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Laparoscopic gastric bypass in a patient with a BMI of 51

This video demonstrates the bariatric procedure of Roux-en-Y gastric bypass, with the Roux limb in the ante-colic position. The jejunojejunostomy is performed with a linear stapler, while the gastrojejunostomy is carried out with a circular stapler; the anvil having been passed down from the mouth into the stomach, attached to the end of a nasogastric tube. This video is suitable for bariatric surgeons. The authors identify the duodenojejunal flexure (ligament of Treitz). They measure a biliary loop of 75cm, shelving that to the left and temporarily attaching it to the stomach before marking it. They then measure a 150cm alimentary limb and place it in the right side of the abdomen, and attach it with a suture to the end of the biliary loop. They create a minimal opening in the two loops with a cautery hook to allow passage of the linear stapler, using 2.5mm staples. They close the opening through which the linear stapler is introduced with an absorbable 2/0 braided running suture. The procedure continues with the closure of the mesenteric defect.

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Laparoscopic gastric bypass in a patient with a BMI of 51

作者群

M Vix, J Marescaux

摘要

This video demonstrates the bariatric procedure of Roux-en-Y gastric bypass, with the Roux limb in the ante-colic position. The jejunojejunostomy is performed with a linear stapler, while the gastrojejunostomy is carried out with a circular stapler; the anvil having been passed down from the mouth into the stomach, attached to the end of a nasogastric tube. This video is suitable for bariatric surgeons.
The authors identify the duodenojejunal flexure (ligament of Treitz). They measure a biliary loop of 75cm, shelving that to the left and temporarily attaching it to the stomach before marking it. They then measure a 150cm alimentary limb and place it in the right side of the abdomen, and attach it with a suture to the end of the biliary loop. They create a minimal opening in the two loops with a cautery hook to allow passage of the linear stapler, using 2.5mm staples. They close the opening through which the linear stapler is introduced with an absorbable 2/0 braided running suture. The procedure continues with the closure of the mesenteric defect.

關鍵字

bariatric surgery, obesity, bypass, jejunojejunostomy

媒體類型

手術影片

期間

15'15''

刊物

2007-06

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Jun 2007;7(06).
URL: http://www.websurg.com/doi-vd01en2068.htm

Laparoscopic gastric bypass in a patient with a BMI of 51

1. Division of greater omentum 00'15''

We begin the procedure by dividing the greater omentum. This opening will allow the alimentary limb to ascend to the gastric pouch without tension. It is performed with a 10 mm vessel sealing device, also known as LigaSure®, which ensures a bloodless division. This allows us to gradually expose the transverse mesocolon.

2. Measurement of biliary limb 01'00''

The foot of the transverse mesocolon is carefully exposed to find the duodenojejunal flexure. This is attached to the ligament of Treitz. No loop manipulation is carried out at this stage. Once the duodenojejunal flexure is localised, a biliary loop of 75 cm is measured with a calibrated fenestrated grasper. This loop is shelved in the left side of the abdomen. It is temporarily attached to the stomach before being marked with methylene blue.

3. Measurement of alimentary limb 02'10''

A 150 cm alimentary limb is now measured in the same way but placed in the right side of the abdomen. It is attached by a stitch at the end of the biliary loop to perform the anastomosis at the foot of the loop.

4. Jejunojejunostomy 02'40''

A minimal opening of the two loops is performed with a hook to allow the passage of a linear stapler. A 60 mm white cartridge is used. In this cartridge, the staples are 2.5 mm in height. The openings through which the linear stapler is introduced are then closed by an absorbable running suture. We use a 2 0 braided suture to do this closure.

5. Closure of mesenteric defect 04'07''

The mesentery defect at the foot of the loop is now closed by a non-absorbable mono-filament running suture to avoid internal hernias. We use a nylon 2 0 suture to do this closure.

6. Creation of gastric pouch 04'50''

The patient is then placed in reverse Trendelenburg position. We approach the cardia. The left pillar of the diaphragm is dissected posterior to the stomach. The anterior superior part of the stomach is then freed of the Belsey fat pad in order to clearly view the angle of His. This zone corresponds to what will be the end of the gastric pouch. Now the opening of the lesser sac is performed by keeping close contact with the stomach beneath the second gastric artery that is observed. A division perpendicular to the lesser curvature is then performed with a linear stapler using a blue cartridge; these are 3.5 mm in height. The lesser sac is then explored and the posterior dissection is then continued towards the left pillar of the diaphragm. A linear division, again using 60 mm cartridges with 3.5 mm high staples is performed perpendicular to the first one. The dissection line is going towards the left pillar, and this is completed, and the gastric pouch if fashioned. A hemostatic running suture this time using an absorbable monofilament suture is performed along the two staple lines.

7. Anvil placement 08'30''

An opening is performed at the left inferior corner of the gastric pouch; this is to allow the passage of the anvil positioned on a orogastric tube that is introduced by the anaesthetist. The probe is removed and a purse-string suture is then performed around the tip of the anvil.

8. Gastrojejunostomy 10'15''

The prepared alimentary limb is divided. It is then opened in order to introduce the circular stapler. The jejunum is perforated by the spike, and the needle valve is retracted. The anastomosis is then performed. When opening the stapler, we unscrew the anvil too many times and as a result it detaches from the head of the stapler. Fortunately, we are able to search for and retrieve the anvil without too much difficulty. The doughnuts are then checked. The alimentary limb is then closed using a linear stapler. Again, we use a 60 mm stapler with 2.5 mm high staples. Two suspension sutures are placed on each side of the anastomosis. A methylene blue test is then done to check the integrity of the anastomosis. We rotate the anastomosis to check the posterior staple line.

9. Closure of Petersen\'s defect 14'00''

Finally, the Petersen’s defect, this is the defect between the transverse mesocolon and the mounted loop of small bowel, this is closed by a non-absorbable purse-string suture to prevent internal herniation. The procedure is now completed.