Laparoscopic gastric bypass

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Laparoscopic   gastric   bypass

Authors
J Himpens
Keywords
laparoscopy,gastric bypass,stomach,anastomosis
Media type
Duration
21'00''
Publication
2004-09
Popular
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, Sept 2004;4(09).
URL: http://www.websurg.com/doi-vd01en1626e.htm

Laparoscopic   gastric   bypass

1. Case presentation 00'10''
We will start by placing our trocars. My first trocar is here, a little bit to the left of the optical trocar. I use a 30 degree angle scope, I look for it before I start insufflating, now I can place the Veress needle to insufflate. We can place our trocars now, I use a 30 degree to do that and I will insert the first trocar on the anterior axillary line, which will be a 5mm trocar. The second trocar to work with is a 12mm in the mid-clavicular line. The next is a 5mm port, which will be used for liver retraction, it depends on the size of the liver, not too big here so it will be slightly to the left of the midline. The last trocar is a 12mm in the right upper quadrant. We will place insufflation over there. The trocars are placed; we can start the procedure by intestinal time, which means I will lift the transverse colon; by doing that, we will lift the omentum. I used to split the omentum but when it is not more prominent like this one, I like to remove it to displace it from lateral to medial to lift and to go straight to the angle of His. By lifting the mesocolon, you will immediately find the angle of His. We start with the intestinal time, it will give you a lot more space to work in and to lift your intestinal loop because we do an antecolic and we will measure around 75cm of small bowel, lift it and provisionally stitch it to the stomach so it will stay there. Then we will measure 150cm and do an anastomosis between that part and the part at 75cm. So we start by doing a bilio-intestinal anastomosis. After closure of the latter, we will close the defect in the mesentery and we will draw our attention to the gastric time. We will then do a transection of the stomach horizontally and longitudinally as you saw Dr. Higa do it and we will try to imitate what he did by doing this time a mechanical anastomosis because it is probably, at least in the beginning of our experience, the simplest to do. So we locate the angle of His by lifting again the transverse colon, which is here, and then we will very gently lift this loop and unroll it clockwise. If you measure it, it is around 50 to 75cm but as a rule of thumb, you can use the first loop that can be easily lifted and reaches the stomach somewhere here and now I will mark immediately what is proximal and what is distal. I can put some burn marks (I don’t care because they will go in the end) just to make sure that at no point throughout the procedure, I lose my orientation because in some patients, that can be a real problem. I will stitch this loop to the stomach, I put a stitch here that will keep this loop in the right position. You can retract otherwise but it’s just a provisional stitch, it doesn’t make a difference at this stage. Sometimes, this is twisted so you don’t know what is proximal or not, that is why those little marks are useful, see them here, so I know this is going away from Treitz angle. I will measure just about 150cm. It will not really make a difference because weight loss will not depend on the length of the alimentary limb, it is just the speed of weight loss that will depend on that. Now we are ready to do the bilio-intestinal anastomosis; to do that, you can do a hand-sewn, you can do a stapled or whatever you feel like. I will do a stapled anastomosis, we will make a little hole in the bowel and make another one in the bowel. That one will be bigger because it will accommodate a bigger part of the stapler; we now have to be very gentle because that is how you can make holes. Very gently you have to pull it along its axis to make sure you don’t perforate it. Now you have a short anastomosis, we need a second one. I will close this opening, it’s better to do it this way at least for me it is. It is perhaps better to do this by hand, which is cheaper. We will close the defect in the mesentery, look at the defect, this is going to be my alimentary limb, this is the alimentary loop going towards the biliary loop, and you see when you lift that up anteriorly. To close that, you need a non-absorbable suture material; if you don’t do that, later on you will have a lot of cases of internal hernias and we have just had one recently and thank god, the patient only came because of crampy pain and not because of a frank obstruction. Take good bites and even if you have bleeding there, don’t worry about it, it is better to have that than a hernia. You can lock the stitch if you want. I use Prolene. We will tie the stitch. Some compression to this hematoma. We