Laparoscopic exploration after Roux-en-Y gastric bypass following intestinal obstruction

This video demonstrates a laparoscopic exploration in a female patient who had undergone a gastric bypass in 2002. Her BMI was 58 at that time. Now it is 20. She had been operated on for an incisional hernia that occurred at the level of the former umbilical optical port site. She suffered from several episodes of proven mechanical bowel obstruction and benefited from medical treatment. However, despite a thorough preoperative work-up, including gastroscopy, colonoscopy and repeat CT-scan studies performed over 6 months, the mechanical origin of the bowel obstruction was difficult to demonstrate. Since the patient had chronic, cramp-like abdominal pain, the exploration of the abdominal cavity using the former port entry sites is decided upon.

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Laparoscopic exploration after Roux-en-Y gastric bypass following intestinal obstruction

Authors

F Costantino, M Vix, J Marescaux

Abstract

This video demonstrates a laparoscopic exploration in a female patient who had undergone a gastric bypass in 2002. Her BMI was 58 at that time. Now it is 20. She had been operated on for an incisional hernia that occurred at the level of the former umbilical optical port site. She suffered from several episodes of proven mechanical bowel obstruction and benefited from medical treatment.
However, despite a thorough preoperative work-up, including gastroscopy, colonoscopy and repeat CT-scan studies performed over 6 months, the mechanical origin of the bowel obstruction was difficult to demonstrate. Since the patient had chronic, cramp-like abdominal pain, the exploration of the abdominal cavity using the former port entry sites is decided upon.

Keywords

Laparoscopic exploration, Roux-en-Y gastric bypass, intestinal obstruction

Media type

Surgical video

Duration

05'35''

Publication

2010-07

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E-publication

WeBSurg.com, Jul 2010;10(07).
URL: http://www.websurg.com/doi-vd01en3001.htm

Laparoscopic exploration after Roux-en-Y gastric bypass following intestinal obstruction

1. Introduction 00'09''

This video demonstrates a laparoscopic exploration in a female patient who had undergone a gastric bypass in 2002. Her BMI was 58 at that time. Now it is 20. She had been operated on for an incisional hernia that occurred at the level of the former umbilical optical port site. She suffered from several episodes of proven mechanical bowel obstruction and benefited from medical treatment. However, despite a thorough preoperative work-up, including gastroscopy, colonoscopy and repeat CT-scan studies performed over 6 months, the mechanical origin of the bowel obstruction was difficult to demonstrate. Since the patient had chronic, cramp-like abdominal pain, the exploration of the abdominal cavity using the former port entry sites is decided upon.

2. Adhesions dissection 01'06''

Here adhesions at the left hypochondrium can be observed. These adhesions are taken down.

3. Bypass reconstruction exploration 01'31''

An exploration is carried out to control the Roux-en-Y gastric bypass. As can be seen, there is no dilatation of the small bowel, and the exploration of the duodenal loop should lead us to find the anastomosis at the foot of the loop, which is visible here. No dilatation above, underneath or at the level of the anastomosis can be demonstrated.

4. Identification of opening of Petersen’s space 02'23''

Petersen’s space is entirely open but, as can be noted here, the alimentary loop goes up anteriorly to the transverse colon. This configuration is commonly found in this category of patients. The exploration of the alimentary loop helps to re-identify the anastomosis at the foot of the loop. Next, the exploration of the common bowel loop is undertaken. It should lead us to the right colon. The exploration allows to identify several dense adhesions at the first small bowel loops. These adhesions will be divided using scissors and then freed using monopolar cautery (with a low voltage, about 15 Watts). Despite its empiric nature, this freeing might be able to reduce the risks of postoperative obstruction. Yet, the random findings published in the literature for several years are not encouraging.

5. Petersen’s defect closure 04'15''

At this moment, the defects found at the level of Petersen’s space can be well observed. This is why the closure of Petersen’s space again using PDS 3/0 material and a purse-string suture is decided upon. Petersen’s space is most probably at the origin of the obstruction and its related postoperative pain. No other defect has been found during the intervention. Therefore, our decision is to discontinue the explorative laparoscopy. The patient is allowed food on postoperative day 1. After a 6-month follow-up, no other cause of abdominal spasmodic pain was evidenced. The patient never had to go back to hospital again because of intestinal obstruction.