A COMBINED LAPAROSCOPIC AND ENDOSCOPIC APPROACH TO ACUTE PRIMARY GASTRIC VOLVULUS

We describe the combined use of laparoscopic and endoscopic techniques in a case of acute primary gastric volvulus. Once the diagnosis is co nfirmed with a water-soluble upper gastrointestinal series, prompt int ervention is required. With an atraumatic bowel grasper the stomach is re-oriented with the greater curvature in its normal anatomic positio n. Two transabdominal wall sutures are placed along the greater curvat ure to fix it to anterior abdominal wall. Upper endoscopy is then perf ormed. Once confident that the gastric mucosa is viable, a 20F ''pull- type'' gastrostomy tube is placed endoscopically, guided by the extern al illumination and probing by the laparoscope. The gastrostomy tube n ow acts as an anterior anchor far the stomach allowing repositioning o f the gastropexy sutures if necessary. Endoscopy confirms the placemen t of a broad, properly aligned gastropexy. Classically, gastric volvul us has been treated by laparotomy. Both endoscopic and laparoscopic te chniques have been individually reported in the treatment of acute and chronic gastric volvulus, however, each has as its limitations. By co mbining the procedures we were able to better assess both the intra-ab dominal and the intraluminal status of the stomach and its position be fore, during, and after fixation to the anterior abdominal wall. The p ostoperative stay seen with the combined technique was less than has b een reported in patients treated by open surgery or by either the endo scopic or laparoscopic methods alone. The combined laparoscopic and en doscopic approach to acute gastric volvulus provides the benefit of a minimally invasive approach, to a better anterior gastropexy. This pro cedure should be considered when confronted with patients with acute p rimary, gastric volvulus.