Hand-sewn laparoscopic Roux-en-Y gastric bypass

Authors

Abstract

Over the last 20 years, the Roux-en-Y gastric bypass has been successfully used as one of many surgical treatments to achieve significant long-term weight loss. This video demonstrates a hand-sewn laparoscopic Roux-en-Y gastric bypass.

Keywords

Hand-sewn, laparoscopic Roux-en-Y gastric bypass

Media type

Duration

28'52''

Publication

2011-04

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E-publication

WeBSurg.com, Apr 2011;11(04).
URL: http://www.websurg.com/doi-vd01en3094.htm

Hand-sewn laparoscopic Roux-en-Y gastric bypass

1. Trocar placement 00'20''

This is the head of the patient up here and this is the umbilical port. I will put in my left upper quadrant port first. It is about the mid-clavicular line, subcostal. It is a 12mm port. Once we get this port in, we will look in and we put in the optical port depending on how big the liver is. If the liver is very large, we are going to put in the optical port down lower. If it is not so big, then we will put it in higher. And then we have the left upper quadrant port here, the right upper quadrant. This port is subxiphoid for the liver retractor, which is totally useless right now.

2. Hiatal region inspection 01'01''

The first thing we do within the operation, especially when you get to heavier patients, we have to see the hiatus. If we cannot see the hiatus, we cannot do a sleeve, we cannot do a bypass, we cannot do a band. It looks this patient is going to have a hiatal hernia so we have to put that on our mind. But I can see the hiatus so I can do virtually any operation I want to. I want to get into the retrogastric space. My Roux limb is going to come in retrocolic and antegastric. To make the operation safe, we really have to take down the adhesions behind the stomach and the pancreas. I will take the Ligasure®. If you are really good, you can use hook cautery, but only few people in the world can do that. I am staying outside the epiplon, just in case later on we have to come back and do something else to this patient, such an esophagectomy. If I pick up on the posterior stomach. Let us take all the orogastric tubes. I lift up the stomach and get back here, so we can see back here very well. Now we can get an idea. This is the arteries here. This was stuck up there, and we just ran the stapler across there. It is nice to get all the adhesions down so you can see that sort of anatomy. We got that placed down. As you see, here is the pancreas. I am going to look for the retrocolic window. Going retrocolic will make a big difference. We will then discuss whether we go retrocolic or antecolic. Everybody has to learn all these ways. We look for where the vessels are. The vessels are going to be coming in vertically to the colon. When you get closer to the root of the mesentery, and that is why it was important to see where the pancreas was, it is always thinner, so the mesentery is a lot thinner. If it is floppy, there is probably not a vessel tying it down. When you look down, you can just pick up the bowel and follow back one way or the other to get the ligament of Treitz.

3. Omentum and mesocolon exposure 04'21''

The patient is still in reverse Trendelenburg. The omentum is not that big, so we can flop it over and push it up. You can see the hole we made from before. I am going to have my assistant hold up on that. The mesocolon acts as a way of holding all the bowel out of the wall, so we have a nice playground to work with here. My assistant is holding the colon up so that we have an open area where I can work with the small bowel. It is important to call this the playground, because surgery should be enjoyable.

4. Identification of the ligament of Treitz 05'15''

The ligament of Treitz is here clearly. I will use the white stapler first. I do not make a big deal about how long these limbs are, because I do not really care. We will measure these things, but in a proximal bypass, I do not think it makes a difference. We make our biliopancreatic limb relatively short so that our endoscopists can come around and they can get to the stomach remnant or do an ERCP or survey if necessary. This will come across right there. I push the green button. Staplers are used now. You do not have to make this too long. When we tied this down, this is pretty floppy, so you don’t really have to make the cut that long. Can I have the grasper again?

