Laparoscopic gastric bypass in a super-obese male patient (BMI = 54)

Over the years, the Roux-en-Y gastric bypass has been successfully used as one of many surgical treatments to achieve significant long-term weight loss. Through a minimally invasive approach, a faster recovery time with less pain and prompt ambulation is possible. However, this procedure is not free of postoperative complications; pulmonary embolism and cardiac problems can make the recovery of these patients very difficult. We show a video of a gastric bypass performed live showing all the preoperative and operative settings of the patient in order to avoid complications. The surgical technique is thoroughly explained.

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Laparoscopic gastric bypass in a super-obese male patient (BMI = 54)

Authors

M Vix, J Marescaux

Abstract

Over the years, the Roux-en-Y gastric bypass has been successfully used as one of many surgical treatments to achieve significant long-term weight loss. Through a minimally invasive approach, a faster recovery time with less pain and prompt ambulation is possible. However, this procedure is not free of postoperative complications; pulmonary embolism and cardiac problems can make the recovery of these patients very difficult.
We show a video of a gastric bypass performed live showing all the preoperative and operative settings of the patient in order to avoid complications. The surgical technique is thoroughly explained.

Classification

routine cases

Keywords

Laparoscopic gastric bypass, super-obese male patient, BMI = 54

Media type

Surgical video

Duration

24'24''

Publication

2009-01

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E-publication

WeBSurg.com, Jan 2009;9(01).
URL: http://www.websurg.com/doi-vd01en2532.htm

Laparoscopic gastric bypass in a super-obese male patient (BMI = 54)

1. Clinical case presentation 00'21''

The patient, despite several attempts at losing weight by dieting, did not achieve his aim and we perform an extensive preoperative workup before operating those patients and perhaps we can discuss which types of examinations are important or mandatory. The patient has had a previous appendectomy in his medical history. Dr. Vix is going to perform the gastric bypass and before the operation, we will also show you some details of the patient’s setting on the operative table; all the details are important in order to prevent complications due to deep vein thrombosis.

2. Patient and table preparation 01'11''

The patient is very large, the legs are spread and they are fixed with wraps around the legs. We now routinely use those cuffs around the calves and the legs in order to inflate and increase the pressure, and to facilitate the blood flow towards the heart so as to reduce the risk of deep vein thrombosis. Those cuffs are connected to the spermatic tube, in turn connected to an automatic pump, which inflates the cuffs every 10 seconds to send the blood to the heart. This system is left in place 24 hours after the operation. We then perform a “crash test” to ensure that the patient is well fixed to the table.

3. Trocar placement 02'17''

First of all, for the trocar setting, the first one that we have put in place is the optical trocar that we place one handbreadth and a half under the xiphoid process, and all the time we use an open technique, which is very easy and feasible with these S-shaped retractors that allow us to see and open the fascia under visual control. This trocar will help to retract the fat, retract the stomach and so on, you will see it. The third trocar is an operating trocar for my left hand in the right hypochondrium, and opposite to it, there is a second working trocar that will be used for the steps that are over the mesocolon. This trocar will be used for my right hand under the mesocolon. The last trocar that we put in place is just below the xiphoid process to retract the liver and to help with the anastomosis. The patient has an 8-day diet with very low fat so that the liver decreases in thickness. You see here that the liver stays in place, of course, as it is a large liver, but it is interesting to have this diet during the days before the operation. I will do an ante-colic, ante-gastric anastomosis approach of the alimentary limb, and you see here we’ll just have to cut a large omentum. It is a male patient so I think that we have more fat in the upper part of the abdomen, it is quite challenging to operate men with important BMI’s; it is easier in women. We finish cutting the omentum; while doing that, we place some traction on the colon and we will push the colon upwards: by doing that, I just want to see where the mesocolon is.

4. Measurement of the biliary limb 04'44''

I expose it very clearly because I have to find the duodenum. Here you have the duodenojejunal junction, you can see it very well here. I have to measure the biliary limb and the biliary limb measures about 75cm long. A little trick, you see I have a 5cm landmark on my grasper here, so I will rotate all the biliary limb in the left hypochondrium. At this moment, I give my assistant the measured biliary limb. We place a stitch between this part of the limb. Don’t move because I have to find the stomach, and so you see I am able to bring the stomach under the liver. I will bring up this bowel close to the stomach and I will do a knot to fix it here. The position of the patient is quite horizontal at this moment, we will change the orientation for the dissection. This stitch will be removed; on the right side of this stitch, you have the biliary limb; on the left side, you will have the alimentary limb. I will mark the biliary limb to be sure I make the right anastomosis.

5. Measuring the alimentary limb 06'39''

The second step is at this moment to measure the alimentary limb; here the little trick is to put all the alimentary limb on the right side of the abdomen to your left side here so that the bowel is not in the way. Here I measured 150cm of alimentary limb, I put a stitch, which will be the upper part of the jejunojejunal anastomosis. We will bring this point in the left hypochondrium. Here you have the stitch on the stomach, just here and behind, you have the biliary limb, you see it on the drawing. This will be the limb in which we will perform the anastomosis and here is the alimentary limb that comes here on the root.

