You need to log in to watch this media!

Click here to log in.

Laparoscopic gastric bypass with hand-sewn gastro-jejunostomy

Authors

Abstract

This is an interesting live video that shows a laparoscopic gastric bypass for morbid obesity with a hand-sewn gastro-jejunostomy and transmesocolic passage. All technical details and tips and tricks are well presented and discussed.

Keywords

Laparoscopic gastric bypass, hand-sewn gastro-jejunostomy

Media type

Duration

38'00''

Publication

2010-04

Popular

Favorites

Audio

Subtitles

E-publication

WeBSurg.com, Apr 2010;10(04).
URL: http://www.websurg.com/doi-vd01en2948.htm

Laparoscopic gastric bypass with hand-sewn gastro-jejunostomy

1. Intra-abdominal view 00'19''

We are just putting in our trocars and I am going to do a survey and tell you what’s going through my mind. You can see that the patient has a kind of a large liver. The first port I have put in is actually in the left upper quadrant, it’s this one here. And this allows me to look down. I can see that the liver is a little large, but I want this port to come in below the liver edge because I need this to be my optical port and I need to see the small bowel. I need to put this port in precisely. I usually put in the left upper quadrant port in first, then I put in the optical port, which is in the midline, and it varies, sometimes it’s even below the umbilicus depending on how big the liver edge is. Once we do this, then we put in our right upper quadrant port here and one of the tricks I think in these patients that are this big, you don’t have a lot of torque on the wall because they are so thick, we have to angle in our ports, not straighten perpendicularly, but angle it in into the objective. And then we have another operative port, which is here, and this maybe a little bit low for us but you can see how this is angled in on the abdominal wall, directly aimed at the root of the mesentery because this is where we want to be. Those are our four ports, and then we usually put in a liver retractor as well, but we’ll put that one in a little bit later. Now the first thing I do is decide whether I can even do a bypass. First thing is look and make sure we have a hiatus, we try to improve safety so we usually use one tube in these patients, and that’s the orogastric tube that we just saw. That decompresses and that also sizes our pouch, and we pull that back to our GE junction, that’s already in and we know that that is done. I can see the GE junction, and I know that I can do a bypass, a sleeve, a band or anything I want. Let me see that fancy Ligasure® device.

2. Gastrocolic ligament opening 02'51''

I want to get to the gastrocolic ligament here because I want to see behind the stomach, in this case I am using the Ligasure® device. Does a great job at hemostasis, doesn’t it? I am a huge fan of bipolar technology so this is actually kind of nice. The AS and BS recently updated the standards to make it a little less investigational and wording. But most of our operations are pretty reversible, even the bypass. Look down this way now. It’s important here, and I saw Michel Vix do this, to visualize back here real well. You can see the pancreas real pretty back here, but I want to make sure that there are no adhesions back here coming in that are going to affect us. I am going to discuss the attributes of retrocolic versus retro-antecolic, retrogastric, antegastric, all that sort of thing. It’s not clear whether or not that guy’s mesocolon is actually pretty small. Let’s say for example that that guy had a lot of omental adhesions, or this was a woman and had had a hysterectomy, I think an advantage of this is to be able to go in supramesocolic and get to the small bowel, if we can find the right plane. I think you should point out that this person didn’t really have much of retrogastric pancreatic adhesions, but that you would have taken them down if they had been there. Right that is a bit unusual, most of the times there is something there that would interfere with us making a nice pouch, or at least make us wonder, especially if we saw a great big splenic vessel hanging up there.