5. Intestine limb measure and anastomosis 06'31''

Most times, I do not measure this, but I think it just illustrates the way in which you can measure things and whether you put things under tension or not. There is 10cm clearly. That is 20. 30. And 100. So that’s about a 100cm. Now I am grabbing here. I can take my eyes off the camera. We will go ahead and suture now. I am suturing this in a particular way. If this is 12 o’clock on the bowel, this is going to be a 9 o’clock on the bowel, here. We are going to come over then to the 12 o’clock. The reason for that will be that when I want to close the mesentery area, I want to do an anti-obstruction suture as well. Polysorb®, vicryl… It does not matter as long as it is proper. I will make a little opening here. I will be opening on this side. I will stick this on one side. I need to come around and close that a little bit. I will pull it on. We do not need the whole 60. The important thing is back here. You must inspect and make sure that you are not coming across the mesentery. This is a good time to inspect the anastomosis. If there is any bleeding from the inside, so there is something wrong. To me, this usually means a stapler misfire or if you come across a vessel, so let’s have a needle driver. Now we can use this to close this up. It does not matter whether you staple it or suture it. I will grab the suture and then pull it down. I just want a nice running suture that works ok. It probably does not matter what we use, whether Ethibond®, silk. Here we have Prolene. I do not like Prolene in the bowel, but it is probably ok in this situation. There is the needle. Needle is out. I will take the Prolene suture now. So when you close this defect, the closer you get to the root of the mesentery, the better it is. But then again, if you get into a vessel, the worse it is, so there is a fine line. In this case, you can see very well. I am just going to put a purse-string. We have seen that every permanent suture is going to migrate into the lumen, next to the bowel. We try to use material that we think intraluminal, so things like silk is going to absorb that. Can I have the scissors now? I am going to do a Prolene in this application. It’s a little stringy but using monofilament suture for intracorporeal suture has its challenges. Now we want an anti-obstruction suture here. Because I made a 9 o’clock on the anti-mesenteric border, I will grab a little bit of the mesentery here and coming up to this, so it automatically configures into a sort of anti-obstruction suture. Everything else is untouched. It is ergonomic. Ergonomically the GEJ is not set up as well as the gastro J on purpose, because we do not need to spend a whole lot of time down here. But it is still one important part of the operation. Leaks at this level have a highest mortality. There is no method but re-operation. The important thing when you have bowel obstruction in a bypass is that you intervene early. Now we have this whole here. I hope it will be big enough for us. In this patient, it will be quite simple to go antecolic as well. Hopefully it does not slip back. If need be, I can do this over again. I will estimate how much that is. The important thing here is not to do a circumferential closure as I used to do because then the suture will migrate and cause a big problem. We really try not to do that if possible. We will lock in. You can do this at the end, I suggest, but you have to be careful. At least one time, I put the anastomosis completely upside down and I had to redo it, so if I lock it in now, I will not have that problem. This is a huge Petersen’s space here so I have to close that up too. I will do the same sort of a purse-string maneuver, but I do not want to go too deep. I don’t want to get hematoma here if I can help it. Let us hold that up there. It is better to use many short sutures rather than one long suture. We will show that on the gastro J. We actually used 4 separate sutures on the gastrojejunostomy. The operation can be divided into thirds: we spent one third of the time on the GEJ, one third of the time on the stomach transection, and one third of the time on the anastomosis. You do not want to tie this up too much, but you want to close at least enough so that you do not have any gaps. Two needles should be coming out.

