Laparoscopic gastric bypass

This video demonstrates a laparoscopic gastric bypass using a hand-sewn anastomosis. The surgeon creates a 100 cm alimentary limb, which is passed in a retrocolic fashion and anastomosed to a 4 cm long gastric pouch using a two-layer hand-sewn anastomosis. The diameter of the gastrojejunostomy is calibrated with a 1.2 cm tube. The surgeon demonstrates the technique of closure of the defects, which may lead to postoperative hernia.

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Laparoscopic gastric bypass

Authors

Abstract

This video demonstrates a laparoscopic gastric bypass using a hand-sewn anastomosis. The surgeon creates a 100 cm alimentary limb, which is passed in a retrocolic fashion and anastomosed to a 4 cm long gastric pouch using a two-layer hand-sewn anastomosis. The diameter of the gastrojejunostomy is calibrated with a 1.2 cm tube.
The surgeon demonstrates the technique of closure of the defects, which may lead to postoperative hernia.

Classification

routine cases

Keywords

Roux-en-Y gastrojejunostomy, bariatric surgery, morbid obesity, handsewn anastomosis

Media type

Surgical video

Duration

20'00''

Publication

2005-10

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E-publication

WeBSurg.com, Oct 2005;5(10).
URL: http://www.websurg.com/doi-vd01en1652.htm

Laparoscopic gastric bypass

1. Case description 00'10''

Ordinarily, I would in a standard patient where we likely use an optical trocar for our initial entry, we don’t use insufflation and I usually measure about 18-20cm from the xiphoid process to put our camera port. This patient has had previous surgery, a cholecystectomy, so we will come into the side with a Veress needle insufflate gas. Now we can change to the 30 degree scope. I like to use non-bladed trocars so that there is less chance of herniation. Now let’s change our camera port.

2. Trocar placement 01'30''

I usually use between 15 and 18cm from the xiphoid. This case we’re going to place this right through the falciform ligament to make it easier to manipulate. We can see the GE junction nicely here. Ordinarily what we would do is to flip the omentum up and get to the ligament of Treitz. In this case, I think we’re better off leaving the incarcerated hernia in and the way we will come through the gastrocolic ligament anteriorly here and get to this mobile.

3. Gastrocolic ligament 02'10''

Since there are many ways to wrap the Roux limb in a gastric bypass, some choose antegastric antecolic, some others use retrocolic retrogastric. I do it the same way I did in an open case and is retrocolic antegastric. Probably there’s not one best way. The reason I choose the retrocolic antegastric is for this very reason. Many of our patients have had previous surgeries and adhesions and then if we take this wrap, we don’t have to take down so many adhesions. I think there’s also less tension on the anastomosis when we come in retrocolic rather than antecolic. Already obscuring the lesser curve of the stomach are some adhesions to the pancreas. So by opening the space right now what we’ll be able to do is to take down these adhesions under vision and have less chance of injuring the pancreas. Here you can see the posterior aspect of the GE junction, which we can identify a little bit later. There are a few adhesions here. We can take these down now just to make our dissection a little bit cleaner and easier. We can see big vessels here, well we’re probably not in the right spot, we’re probably too close to the colon itself. Now the problem we get is if the patient has a very short colonic mesentery. Sometimes we can still leave the hernia in place.

4. Opening of mesocolon 04'37''

Now when we don’t know where things are, I like to use a Penrose drain or something soft in order to help identify the spots where we need to be. Then we look at it on top and if we can find it here, then we’ll know at least we have a rout one way or the other and we’ll go ahead and transect the small bowel here perpendicular to the line of the bowel.

5. Transection of small bowel 05'20''

And then, we’ll measure our Roux limb and we’ll perform all the small bowel right here. Transect the bowel here. That looks pretty good. We don’t have to take much mesentery here because it reaches up very nicely. Now I’m going to measure our Roux limb. So I anticipate and stretch it out probably 10cm. This patient’s BMI is 48. In my practice, we’re not allowed to go beyond 150, well 100cm for any patient because of insurance issues and the standards of care. We make everybody 100cm long. Ordinarily we’d place a stay suture here. It looks like we have good vascularity. We’re going to fix it this way, maintain our orientation and then we’ll make an opening on one side.