3. Mesocolic window 05'29''

So now he is making the window through the mesocolon, just to the patient’s left of the ligament of Treitz. I am just trying to look at it from my standpoint. I believe in less work, we couldn’t see it that well from above that well, let’s go in below, let’s reflect the colon upwards and see what it looks like, so let’s look down, here is the ligament of Treitz. So he’s pushed it underneath the liver, grabbing the mesocolon and elevating it up, then it’s easy to find the ligament of Treitz. Hold that for me and let’s see the Ligasure® again and to find that retrocolic window. Can you point out some anatomical landmarks, why you chose that spot to go through? Basically, I am looking for a spot where it is not very tethered down, unfortunately there isn’t very much in anatomical landmarks except for what I’m looking at is how the tissue is actually moving. So finding this retrocolic window should be pretty easy, if it’s not easy in patient like this, I would just go antecolic with my Roux limb, but it should be a pretty avascular plane and just above where the ligament of Treitz is. Look down, here is the ligament of Treitz here to get up into this area here. Since this patient has got a pretty small omentum, I just want to see where we were before, and that’s how close we were to guessing from above. You can go from above, below if you are going to go retrocolic, now if we were going to go retro-antecolic, we would want to split all this omentum, and the problem I find with most of my patients is they’ve got omentum’s going all the way from here to Baltimore and it takes me a long time to split that, so it’s efficient to come in below and not worry about it.

4. Jejunal division 07'51''

The first stapler we are going to use is a 60mm on a white stapler. In the old days, before we knew about the foregut, hindgut, duodenal-jejunal exclusion that sort of thing, we just instinctly wanted to make the biliopancreatic limb as short as possible so that the endoscopists had an easier time getting around it. These days it also makes sense to go further on down, but truthfully we found little difference in our long-term results or diabetes resolution whether short or long, what I am looking for is just a nice area so that I can bring this Roux limb up without any tension. Is it 45 or 60? 60. It looks smaller. I’ll take the Ligasure® device. So surprisingly you really don’t have to take too much of the small bowel mesentery to mobilize it up, but we are going to go ahead and mobilize it a little bit more. So here is a 10cm ruler.

5. Roux limb measurement 09'09''

We really don’t want to create a Roux-en-Y, we want a wide picture of what we are doing, this is going to be the Roux limb here, I’ll measure 10 and purposefully take this and stick it down here so that we can see what we are doing. There’s 10, there’s 20, 100. By convention, we are making a 100cm Roux limb, doesn’t make a difference if it’s 70 or 150. I’m going to take my ruler out and I’ll have the suture now. We’re going to use some absorbable suture, this is the 3/0 Polysorb, and so my suture line, I am actually not going to go antimesenteric, I’m going to come in about 9 o’clock on the small bowel and I’ll show you why in a little bit. That’s going to be taken to the 12 o’clock position here. The sutures are about 15cm long. I don’t know how many knots we put in Polysorb, in Vicryl we usually use 3, you’ll put 4 in just in case. And again, we’re always looking at the mesentery, we want it to look like a little flower, here’s the Roux limb over here, biliopancreatic limb, common channels so that we don’t make a Roux-en-Y. Is this out of focus for you? Now I take my double-action grasper, that one the blue one.

6. Jejuno-jejunal anastomosis 10'59''

Then we’ll spread a little bit in there. Then we’ll put our stapler in there. Stapler going in on this side, bring it around, then we use that post to bring it up, open up, pull out. And then we check for bleeding. One of the first signs of stapler misfire is bleeding intraluminally after this sort of thing and it looks pretty good. Now we have our suture that’s parked in there, that we used, now we have this suture here, and we’ll want to look at this corner very well, as we use the Ultracision energy it doesn’t bleed very much, I don’t need quite so much string, so we’ll go ahead. So another principle of suturing is that we want the suture length to be just right, so if you use too long a suture, then you can trip over yourself. We don’t want to make it too hard on nursing staff, so we cut the sutures to a certain length and then adjust intra-abdominally in order to get it just to where we want it to be. So we purposefully put our ports in to take advantage, we really want our ports to be optimized for the gastric pouch, so we compromise a little bit on the jejuno-jejunostomy, so if I have to sew a little bit on the anatomy backwards, upside down here, that’s ok because I really don’t really need to make anything special down here and as long as you don’t compromise on the pouch size. You can see we are sewing directly to the post so we avoid sewing the suture to itself. Every suture has its own characteristics and absorption rate, to work on the pancreas we would use the PDS rather than the Vicryl suture because it absorbs too quickly. So that’s that. Now I want to inspect this staple line here. Can I have a grasper? It is not a staple I usually use, it looks pretty good.

