One of the major complications following a gastrectomy is the duodenal stump leakage. This severe complication is hard to solve and can be life-threatening. It can occur in up to 5.7% of patients. Reinforcement of the stapled duodenal stump with an invaginating suture line is a good option to prevent leakage or avoid it from becoming clinically relevant. Some authors present a duodenal stump leakage rate of 0.7% versus 5.7% with and without reinforcement, respectively (p<0.001). I have always reinforced the duodenal stump using a continuous absorbable suture, invaginating and covering the entire staple line.
Laparoscopic gastrectomy is now accepted as one possible approach, but it is associated with an increased risk of duodenal stump leakage. According to Wenwu Liu from the Department of Gastric Surgery of the Sun Yat-sen University Cancer Center in China, this is due to an incorrect closure of the duodenal stump compared to the open approach. The reinforcement suture is harder to perform laparoscopically, good suture skills are needed, and eventually, many surgeons do not perform it because it is difficult.
Wenwu Liu et al present an original paper showing their reinforcement suture technique, a cabbage suture. I would like to highlight the video showing the perfect coordination between surgeon and assistant. It is impressive.
They place the patient in the French Position and use five ports for laparoscopic gastrectomy. The surgeon is on the left side of the patient, the assistant on the right side, and the camera assistant between the legs. A 60 mm linear stapler is used for dividing the duodenum 2.0 cm distal to the pylorus. The reinforcement is conducted with a 3/0 knotless continuous suture in a seromuscular fashion. They describe an invaginating suture starting at the upper corner (near hepatoduodenal ligament) of the duodenal stump. The first stitch is placed on the medial wall 0.5 cm away from the staple line and parallel to it. Then a stitch is placed on the lateral wall, 1.0 cm away from the staple line, and parallel to it. The following stitches are placed vertically. The inferior corner is covered with two stitches parallel to the staple line as in the upper corner.
According to Wenwu Liu et al, reinforcement of the duodenal stump in laparoscopic gastrectomy is as important as it is in open surgery. Several suturing techniques have been reported but require at least 1cm of duodenal stump which is sometimes unavailable. Lembert’s suture is also a possibility but requires many knots, making this suture more difficult and time-consuming. The authors state that the technique they present (cabbage suture) requires only 0,5 cm of a duodenal stump, the lateral wall is used to compensate for the lack of medial wall, and the knotless device is of good help.
I believe this is the common suture many surgeons usually perform for invaginating staple lines in digestive surgery. However, I advise watching the video to see it laparoscopically. The authors present a very good technique with fantastic coordination.
You must not change surgical technique rules to make it possible by laparoscopy. However, you can use surgical devices to ease the technique and make it possible by laparoscopy. Do it laparoscopically but do it correctly.
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Dr. Carlos Eduardo Costa Almeida
General Surgeon
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