Laparoscopic Roux-en-Y gastric bypass (LRGBP) redo after laparoscopic sleeve gastrectomy in a morbidly obese woman

With more and more bariatric procedures being performed, it is predictable that more patients will suffer from complications necessitating re-do surgery. We show the case of a laparoscopic sleeve gastrectomy being transformed into a laparoscopic Roux-en-Y gastric bypass.

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Laparoscopic Roux-en-Y gastric bypass (LRGBP) redo after laparoscopic sleeve gastrectomy in a morbidly obese woman

Authors

M Vix, J Marescaux

Abstract

With more and more bariatric procedures being performed, it is predictable that more patients will suffer from complications necessitating re-do surgery. We show the case of a laparoscopic sleeve gastrectomy being transformed into a laparoscopic Roux-en-Y gastric bypass.

Classification

complex cases

Keywords

Laparoscopic Roux-en-Y gastric bypass, LRGBP, redo after laparoscopic sleeve gastrectomy, morbidly obese woman

Media type

Surgical video

Duration

09'30''

Publication

2010-02

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E-publication

WeBSurg.com, Feb 2010;10(02).
URL: http://www.websurg.com/doi-vd01en2844.htm

Laparoscopic Roux-en-Y gastric bypass (LRGBP) redo after laparoscopic sleeve gastrectomy in a morbidly obese woman

1. Clinical case presentation 00'18''

We show the case of a laparoscopic sleeve gastrectomy being transformed into a laparoscopic Roux-en-Y gastric bypass. The patient is a 45-year-old woman who had a gastric band placed 5 years ago for morbid obesity with a BMI of 43. Thanks to the gastric band, the BMI was reduced to 35 but the development of a superior gastric pouch required the removal of this gastric band. Once the band was removed, the patient’s BMI went back to 42. The patient desired a new bariatric surgery and a laparoscopic sleeve gastrectomy was performed at that moment. Six months after the sleeve gastrectomy, the patient complained of an incapacitating reflux that anti-secretory drug agents could not treat. We therefore decided to transform the sleeve gastrectomy into a Roux-en-Y gastric bypass.

2. Trocars placement 01'07''

Trocars are positioned conventionally. No epigastric trocar was needed due to the hepatic adhesions. A trocar was placed one handbreadth and a half under the xiphoid process for the camera; a 12mm trocar is placed in the right flank; a 5mm trocar is placed on the left anterior axillary line and two trocars are placed on the left mid-clavicular line, one at the height of the optical trocar and the other lateral to the umbilicus.

3. Dissection of adhesions 01'45''

We see the operative field as it is at first, with multiple omental adhesions joining the stomach to the liver. As a first step, it is important to dissect all the adhesions in order to find reliable anatomical landmarks. This dissection can be performed with the Ligasure® device or with a monopolar hook depending on how dense the adhesions are.

4. Dissection of left border of stomach 02'18''

The anterior and superior portions of the stomach are entirely dissected. We then free the left border of the stomach as there are no vessels in this area, and so as to prepare for the gastric division. The lesser sac is once again identified. All the adhesions of the stomach’s superior portion have been taken down up to the stomach’s medial part in order to have a good exposure of the area where the gastric division will be performed. Once the left border of the stomach is dissected, we complete a passage in the lesser omentum at the level of the smaller curvature; this passage is created under direct visual control to avoid vascular injuries and preserve a good vascularization of the gastric pouch.

5. Introduction of linear stapler 03'28''

A loop is installed at that moment to facilitate the introduction of the Endo-GIA linear stapler. We also check that no clips that could have been placed during the previous procedure are still there. Once this gastric passage has been achieved and that we know that the gastric division can be performed, we will mount the alimentary loop.

6. Identification of duodenojejunal flexure 03'48''

The duodenojejunal flexure is identified and we measure 75cm from the flexure, and this portion will be fixed to the stomach as a landmark; here it is the biliary loop.

7. Biliary loop marking and alimentary loop measurement 04'16''

The biliary loop is marked with blue ink, we measure out a 150cm alimentary loop before performing the anastomosis at the foot of the loop. A landmark thread is placed in order to identify the two anastomosed loops.

8. Biliary loop anastomosis 04'40''

Then the small bowel is opened to allow for the introduction of the 60mm Endo-GIA linear stapler with a white cartridge.

9. Closure of stapler’s introduction site 05'06''

Then the stapler’s introduction site is closed. Here we can observe the anastomosis.

10. Alimentary loop division 05'20''

The alimentary loop is then divided and brought towards the stomach to perform the gastrojejunal anastomosis. This division of the mounted loop is also performed using the 60mm Endo-GIA linear stapler, white cartridge.

11. Stomach division 05'40''

The stomach is divided using a green stapler because of the thickness of the gastric tissue. Here a small bleeding occurs since the green stapler provides a stapling that is less meticulous than the blue stapler. A final row of blue staples is achieved. The stomach is completely divided.

12. Anvil retrieval 06'07''

An incision is performed in the stomach in order to retrieve the anvil of the circular stapler. The orogastric tube is retrieved, with the anvil at its end. It is then removed from the anvil.

13. Purse-string creation 06'40''

A purse-string is then fashioned around the passage of the anvil in order to achieve an adequate anastomosis without any dehiscence.

14. Gastrojejunal anastomosis 06'48''

The alimentary loop and the stomach are very close to one another. The anastomosis is carried out without any traction. Here a few stitches are applied in order to complete the hemostasis of the staple line on the stomach. Then the alimentary loop is opened with the hook in order to introduce the circular stapler for the anastomosis. The introduction of such a stapler is fairly easy and this new DST circular stapler does not require the removal of the perforating spike, which is incorporated in the stapler. A gastrojejunal anastomosis is then performed. The integrity of the two doughnuts is controlled. The stapler’s introduction site is closed using a row of white linear staples. A running suture is also carried out on the staple line of the remnant stomach to limit the risk of gastro-gastric fistula.

15. Suspension of gastrojejunal anastomosis 08'59''

A suspension stitch is placed on each side of the gastrojejunal anastomosis using absorbable suture material. These stitches are aimed at relieving any tension on the gastrojejunal anastomosis. The last step consists in closing the Petersen’s space located between the duodenum, the transverse mesocolon and the alimentary loop to be mounted. Exposure is sometimes made uneasy due to the importance of the adipose tissues. A purse-string is performed to correctly close this space using non-absorbable suture material.