7. Mesenteric defect closure 13'33''

Now we have a mesenteric defect here, the question is do we close it or do we leave it alone? And the answer is we close it. So we are going to use a permanent suture and we’ll talk about internal hernia defects and small bowel obstructions tomorrow, but I really believe that if you leave a mesenteric defect then you should close it up, you need to use permanent suture and you’ll still going to have internal hernias and bowel obstructions occasionally, but it won’t be nearly as frequent as if you didn’t close it up. At Hackensack, in his open operations, he didn’t close the defects, so for a while we had a very high rate of internal hernias. I started with open surgery, and we would just put a few Vicryls. Now see the reason I went in at a 3 o’clock position on the small bowel here. Another New Jersey surgeon, Bob Roland popularized the idea of suturing these things up there as little so it doesn’t kink here, so we are using this closure in order to prevent a kink as well. It’s not truly a Brolin suture, but I think the idea is important and I think he should deserve credit for that. It will not kink; the other thing I like about it is that it oversews the staple lines too. So any chance I get to oversew them, I like to take without being too anal about it. So now I need to have a quick line here running down this way, I don’t want to get too deep, I just want to stay next to that staple line so that I don’t cause a hematoma because a hematoma in this area really is a bad deal. I haven’t struggled too much from doing it. I just want to show you this a little bit better; coming around just prevents that from kinking right there, makes it nice and linear. Because we never knew what assistance we were going to have, so we did it to be independent. We’ll go ahead and put our Roux limb underneath the colon, bring this up, I am going to put just a little bit more, just in case, maybe I’ll be able to demonstrate why in a little bit. We’re going to close this up. You can see I’ve used the same suture, I’ve cut a little bit long, just so I wouldn’t have to exchange instruments so much while I’m in there. Now I don’t want to go real deep here, what this permanent suture does, it does set up some adhesions. So if we go back in here 3 years from now, this mesentery is completely fused and so this patient has a zero lifelong history of getting internal hernia; that’s what I’m aiming for. I don’t expect the suture to be around for ever, but I do want to set up the adhesions to make it so. Even if you do open surgery, you are still going to see internal hernias now and then, I’m sure that original descriptions of internal hernias were in open surgery, they were in transplant groups, but even in gastric bypasses. Harvey Sugarman for example noted that.