6. Jejuno-jejunal anastomosis 07'52''

To do this, we will use an endo-GIA with a white cartridge, and just with the hook, you see it is enough. When the entry wall is opened, I push my hook inside. Here the wall is very strong, I am struggling a little bit with the wall. I will bring up the second limb like I showed on some tables yesterday in the lab, I bring it round like trousers. It is a 60mm long and when it is performed, I open the GIA inside and close it again so I don’t increase the hole. I will do 2 running sutures of PDS, the first stitch will be on the lower part of the anastomosis. I just finish closing the anastomosis. It’s the second running suture that I did from the upper part to the lower part. You see it’s sometimes not easy to manage an obese patient. The first stitch I put is the one on the lower part here because when the wall is opened, it is very easy to put the first stitch here, so I just stay and do the knot and then my sutures are just kept there and wait. After that I begin again on the upper part, at this moment, I have to close the hole in the mesentery, you see this opening here, so I put the end of the alimentary limb by opening it like a book.

7. Closure of the mesentery defect 11'06''

I will put an absorbable suture to close this defect on the lower part of the mesentery. If you want, you can go through this loop here with your needle, I don’t do that for the digestive anastomosis, just for closure. I think the defect of the meso is OK because we don’t create enough adhesions in laparoscopy to close these holes. Using the open way we used absorbable sutures, but here in laparoscopy when you go back you find a very nice hole opened, and even with that suture, sometimes you can have some openings, a secondary opening when the fat is going away with the weight loss.

8. Preparation of the gastric pouch 13'04''

Here we have to tilt the patient. We introduce the liver retractor. We have a severe tilting there, 45 degrees I think, you will see the upper part of the stomach. The first step here is to open this gastrophrenic ligament here. Here you just open, see the way the posterior aspect of the stomach of the cardia here, I open the peritoneal sheath here that is very important to finish my staple line here and to find an opening when I finish the staple line. The first gastric vessel is here in the upper part under the fat, the second one is here, and I will just put my opening of the lesser curvature here and we will open the lesser sac here very close to the lesser curvature. Here you see the posterior aspect of the stomach very nicely and I will try to enter the lesser sac. You see the lesser sac beautifully as well as the posterior aspect of the stomach here. Today, we have few indications of the gastric band due to the poor results after 5 or 6 years and the complications that occur at the same time. For the band, the problem you have is that the band is really patient-dependent in its results and it’s easier to lose weight with a bypass than with a sleeve gastrectomy. At the beginning when I tried to make some bypasses here, I had to explain for a long time to the patient that this complex operation is better to lose weight, today patients want a bypass and not a band, at the beginning it was exactly the opposite. We try to do the retrogastric tunnel, so it’s very important you see that the bulge of the posterior wall of the stomach will keep outside of the staple line so you don’t have a huge pouch at the upper part. This is the second vertical staple line, and we will go up very gently and slowly in order to make a very nice gastric pouch here. You see we are very close to the spleen here, and sometimes you can have some little injuries. At the beginning of the experience, we absolutely wanted to remove all the fat that we had here in the upper part of the abdomen, when you pull fat you have more fat coming here and the lesson today is to go very close to the cardia, to dissect the posterior aspect of it, to go to the posterior aspect of the stomach, and you don’t take care of the fat, you keep it in place and that’s enough. In this case, I saw very well what I did and with some experience, I think that you don’t need to use the bougie. I think it is a good thing to use the bougie at the beginning just to be sure that you are in the right direction and that you have enough tissue remaining on the esophageal region and not make a stenosis there. When you buttress it, it is not necessary to oversew of course, I had some fistulas on each side and usually it is a good job for the resident that is learning to handle an intracorporeal needle and suturing, even if the running suture is not completely perfect, it doesn’t matter, but it is a good exercise.

9. Transoral insertion of the anvil and intra-abdominal extraction 18'07''

This is a prepared anvil, the anvil is tilted and so it doesn’t take too much space when going down through the esophagus. It is an orogastric tube and the anesthesiologist pushes it through the esophagus, we take it in the stomach and after that, we will remove the tube, you will see it inside. I have made a little opening in the pouch, just at the angle of the first two staple lines because that is the region with the worst vascularization. Here you see the tube coming through the little hole in the stomach. Second grasper, you will put the tip here inside the anvil here, I will put a purse-string around. I am just cutting the bowel, I am cutting the alimentary limb here. I will use the Ligasure device to enlarge a little bit more here the distance of the mesentery between the two parts. Why did you put a clip on your suture? Because I was unable to continue my knot, it was a little bit too short. I will open the staple line with the hook to introduce the device. I think that with the circular stapler, you can do smaller pouches than with the linear stapler you can also sew it by hand. It is interesting because you can establish protocols of all the procedure so all the team will learn how to do a gastric bypass and that is interesting.

10. Gastrojejunal anastomosis 20'49''

I introduce the stapler. We have just to organize the field inside, we use the upper trocar to take a long part of bowel from the alimentary limb, I will give this to my assistant and so you see we can bring the bowel up, and I bring the stapler in the field. We are inside through the wall. We go back. I have to find my anvil, here it is and here is the stapler. The blue landmark is here, here I check and so I will fire. You can tell when the head tilts, we will check immediately the doughnuts. Here you have the doughnut coming from the bowel, it is totally circular of course, and here you have the gastric doughnut that is not interrupted too. We close the stapler and remove it. I close the jejunum with a white cartridge. I close the bag used for the extraction of the specimen here. This is the closure of the bowel here. Just to finish, I will put a stitch on each side to suspend the anastomosis and afterwards I want to close the Petersen’s space.

11. Petersen\'s space closure 23'50''

I can just show you where the Petersen’s space is, here is the alimentary limb climbing to the gastrojejunostomy. This is the meso of the alimentary limb and here you see the Petersen’s space and on the other side you have the duodenum. We just have to close that.