Laparoscopic RYGB: hand-sewn gastrojejunostomy, stapled technique

This video demonstrates a gastric bypass in a patient after failed gastric band. The band had been removed 5 months prior to this surgery. The surgeon performs a gastric bypass with a 30 cm biliary limb and a 100 cm alimentary limb. The Roux limb is positioned in a retrocolic fashion and the gastrojejunostomy is performed by a hand-sewn two-layer technique. The gastric pouch construction requires careful dissection of the adhesions from previous band.

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Laparoscopic RYGB: hand-sewn gastrojejunostomy, stapled technique

Authors

Abstract

This video demonstrates a gastric bypass in a patient after failed gastric band. The band had been removed 5 months prior to this surgery. The surgeon performs a gastric bypass with a 30 cm biliary limb and a 100 cm alimentary limb. The Roux limb is positioned in a retrocolic fashion and the gastrojejunostomy is performed by a hand-sewn two-layer technique. The gastric pouch construction requires careful dissection of the adhesions from previous band.

Classification

complex cases

Keywords

reoperative bariatric surgery, gastric bypass, Roux-en Y gastrojejenostomy, gastric band

Media type

Surgical video

Duration

13'00''

Publication

2005-10

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E-publication

WeBSurg.com, Oct 2005;5(10).
URL: http://www.websurg.com/doi-vd01en1847.htm

Laparoscopic RYGB: hand-sewn gastrojejunostomy, stapled technique

1. Case description 00'00''

This is the case of a 39-year-old male patient with a BMI of 49. The patient had a gastric band placement 2 and a half years ago. The patient lost some 40 kilograms representing less than 50 per cent of the total weight loss objective. A few months after this, the patient started to regain weight even though he had improved his eating and lifestyle habits and the decision was made to remove his band. A Roux-en-Y gastric bypass was indicated.

2. Trocar placement 00'33''

We begin the intervention by placing 4 trocars, a fifth we place at the time of gastric dissection. A 10mm trocar for the camera is placed to the left of the umbilicus. Two additional 10mm trocars are placed as working ports for the surgeon. A 5mm trocar is positioned in the left subcostal region. This will allow introduction of the assistant’s instrumentation. A 5th trocar will be placed later during stomach dissection. We start by making an opening in the transverse mesocolon to the left of the right colic artery. This will allow the Roux limb to ascend towards the stomach.

3. Biliary and alimentary limb 01'20''

We measure approximately 30cm of jejunum from the ligament of Treitz and divide it at this point with a linear stapler. A sufficient portion of the mesentery is divided to avoid tension on the Roux limb. A Penrose drain is sewn to identify the end that will become the Roux limb of the bypass. It will also facilitate its handling. We measure approximately 100cm for the final size of this gastric limb and at this point we will perform the jejuno-jejunal anastomosis.

4. Jejuno-jejunostomy 02'05''

We start the anastomosis by placing a stitch to bind together both limbs of jejunum, and at the same time we can use this for traction. Then a small enterotomy is made on each limb to receive the jaws of the Endo-GIA. Once the stapler is well positioned, the anastomosis is performed. This stitch helps to hold the anastomosis in place and avoid unwanted tension. The knots are made extracorporeally and descended with a push-knot device. Then the defect is closed by a hand-sewn running suture. We find that it is safe and rapidly performed. This is the final result of the anastomosis. Now we are going to close the so-called Petersen’s space, the remaining antimesenteric defect in order to avoid any potential hernias.

5. Diagram procedure 03'55''

A diagram is shown of the procedure that is being performed, the position of the Penrose drain and the position of the anastomoses. The Roux limb is being passed in a transmesocolic antegastric fashion. An extra 5mm trocar is placed in the right hypochondrium for use by an assistant. Adhesions are encountered and these are divided. The omentum is dissected off the anterior surface of the stomach and dissection is continued along the greater curvature.

6. Gastric dissection 04'47''

Laparoscopic bariatric surgery, particularly Roux-en-Y gastric bypass is technically demanding. The surgeon must be familiarized with bowel anastomosis, intracorporeal suturing and knotting techniques. The left crus is dissected preparing the area for the gastric pouch. The gastric pouch will be small about 30mL and it will be coupled with a small gastrojejunostomy of about 2cm.

7. Gastric pouch 05'31''

The pouch is created using a linear stapler and a second row of staples is applied to make sure that this continues towards the apex so that the gastric pouch is made. The dissection is continued in the retrogastric space and the pouch is orientated vertically by multiple firings of the linear stapler towards the angle of His. An opening is made in the omentum in order to allow the small bowel to be brought up to the stomach. Here you can see the small bowel being set in place for anastomosis.

8. Gastro-jejunostomy 07'20''

The Penrose drain is then cut off and the small bowel is anchored to the pouch by a posterior suture. The stomach and the bowel are opened approximately providing a defect of 2cm. Following this, the 2nd posterior layer is placed. The result will be a two-layered continuous anastomosis between this pouch and the stomach and the small bowel. The nasogastric tube is retrieved from the gastric pouch and placed distally into the small bowel. The anastomosis is then continued in a similar fashion to how it would be performed in an open operation. However this time, it is being performed intracorporeally. The anterior layer is now placed. Once again, a continuous running suture is used. Roux-en-Y gastric bypass is considered one of the most technically demanding procedures and the learning curve is steep. It is considered to be between 50 and 150 cases.The Roux limb is pulled to its definitive position and fixed to the transverse mesocolon. The transverse colon and omentum are then brought back to their usual position and the procedure ends.