Laparoscopic RYGB: linear stapled technique

This video demonstrates a gastric bypass for morbid obesity using a linear stapler to complete all the anastomosis. The surgeon demonstrates a safe use of this technique. The other features of the case are in keeping with a standard Roux-en-Y gastric bypass.

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Laparoscopic   RYGB:   linear   stapled   technique

Authors
C Gracia
Abstract
This video demonstrates a gastric bypass for morbid obesity using a linear stapler to complete all the anastomosis. The surgeon demonstrates a safe use of this technique. The other features of the case are in keeping with a standard Roux-en-Y gastric bypass.
Classification
basic techniques
Keywords
Roux-en-Y Gastric bypass, laparoscopic, stapled anastomosis
Media type
Duration
18'00''
Publication
2005-10
Popular
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, Oct 2005;5(10).
URL: http://www.websurg.com/doi-vd01en1849.htm

Laparoscopic   RYGB:   linear   stapled   technique

1. Trocar placement 00'20''
Obviously, the umbilicus is here. And the xiphoid is just above with the liver retractor is here. We tend to go above the umbilicus and to the right so that we avoid the falciform up here, and we’re kind of looking over and down. We want to be looking down. So we usually go 3 or 4 fingers over, and about 3 or 4 fingers up from the belly button. If you anticipate, this is the hiatus up here, then you look at the end of the instruments and to accommodate for the device as long as the instruments can reach up to basically what you anticipate is the angle of His that is a good trocar position. Once the scope goes in, I realize that you’re not too close, you’re too high, it’s almost directly opposite, and just up a little bit so you have plenty of length. And then it’s usually just for me 2 fingerlengths apart, you see my 2 fingers there. So that’s just how I decide. If it comes over nicely, that’s a comfortable trocar position and then I just go directly opposite my right hand for one assistant’s port over here. So you have 4 trocars here in a semi-circle, a kind of basic approach to laparoscopy oriented around the target. We put the lap-band tube in the mouth, and you see it here, can we have the balloon? Then I blow the balloon up to 30cc of air. You can see the balloon coming up here. Can you pull back to do the resistance? We do that to try and calibrate the pouch. We have some idea that will be consistent in terms of size. So if we look down at the vessels, some people will count the vessels, will go 1, 2, 3. So we’ll basically mark the pouch down here. And you have to remember that the pouch is going to look bigger as we go our way down. It’s always going to be smaller than you thought it was. It’s always easier to make it smaller but impossible to make it bigger. Balloon empty down. So we’re doing a pars flaccida just going in here. And there may be another layer here. Will you be taking the vagal nerves then with this approach. Yes, I was resistant to it at first but we’ve been doing it for a year now, and there has been no problems with it, except that she’s got a little layer here. Normally I take a vascular load of the stapler and we just divide this.
3. Gastric pouch 04'40''
You have to inspect these. If they don’t cross properly, you didn’t apply the stapler right. And if you’re not happy that it sealed well, then I would put an interrupted stitch. But that doesn’t happen very often. And now you see the pouch. People are going to say the pouch is too big but let’s wait until the end. It’s very critical that the staple lines overlap properly. And with the plastic I’m pushing the posterior wall away so that these overlap here. I’m going to the angle of His. You see here the GE junction. Please advance the tube. We’re going to show you that we know where the esophagus is, and one of the important things about learning curves is that if you don’t know where the esophagus is, advance the tube and it should easily pass into the pouch. You see it coming in there. You see it’s going to be about the size of the balloon and we’ll demonstrate that at the end. So we’ll fire this here. We should be to the last firing now when I look behind the stomach and make sure that we’ve opened up the window, so we can see the spleen and we don’t want to damage the spleen. I like to find the diaphragm here if at all possible. So what we’re going to come out is right here. There’s a little lymph node there. If I went up, I would only go up about 2cm and that would be fine. Back to the stapler. Angle of His is here, esophagus is to the left, we can see the spleen there, we’re on the diaphragm. This is the way it should look and we use one extra cartridge (it’s a lot less expensive than a leak). And then we want to retract, we usually hold things over and we look this way, we make sure that we did not pick up one of the short gastrics in the blue load because that would be bleeding pretty well. We want to make sure that we didn’t scoop something up, look here to make sure that we’re not in the hiatus, you can see there’s the fundus there. And then we can pull back and take a look here at the pouch. Look at the size. It always winds up looking smaller after you’d stapled it than when you started. And you can see the marks on the GIA on the plastic. See them? This is my average pouch size. You can see the GE junction is here, anterior wall and there’s the 6cm marks, and there’s our anastomosis. Remember we’re going to go inside the side so when we take that off, we’re also going to be taking off anterior wall. So we’re going to make it smaller as we make the anastomosis. Now we pull this over this way.
5. Gastro-jejunostomy 10'00''
The reason why I just don’t open the staple line is because you don’t have control. You see how we have anastomosis on the healthy anterior wall, there’s no ischemia, if you go in here, then I don’t know if I’m going to be on the lesser curve or on the staple line or if I’m going to have ischemic bridges. And I like to see this bleeding from the gastric wall because there is also the question of marginal ulcers and ischemia leading to structures, and all kinds of other things, and so we have a good blood supply, we have no tension, and we have the anastomosis centred on healthy tissue without crossing staple lines. So this is one corner stitch through the staple line. I used to carry my own instruments, I may have to start doing that again. We’re going to advance the tube to the anastomosis now. So you see how big is the anastomosis. Give it a little push. Give me the dissector. Did you see how we did the anastomosis, how we closed it. So we took off this extra centimetre of the pouch. Can you pass me the scissors? Now methylene blue. Now we’re testing with one insufflation, that’s 60cc, 30cc more to get pressure. You see how its just standing? I really punch it hard, even if I see a little bleeding here I like it. You can suck it out. Everything’s sealed here. Healthy bridge of stomach here. You see there’s not a lot of back wall as here is the lesser curve. We want to look here, which is very important. Look up at the scope. Look to the left here. I want to check the apex, make sure you didn’t tear anything here. You can see the lesser curve. And we took off extra stomach right up to here, measuring about another centimetre. We brought that up from the ligament of Treitz. This is proximal, and this will be distal. And we’ll march down the distal limb 80 to 90cm because I don’t have a stick to really calibrate and I’m going to assume from here to here, it’s about 5 or 5 and a half centimetres. We’re going to march about 80 using this calibrated, and the anastomosis will be from here to here. So you have several visual cues. You’ll be able to look at the small bowel mesentery, make sure that it’s not rotated see. And if you really want to do this, and I think that the most important thing is not let the assistant let go of the proximal, we can trace this all the way up to the ligament of Treitz, which will be under there. That’s about 5, 15, 80.