6. Hiatal region approach 15'18''

Now let us put in a liver retractor. I am going to criticize my port placement. I put my ports a little bit lower than I should have. It is going to make a stretch a little bit. Just the 30-degree scope. I use that for just about everything. Here, as we come around, we can see the left crus easily. You can see this here? It is some kind of pseudo thing from a hiatal hernia just coming around that way. That gives you an idea there is probably a hiatal hernia. Let us go this way and take the fat pad off of this guy. It’s my fault for putting the camera too low. We will go in the pars flaccida here. I do not want to take that with the hook. There is little accessory vessels, quite substantial, but I will not take them. It is still a hypothesis. I think that taking down and looking for the hiatal hernia is an important part of the band, and they had less re-operations. Anecdotally, every patient I revise, for instance, for weight loss on a bypass all have a significant hiatal hernia. The question then becomes: if I fix the hiatal hernia in every patient, am I going to get better results? We have been looking at this for the last two years and we found that 70% of of the time we cannot predict a hiatal hernia based on an endoscopy or upper GI series. And the only real way to know if you have one or not is to do this dissection. Maybe there is not a hiatal hernia I want to fix, but I will take a look back there. This dissection next with the Harmonic® scalpel does not really take much time, maybe 5 minutes or so, and I think it is a little bit safer. I think it is important for all the procedures to be able to identify the crus. Here is the hiatal hernia. Let us put a stitch or two in there. I am going to put in a slipknot, because if I pull this up this way, all comes out, so I can slip down. So a little slipknot is good. I will take the scissors. If you look at this hiatus, it looked very benign. None would have taken a part of this hiatus, I think. Let us stop the sealing and go on with the bypass. Here is your needle. And here is your scissors. Where is the GEJ? Ok, there is good. Let us come right about like this. It is hard to know a lot of the early laparoscopic series probably made lots more pouches than the open series, but it seems as though we are getting better weight maintenance.

7. Gastric pouch 20'00''

My first landmark is just high above and the GEJ junction down. Sometimes it is worth that vessel and sometimes it is not. I really want a 5cm pouch or less in length, and I am coming in perigastrically here. I think a small transverse pouch is fine. It is not very revisable. The smaller proximal pouches may be ok but I will use the hook. As I rotate the pouch around, then I go to the back side. And because I did that dissection early on behind the stomach, I feel a little more comfortable. Things are going to be stuck up here, and it is safer. This is from the right upper quadrant port so we can come in transversally. I will come across here. No other tubes around the stomach. And then we can put the bougie in. That is the posterior part here. Bleeding is probably coming from the staple line there. Let us go ahead. There is a bougie in there. Can you pull back the bougie a little? There it is. That is something we have to watch for in this patient. Here it is easy to come out lateral, because there is adhesions still right here. But that is not where we want to be when we do this, because we already dissected. Here is the angle of His. We really want to come in this way. Green stapler. Now we staple across. I think it is probably ok back there. This needs to come up to the pouch, like this. This is the bottom of my pouch.

8. Gastroenteroanastomosis 23'10''

There is my Roux limb. Now I will take the Polysorb® again. The second rule is: obviously behind the anatomy that someone else can figure out, because someone else is maybe working after you. I will bring the camera in. You should anticipate that in almost every operation you do, someone has to be there behind you. That port is a little bit low. We are having to push against it. In the end, I guess we still do not have a good idea how a bypass works. The best we can do is to optimize the anatomy as to what’s worked in the past. This is going to be posterior. I am going to go away at a corner here. We know that I cannot forehand that, so we are going to turn around and do a backhand. I think in intracorporeal suturing, the backhand is an important method, because you cannot twist around and do things forehand. We are putting our knot. We just bring our hand around and automatically reverses the knot, so you can pull it down. There must be a pool of blood somewhere. If I make my string the right size, I can use it in order to set my needle, so I can pull up on the string and I can use the pivoting action of my grasper to set my needle, so now it is perpendicular to my line so that when I grab my needle I come in, pick it up and then I know that I’m going to go straight across my anastomosis. We use tension in order to set the needle. I am coming and I grab it posteriorly. I make sure everything is nice and tight, pulling up this way. But I make the tail shorter and longer intracorporeally depending on the needs so that they automatically resize the suture depending on the patient. Now I have switched and I am coming anteriorly. I could backhand as all do back there, but that is not efficient, so I am going to leave it like this. I will take the suction. Let us put the tube across the anastomosis now. This is the purse-string that I want to suture to. Here I cannot see that well, so I want to go beyond the last suture. I will go back here and go behind that staple line. There is the bypass, retrocolic, antegastric. So now when you re-operate on this patient, it will be a lot easier. That is pretty much it.

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