will now concentrate on the stomach, see the first thing is that there is a gastric tube in the stomach, we will ask to have the tube pulled back into the esophagus. I will now try to select this part on the stomach, which will allow for a safe transection. The patient is placed in reverse Trendelenburg; for liver retraction, we have this instrument here. I will show you where to transect the stomach. You take the loop that you have just isolated and you see to what level you can very easily lift the loop, which is just about here, it is always the same level. We isolate the lesser curve, and then we can use the Endo-GIA (I use a 60 blue). As we do that, you have to push the stomach back. I usually don’t free the angle of His here, I want to go from posterior and since I am going to do a stapled anastomosis, I want to free this a little bit because otherwise you run into trouble and chances of bleeding at the anastomosis. So I really want to clean this up, now we get a good view on the posterior aspect of the stomach. Now you have to push the fundus laterally. We want to remain close to the left crus so we have to deal with the little attachments, beware not to damage the pancreas that you see right here, all that is pancreas. I’ll make my way up and push the fundus laterally, sometimes you will get inside the mediastinum doing that, you can only be satisfied when you see what you get. I will do the stapling here just to the left of the left crus. We check again posteriorly, with a 30 degree angle scope, that is no big deal. We will now do the final transection of the other crus. Here is the hook; for safety, I will use another 60. Now I will oversuture the distal stomach and not stitch the sponge and not worry about it, tighten it at the end. People say you can use green cartridge on stomach but even blue is already quite bloody. Now we have to do the anastomosis between this gastric tube and the small bowel. This is the anvil, you see here the spring, we put the stitch in the 2 holes opposite the string, I am just removing the spring. The spring is gone and you push it down until you hear a snapping sound, then you can see that you can tilt the anvil. We then tie the knot to keep the anvil in its tilted position. This tube is a pretty rigid one, I will use that to stitch close to the anvil. We tie this loosely to the tube, we will be able to advance it through the mouth and pull the anvil into the operative field. We bend this a little bit on top so the tube has the potency to angulate interiorly. We ask the anesthesiologist to introduce this through the mouth. I am holding this and pulling on it so there is no angulation, it always goes straight down to the staple line. I try to locate the midline here, then we grab the tubing and we very carefully pull it out through the left upper quadrant trocar. Now it is essential that no resistance whatsoever is ever felt. As you pull it out, be careful that you don’t dislodge the anvil. It is not a difficult suture, you have very good visual conditions. Now the stomach part is ready for the anastomosis. The advantage of this technique is that we will immediately find the loop because it is hanging here. There are 2 parts to it, one is marked, the other one we will use and one that was used for the anastomosis with the biliary loop. Don’t put any traction and we will only cut the part of the bowel that is facing us. Now we will introduce the EEA, insert that in the bowel loop that is sitting here. See there is a lot of traction on that, you can imagine that if you do that in that biliary anastomosis, it is probably not ideal. If you do use ileum like in the BPD, you can imagine that it is not easy to introduce a circular stapler in there. You then snap the 2 together, make sure there is no fatty tissue in between. Then you unscrew it a little bit and you’re ready to take it out. And the anvil was unlocked. Now the important thing is to go look and see that we don’t have bleeding at the anastomosis. If you have the slightest doubt about bleeding, you have to go look and inspect the anastomosis. I have never seen that, let’s first inspect the anastomosis, I want to immerge this in water then we can inspect with the scope in the water and locate bleeding. At the place where we opened the bowel, we will resect this and you have to be really flush with the anastomosis. We then go down to the bilio-digestive anastomosis here. The advantage of cutting this out is that it will reduce the traction on the anastomosis as well. Now we have a whole bunch of things to remove. We will close Petersen’s defect, which goes this way, just flip this to that side, and Petersen’s defect is between the mesentery and the transverse colon, which is here. This is the beginning of Petersen’s defect, I usually put a little superficial stitch to the stomach, which is some kind of anti-rotational stitch. Use the fat around it.