8. Petersen\'s defect closure 17'35''

Here is the Petersen’s defect, and it’s a pretty good sized one so things can go through, so we’re going to close that too. I’ll take the other silk. I like what you said about the suture manipulation, Garth. So we’ll go ahead and just close this little thing up. Now you don’t have to close this up now, you can close it up at the end, I just don’t like going back and forth. Once I get done with one area, I want to move on and go to the next, I don’t want to have to go backwards. Once you get started, and on larger patients, you’ll come to realize that less manipulation of the omentum and things you do, the fewer problems you are going to have, especially with bleedings and all that stuff. So now hopefully we are done with the bottom part, and we are going to work on the challenging upper end. This is going to be a challenging patient on the top end actually. I think the exposure is going to be tough, I think there is going to be a hiatal hernia here and I think we are going to fix that. I should demonstrate how to do things wrong too, it’s probably more instructional. Now let’s take this and we’ll put this all down. Take our omentum. I think another important other thing when you move on from the bottom, is that the camera never moved out of sight, his Roux limb was always in view. If you get the camera dirty and pull it out, you may miss its sign, which limb is which when you go back in and so then it’s easy to make a Roux-en-circle like you said. This is going to go in subxiphoid this liver area and I will put in a liver retractor of some sort. I will put this up like this maybe. You haven’t seen one of my graspers? Let’s hold that out of the way like that maybe, no like that. Alright let’s look over here. If you’re going to do bariatric surgery, you’ve got to know lots about the hiatus. The hiatus has just got to be a second nature, whether you put a band in, whether you do a bypass or a sleeve. I was really happy to see Michelle do a lot of nice dissection up in this area because I think that’s important. Given my assistants are having a hard time figuring out what I’m doing here, I apologize. They’re doing a good job. Interestingly, we started off by saying we hardly ever see hiatal hernias in our patients with bypasses, and then we started to do a lot of revision surgery and it’s like every revision patient I ever did with a bypass has a significant hiatal hernia. And then we said let’s do endoscopy on all our patients ahead of time, see if we can identify things. And we found a significant number of hiatal hernias and then we say, well let’s correlate that with intra-abdominal findings and we found that the incidence of hiatal hernias are rather high if we actually take apart and do this kind of dissection. And then, Chris Rennan and their group and George Fielding came out with their studies looking at bands and repair of hiatal hernias and failure rates and things like that. Where I put my stapler, if I really want to exclude the stomach, then the only way to do that is to take the fat off. You may keep this. Now we can see things a little better, can’t we? See the shears. We can see the crus coming in here and we can see this stuff here. So we’re going to come up and around, and then we’re going to come to the other side. See it’s fairly avascular here, I hope. And then we’re going to go up this way a little bit. See there are some vessels up in there so we’re going to switch to the Ligasure®. Now it’s interesting what this looks like here let’s use other device, the Harmonic, the Ultracision thing. We’re doing a lot of instrument exchanges just because no other reason than my infamiliarity with some of these devices so I’m not sure how hard to push it. They’re all working well though. Alright now, hard part is all this fat here and we should be looking at that stuff down out of our way just by grasping onto that, pointing out laterally just a little bit. Hold that, hold that. We’re going to check to see if there’s a hiatal hernia. Because we don’t really know how these operations work but we do know what, we think we know why they fail, at least anatomically. So what we want to do is optimize things out the door and get go. Looking at that, I think that I could do bariatric surgery. Hold this one. We can see there’s a defect here. It’s only because now the next suture I want is an Ethibond suture. Can you pull back the tube an inch? Can you pull back the tube a little bit? Why do you think that contributes to the failure of the gastric bypass? I’ve no idea. It’s just like I said almost every revision I do, they have a significant hiatal hernia. If you repair the hiatal hernia, they have less explants and improved performance; in the short run doing re-operative surgery is not easy, I mean but what I’ve noticed, what is kind of interesting is that if you don’t dissect posteriorly, you’ll miss the hiatal hernia a lot of times. So I’m not one of those guys who stick and put sutures in anteriorly and calls it a day. I don’t think that’s adequate, so let’s make a pouch. We don’t want it too much longer than 5cm. Now we know exactly where the GE junction is; it’s coming across there, it comes in obliquely. There are some vessels right there. Let’s have the single action grasper now just like that. Let me see the Harmonic thing. It’s more of a distance, I’m looking at maybe starting the dissection about 5cm off the GE junction, see so the angle here is actually a little bit lower down here I think. So you mention a little bit about the differences in techniques so we’re going to make our pouch lesser curve-based.

9. Lesser sac opening 26'18''

Now I’m rolling the stomach out because I want to get into the lesser sac’s space there. We can just talk about whether or not we need to preserve that vagus nerve or while we go perigastric to section here or not. That stomach’s emptied properly right? Not that we have to do that very often but sometimes we do. Most of the times, we just use the regular Harmonic scalpel that comes across here but I know each device has different levels of hemostasis, and so last time I used this device I really got into a lot of bleedings. I was a little gun shy of it. Now this lesser curve is always a lot thicker than you think it’s going to be, especially in male patients so we just keep winding around. You can see there are lots of big vessels here. Let’s see the Ligasure® again. We haven’t had that occasion where our fellows made a hole there. We need to compare fellow notes though. This is going to come from the right upper quadrant port and we’re going to come straight across here a little bit.

10. Gastric division 28'00''

We put this behind here because we’ve gone all the way through. and then we’ll see. We still have some adhesions back there but you can see that stomach right there. I don’t like the way that it looks. Take another blue stapler, another blue cartridge; our anesthesiologist passes the tube in. Can we have the tube in, the tube down? Is it a bougie you’re passing or? It’s that tube we put in. Here it is. Good, stop! Alright, there you go. And now lift that up a little bit. Hold that there. Just hold this one, let the other one go. And you can see by doing that dissection along the crus, we can see the crus pretty well right there. And then we can put this articulating finger up this way. And that will do some fancy sewing real quick. Just articulate this a little bit. No it doesn’t. There it is. OK, nice staple line, hemostatic all the way across, confirmed. And now we have a pouch coming in right there. So let’s see our grasper, let’s see if I can find have our Roux limb now. So we can take this limb retrogastrically or antegastrically now. So we’re going to bring that up just like that I think. I don’t believe that it causes more ulcers than the other ones; I think that it’s an associated finding. You can bring it in now. So now for this anastomosis, I’m actually going to sew the Roux limb to the posterior staple line right here so that we can triangulate on this anastomosis, because I always figured this was the hardest part of the operation, it’s a do this part.

