, transgastric cystogastric tube placement attempting to accomplish the same overall goals. The laparoscopic approach provides another "access route" that allows a better visualization as well as the ability to use laparoscopic surgical techniques not limited to the narrow access port of the gastroscope. Two trocars are placed into the lumen of the gas-distended stomach to provide the access for the cystogastrostomy. The gastric lumen becomes the counterpart of the gas-filled peritoneal cavity used for conventional laparoscopic operations (A-1).

The operation begins by placing a periumbilical trocar for introduction of a laparoscope (5mm or 10mm). Two additional trocars are inserted in the mid clavicular line several centimeters rostrally on either side of the camera trocar.

A nasogastric tube is passed into the stomach and attached to a laparoscopic insufflator. CO2 gas is instilled to inflate the gastric lumen until the anterior gastric wall comes within a few millimeters of the anterior abdominal wall as visualized via the laparoscope. A radially expanding 10-mm trocar is inserted into the stomach as follows. First, pass the trocar through the abdominal wall where the anterior surface of the stomach abuts the abdominal wall, usually in the left epigastrium. Then poise it at the desired entry site on the anterior gastric wall and pop it into the stomach using a quick snap of the wrist. Pass a 5-mm, 30 degree laparoscope down the trocar and look into the gastric lumen; because the gastric walls reflect light so well, the view is bright and full of detail. Insert a second trocar into the stomach 6-10 cm from the first one. Check that positioning is satisfactory for intragastric surgery by passing the 5-mm scope down each of the trocars. The radially expanding trocars create snug, gas-tight puncture wounds in the stomach; conventional cutting trocars make wounds that leak (A-2).

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