6. Jejuno-jejunostomy 07'20''

Now let’s see if the opening I have made is going to be large enough to place the stapler in. Yes it goes in. That is the jejuno-jejunostomy. The sutures are perfect in length. You can see we can use both stapling devices, they work nicely. The advantage or one of the other is mostly in what you’re used to. Now if possible, it’s a full-thickness but sometimes I’d use an extramucosal stitch in order to reduce. I don’t like to have the mucosa like that. One time I close these with 2 layers but I admit no difference going to one layer, it just saves me some time. So I should be able to close this and I purposely made a stay suture little long so that now I can sew to it. Let me have the empty driver back. I will need the prominent suture. Let’s close it like this to help prevent kinking. This is called an anti-obstruction suture. I’m going to start suturing to the staple line, which ordinarily causes some adhesions anyway. Here I almost have to do a purse-string coming down this way. I really want to close this up entirely. The closer I get to the root of the mesentery, the less sutures I have to take. But if I get in too deep in the vessel, then more likely I’m going to cause ischemia. Here I’m going to try and come around again. I’m just going to pick up the superficial layer not necessarily the fat. This is an area of postoperative obstruction that occurred earlier on, sometimes the patient will become distended. There will have an obstruction right here from a kink. I’ll go right to the corner. Let me go and tie this down. I just want to make sure that this opening is large enough to accept the Roux limb without causing obstruction here. Make sure it’s oriented correctly. The 1st thing we want to identify is the angle of His so many times we’ll have to dissect this free. In order to define this, I see the diaphragm here, the left crus of the diaphragm and I can use blunt instrument to help define this space of the angle of His a little bit better so that when we dissect here, it’s essential to exclude the fundus so the pouch is not dilated and it’s also important not to impinge on the esophagus because if we do that, the patient may have a leak. This is the GE junction right here and this is 4cm. I’m selecting a spot about 4cm down from the GE junction, which is about right here. Now fire!

7. Gastric pouch 14'00''

Now I need my esophageal retractor. Make sure it’s under vision so that we come in. That’s a very dangerous maneuver, I don’t like it but after you get used to it. Now we’ve completely transected. The Roux limb should in fact if we want it to, reach all the way to the GE junction. I’ll do a 2-layer hand-sewn and we’re going to use the posterior layer. I’ll calibrate this anastomosis according to this tube. The tube is 1.2cm so my anastomosis will be 1.2cm internal diameter.

8. Gastrojejunal anastomosis 15'20''

We’re going to come in and out and then we’ll pivot and do a reverse angle backhand in this way. This is the corner where we can\\\\'t see very well. It’s important that we go back far enough now. Let’s come outside in. I’ll saw this anastomosis from the inside now and come straight across this way. I’m anterior now, let’s have another suture and we’ll do the same back in this way. I’m not going to narrow this. I’ll get the suture line way up there. So by going this far back from the last suture, we know how we’re going to do this very good at the corner even if we can’t see that well. We don’t need to cut this one because it won’t get in our way. Everything else has been a compromise, difficult to expose or lower anatomy, and sometimes little lower on the stomach than I want to be but all I want to make sure that this anastomosis is not difficult to do. But now if anything happens to this anastomosis is that patient has a leak or has an ulcer, needs a revision, is very easy to get to. See that big vessel there. We’d better avoid it. I make the anastomosis retrocolic antegastric. Here’s the 1st suture we’ve done. At this point, after we get a few knots in here, the orogastric tube can be removed. But I inspect to make sure everything looks good. Now we have to go backwards and close the mesentery the thing I didn’t do before. Let me have my graspers again, we hold that up. We must make sure we close that up. Now we let this go. From this side, we have to go all the way this way. It’s important to close one side all the way to the other because the bowel obstruction incidence is less but it’s not zero. But I still think if it’s done antecolic that you must close the space. It is a problem. No bleeding. Let’s look back on top.