Surgical Highlights

A two-team approach is possible, significantly shortening the operative time. Harvest of the jejunal segment may be done via an open abdominal procedure or lapar-oscopically (81). The jejunal segment is taken 3 feet distal to the ligament of Treitz to facilitate the subsequent enteric anastomosis. The length of the segment should equal the length of the defect plus 3 cm to accommodate the exteriorized monitoring segment (82). The exteriorized monitoring segment is a portion of the flap separated from the main flap along the radiating mesenteric vessels and draped onto the skin through the neck incision. This segment of bowel reflects the health of the main flap and is inspected for mucus production, peristalsis, and color. After approximately 3 days, the base of the monitoring segment is cauterized or suture ligated and removed.

Prior to harvest, the jejunal segment should be marked as to the direction of peristalsis. It should be placed in the neck so that peristalsis is from proximal to distal (antiperistaltic positioning results in dysphagia); it should also be placed on some stretch to eliminate redundancy.

Figure 69 Transilluminated jejunal flap in situ. The vascular supply to the flap is from the jejunal arteries (branches of the superior mesenteric artery). Note the arcades within the mesentery that encompass the jejunal segment.

Postoperative care consists of placement of a nasogastric tube for stomach decompression until bowel sounds resume, at which time feeding through the tube may be slowly advanced. As an alternative, a feeding gastrostomy or jejunostomy tube may be placed during the original harvesting procedure. A jejunostomy tube allows immediate feeding prior to the return of bowel sounds. Oral feeding may commence on day 7-10 after surgery.

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