Laparoscopic gastric bypass

This video demonstrates a gastric bypass using stapled anastomosis. The surgeon uses a linear stapler to create a Roux limb with a 75 cm biliary and 100 cm alimentary limbs. The Roux limb is brought up in an antecolic fashion and the gastrojejunostomy is created with a EEA stapler. The anvil of EEA is passed transorally. Petersen's defect is closed and the excess bowel is removed.

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Laparoscopic gastric bypass

Authors

Abstract

This video demonstrates a gastric bypass using stapled anastomosis. The surgeon uses a linear stapler to create a Roux limb with a 75 cm biliary and 100 cm alimentary limbs. The Roux limb is brought up in an antecolic fashion and the gastrojejunostomy is created with a EEA stapler. The anvil of EEA is passed transorally.
Petersen's defect is closed and the excess bowel is removed.

Classification

routine cases

Keywords

gastric bypass, Roux-en Y gastrojejenostomy, circular EEA stapler,

Media type

Surgical video

Duration

25'00''

Publication

2005-05

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E-publication

WeBSurg.com, May 2005;5(05).
URL: http://www.websurg.com/doi-vd01en1714e.htm

Laparoscopic gastric bypass

1. Trocar placement 00'14''

The operation begins with the exposure of the greater omentum. In this case, we find a relatively small omentum that can be safely divided by scissors using monopolar coagulation. The division of the omentum is not necessary in all cases, but it is useful when the omentum is bulky in order to minimize tension in the gastrojejunal anastomosis. Next is the exposure of the ligament of Treitz. This maneuver is easily accomplished by the upward traction of the left part of the greater omentum and transverse colon.

2. Omentum division 00'46''

The next step is the measurement of the biliary limb, which will be excluded from the transit of nutrients. We routinely measure a length of 75cm distal to the ligament of Treitz. To facilitate and standardize the measurement of the length, a steristrip is placed at a distance of 5mm from the tip of the grasper in the right hand. At 75cm from the ligament of Treitz, the jejunum is divided using a 45mm Endo-GIA (white cartridge).

3. Biliary limb 01'19''

We immediately mark the distal end of the jejunum using a few clips in the staple line. This is very simple and reliable trick to avoid any confusion between the biliary and alimentary limbs. At this point, a length of 150cm, the alimentary limb is measured in order to choose the site for the entero-enteral anastomosis. The enterotomy should be as small as possible but good care should be taken in making sure that the mucosa is actually opened.

4. Entero-entero anastomosis 01'59''

The advancement of the Endo-GIA stapler is then done and fired. For the closure of the enterotomy, we always prefer an intracorporeal suture since stapled closure will carry a significant risk of stenosis. We use 2 running sutures begun on each corner of the enterotomy. The lower corners are placed first because when the enterotomy is still wide open, it is easier to make sure that that stitch incorporates the real corner and do not leave an opening inferior to it. We use a 3/0 monofilament suture to close the bowel as this facilitates the ease of the running suture and saves time. We perform a routine closure of the mesenteric defect as it is being shown that the risk of internal hernia is significant after a laparoscopic gastric bypass. To do so, the end of the duodenal limb is pulled to properly expose the mesenteric defect, and again a 3/0 suture is used. In this example, the surgeon remains between the patient’s legs and uses a backward oriented suture technique to close the defect. Alternatively, the surgeon could move to the right side of the patient and perform a forward driving suture movement. A running suture is left loose just until the last stitch and is gently pulled at the end. This stitch should incorporate the serosa of the bowel to ensure a complete closure of the defect. The suture is finished with an intracorporeal knot or clip as in this case. At this point, the inframesocolic portion of the operation is finished, and we advance the camera into the 12mm port in the epigastric area at the midline. A very small incision of the lesser omentum is performed adjacent to the gastric wall in between the first 2 vascular arcades or just below the 2nd one.

