Laparoscopic gastric bypass after band removal: hand-sewn gastrojejunostomy

A subgroup of patients who receive the LAP-BAND fail to lose enough weight or present severe complications. Gastric bypass, which has both restrictive and malabsorptive components, is a good second-line choice for patients who did not do well with the band.

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Laparoscopic gastric bypass after band removal: hand-sewn gastrojejunostomy

Authors

M Vix, J Marescaux

Abstract

A subgroup of patients who receive the LAP-BAND fail to lose enough weight or present severe complications. Gastric bypass, which has both restrictive and malabsorptive components, is a good second-line choice for patients who did not do well with the band.

Keywords

Laparoscopic gastric bypass, band removal, hand-sewn gastrojejunostomy

Media type

Surgical video

Duration

17'06''

Publication

2011-12

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E-publication

WeBSurg.com, Dec 2011;11(12).
URL: http://www.websurg.com/doi-vd01en3466.htm

Laparoscopic gastric bypass after band removal: hand-sewn gastrojejunostomy

1. Clinical case presentation 00'19''

This is the case of a 34-year-old woman who had benefited from gastric band placement 6 years ago. Her initial BMI was 43 and she then lost weight to reach a BMI of 35. Unfortunately, dilatation of the pouch situated above the band along with total food intolerance made the removal of the band compulsory as an emergency case. Further to the patient’s weight control over one year, the patient experienced once again fairly rapidly a weight gain. The patient’s BMI reached a BMI of 38. Decision was therefore made to perform a gastric bypass in this patient.

2. Adhesions dissection 01'06''

As soon as the trocars have been introduced, the first thing to do is to check the operative feasibility because of the presence of several adhesions between the stomach and the liver. These adhesions are taken down by means of the monopolar hook in a very safe fashion in order not to cause any damage to the gastric serosa. This first step is indispensable to understand the anatomical relationships at the superior portion of the stomach.

3. Left crus dissection 01'46''

Once the different adhesions have been freed, dissection of the left crus is initiated by removing the gastrophrenic adhesions in order to have the posterior part of the stomach in contact with the left crus. The peritoneum is opened at this place. This maneuver will allow for an easy exit of the linear stapler.

4. Lesser sac opening 02'12''

An incision at the level of the lesser curvature is then performed so as to dissect the tissues and reach the lesser sac. This dissection is carried out in contact with the stomach using a forceps in a very cautious manner. Under direct view, entrance into the lesser sac is controlled. This maneuver is performed under visual control in order to avoid any damage to the posterior portion of the stomach. Here the lesser sac is opened.

5. Gastric pouch creation 02'50''

An automatic linear stapler (60mm long) with blue cartridges is being used. A first firing is made horizontally and the pouch is completed by a row of 60mm vertical staples. The posterior gastric channel is controlled until reaching the area lateral to the left crus. At the superior part, a small gastric bridge is left. A gastric channel is created in a retrogastric fashion and a last row of blue staples is fired.

6. Running reinforcement suture 03'50''

The stomach is separated from the gastric pouch and a running hemostatic reinforcement suture is made on to the two stapled lines –here the staple line of the gastric remnant. The suture material used is V-Loc™, which bears a loop at its end, hence avoiding to perform the first knot. Because of its texture, this thread can be fastened progressively as the suture is made without any re-opening. It is therefore unnecessary to stretch this running suture. This suture is performed on both sides all along the staple line on the portion of the distal gastric pouch and simply on the superior portion of the proximal gastric pouch. One of the interests of using this thread lies in the absence of necessity for tying a knot when one has finished the suture line. When the two running burying sutures have been completed, the gastric bypass procedure is carried on.

7. Biliary and alimentary limb measurement 06'10''

The biliary and alimentary limbs are measured. To do so, the omentum is totally lifted up. A window is created in the omentum, hence allowing to bring the alimentary limb upwards. This window is performed by means of the Ligasure® vessel-seaming device. As soon as the window has been achieved, the transverse mesocolon is retracted cranially in order to uncover the duodenojejunal flexure, which is easily found.

8. Biliary limb measurement 06'47''

A biliary limb is measured over 75cm. It will be attached to the stomach at the superior gastric pouch. Here a PDS suture material is used to attach the alimentary limb to the gastric pouch. The anastomosis will be carried out in two stages. Here the biliary limb is marked by a blue line in order to facilitate its identification later on.

9. First posterior running suture 07'52''

A first posterior running suture is carried out. It will bring the small bowel wall and the stomach together at the level of the line of staples and will create a posterior support plane

10. Gastric and jejunal lumen opening 08'26''

When this posterior plane has been completed, the gastric and jejunal lumens are opened using a monopolar hook. In this case, the absence of major tension on the small bowel makes the opening of the jejunum fairly difficult. It is an opening of approximately 3cm, which is performed on the gastric wall as well as on the jejunal wall.

11. Second posterior running suture 09'18''

Once the two lumens have been opened, a posterior running suture is performed using a 3/0 Polysorb™ suture. This plane is the most difficult to perform. Both the small bowel wall and the gastric wall must be grasped, in suboptimal visual conditions, because of the budding of the two mucosal membranes.

12. First anterior running suture 10'29''

When the posterior running suture has been performed, an anterior sero-serosal or sero-muscular running suture is performed, which will close the two lumens. This third running suture is easier to carry out. Because it is performed in a sero-muscular fashion it allows for a burying of the mucosa, and for a better visualization of the suture line.

13. Second anterior running suture 11'26''

This anastomosis will be completed by an anterior sero-serosal suture, which gives us a guarantee of total airtightness.

14. Anastomotic test 11'42''

The anastomotic patency is checked using a 36 French catheter, and a methylene blue test is also carried out. This test is performed prior to the sero-serosal running suture, in order to be able to replace a stitch should there be any anterior leakage. The anastomotic patency is controlled again, once the suture line has been finished, and another blue dye test is carried out. A 150cm long alimentary limb is then measured. It will be brought proximal to the biliary limb, which has been stained prior to the gastrojejunal anastomosis. Both limbs will be brought together using an absorbable monofilament suture.

15. Jejuno jejunal anastomosis 13'35''

The alimentary and biliary limbs are then opened in order to perform the anastomosis of the foot of the loop. This opening is carried out using a hook. A linear stapler is then introduced; it is a 45mm long white stapler allowing for the realization of a jejunojejunal anastomosis. The mark of the blue dye test can be seen on the biliary limb, which is still together with the gastrojejunal anastomosis at this moment.

16. Enterotomy closure 14'19''

The entry points of the linear stapler are closed by means of an absorbable monofilament running suture. The mesenteric defect at the foot of the loop should now be closed, using a non-absorbable monofilament running suture. A loop is tightened at its extremity in order not to make the first knot. Stitches should be sufficiently deep to stay in place and not to cause any peritoneal damage. This running suture helps to avoid any bowel loop incarceration in the mesenteric defect at the foot of the loop. The biliary limb is then separated from the gastrojejunal anastomosis. Until now, it was in contact with the gastrojejunal anastomosis to facilitate access to this loop. A 60mm long white linear stapler is used for division purposes.

17. Petersen\'s defect closure 16'12''

The Petersen’s defect should now be closed. Here it is fairly easy to find it. It will be closed using a non-absorbable monofilament purse-string.