5. Gastric pouch 04'06''

We take great care to minimize this incision and the use of coagulation to avoid devascularization of the gastric wall or direct injury to the wall. Cautery is only used to make a small opening. The remainder of the dissection is performed in a blunt fashion with a fenestrated grasper. The right hand retracts the stomach wall upward and to the left whereas the grasper in the left hand basically makes the path towards the lesser sac. When the lesser sac is entered, we will be able to introduce a 60mm linear stapler to divide the stomach horizontally. Besides making sure to remove the nasogastric tube, at this step, the assistant and the surgeon’s right must pull the stomach towards the left and caudad in order to flatten the stomach and avoid stapling only the anterior gastric wall or also possibly making an asymmetric division of the stomach.

6. Gastric division 05'09''

After the first horizontal division, a 33 French orogastric tube is advanced in the stomach by the anesthesiologist and a vertical division of the stomach is performed with several fires, usually 2 to 3, utilizing a 45 or 60mm stapler. The use of the 30 French tube has the advantage of avoiding the staple towards the esophagogastric junction, creating a stenosis. It also provides a guideline to safely retract the stomach towards the left, excluding the fundus of the stomach, which is crucial to ensure a small size pouch. This is the 2nd and probably last firing of the linear stapler and as you can see one would be invited including the fundus and the pouch would have theoretical consequences of leaving a part of the stomach with loose muscular fibres and would be prone to enlargement. Also according to other authors it could have negative implications in relation to the obesity-related peptide ghrelin. We always perform a terminal lateral gastrojejunal anastomosis using a circular stapler whereby the anvil is passed through the mouth by the anesthesiologist attached to a nasogastric tube. The orogastric tube is pulled and removed from its distal end and freed from the anvil as shown here after its advancement through the terminal portion of the gastrum. We make sure that the anvil is flipped back to a 90 degree position, and here we show a purse-string utilized to properly approximate the gastric wall to the anvil ensuring a good anastomosis. The distal end of the jejunum will now be searched and is easily recognizable from the clips that we placed along the staple line earlier in the procedure. We will now advance this limb to the portion of the omentum, which was divided at the beginning of the case, and an enterotomy is performed on the anterior side of the bowel so that the posterior aspect of the bowel can be used to pull the intestine with a circular stapler as you will see shortly. The circular stapler is introduced through a small enlargement of the incision at the site of the 12mm trocar in the left flank. We utilize a wound protector to ensure protection of the abdominal wall and maintain a pneumoperitoneum by wrapping the drape around the shaft of the stapler. The stapler is advanced for 5 to 6cm in the bowel, and tension is made so as to ensure that the trocar rapidly and sharply perforates the antimesenteric border of the bowel.

7. Gastro-entero anastomosis 08'15''

The approximation of the anvil with the device is then done and re-approximation of the 2 instruments is fired. The donuts will be checked for their integrity and the circular stapler will then be removed and replaced by a 12mm trocar. To close the enterotomy, we utilize 2 firings of the 60mm stapler. The excess bowel will then be removed after placing it in an endobag. We always place a stay suture on the right side of the gastroenteral anastomosis to minimize tension on the anastomosis as shown here.

8. End of procedure 09'00''

We review the gastrojejunal anastomosis as shown here. The last step of the procedure is the closure of the Petersen’s defect, which is an opening that is situated between the mesentery of the alimentary limb and the transverse mesocolon when performing the antecolic gastrojejunal anastomosis as in our procedure. To properly expose the Petersen’s space, the transverse colon and the greater omentum are retracted caudad and retracted cephalad by the assistant and the surgeon’s right retract the afferent jejunal limb toward the left of the patient. The defect is closed by a running non-absorbable monofilament suture. This closure can be performed either from between the patient’s legs as in this case or in the right of the patient as previously discussed with the other mesenteric defect. The last stitch is anchored on the tenia coli and also will include some omental tissue after making sure that the transverse mesocolon has been tightly closed. This completes the procedure.