11. Gastrojejunal anastomosis 30'20''

I think the hardest part of the operation is actually not the anastomosis, that’s why it doesn’t matter if you hand-sew it with the circular stapler, linear cutter it as long as it doesn’t leak. I think, for me, the most difficult part is just getting a good pouch, making sure that pouch is perfect as it can be, especially in challenging patients, patients that are bigger, the super-super-obese, the BMI 70 and 80, and as you might imagine the reason why we’re doing a revision is because the patient needed some more weight loss, they’re having marginal ulcers, they are having solid food dysphagia and all those other things we see. So I’m walking this on purpose. It’s all about being lazy Garth. And the tube is 1.2cm in diameter so let me see if I can demonstrate that. That’s it. Suction! So now we have one layer posteriorly. We’ve opened up the bowel, we see the scissors. Let me cut this needle off, I don’t want it any more. Scissors! So this is going to be a posterior running so start in the corner. Come around, I’ll quickly do a back hand, and now I’m actually going to put in another. Camera! I’m going to retract on this anastomosis for myself with this hand. You can see this is not like open suturing when you’re having your assistant retract for you. You’re actually retracting for yourself. And that way you avoid all that scissoring and fighting and backward motions and things like that. My knot is on the outside, so I’ll come outside in. And my suture is a little bit long, and you can see the mucosa on both sides. So this back row is pretty strong because it’s almost like two full-thickness running sutures. So now as we turn the corner, we’re going to have to do some back-handing there, so come around right at the corner and bring it through, we’re going to do a little pivot motion you saw Michel Vix do, and then come outside of the corner in. Grab it through, and then we can come around turn the corner this way. So the idea is to control the needle by controlling the suture. So we’re not manipulating the needle so much as we are the suture. Let the needle dangle, grab it, do a turn so that you can line it up to where you want it to be. I don’t like sewing backward so we’re going to start another suture line toward myself this way. I’ll take another suture as I suck on that a little bit. So we’re doing two continuous running sutures but the difference is that even though there are 4 different suture lines they are sutured to themselves, what you think Garth about setting you needle down properly, if you set up your needle and you grasp your needle so its perpendicular to your line like this, even though it’s oblique, once you start, you’ll finish exactly out of this way. So start this way or finish that way. So now that knot is right where we want it. It’s a little trick on setting your needle because you cannot always see it all that well. I’m going to make my tail really long here because I don’t need that kind of suture length. And if have just the right length, I can pull up and reset my needle without too much fooling around. Pull up and now as you close this up, what we’re going to do is take the tube and we’re going to push that across so we want to have the tube come in now. So tube in! So it comes across. Come in now! There you go! A little more! Just leave it right there. We know the tube’s across the anastomosis so we know that it’s patent and we’re going to calibrate that anastomosis with the tube. So I don’t get confused which suture is which, this one has a needle on it. So I’m taking one needle out, one needle in, you can hold that. So this one goes to this one. That needle’s out, let it go. So what we’re going to do is go beyond that last suture, and come on in, trying our way out here, and we’re going to come up in here and grab this, so we absolutely make sure we close that angle. So here I don’t care if I go horizontal, I just want a good serosa-serosal bite. PDS just work well here too. A little harder to handle. I like the security of a two-layer anastomosis. If this was a high risk patient, a renal failure, I’d probably leave a drain but other than that with our primary patients, I generally don’t use drains. OK, let’s take our orogastric tube out now. Pull that out all the way! Tube out! OK, so that’s it! So there’s our anastomosis. I’m pretty happy with the anatomy, the pouch is nice and tight, this lesser curve, we fixed the hiatal hernia. I’m pretty happy with the anatomy, this is not the easiest case in the world but not the worst either. OK, so there’s our Roux limb, retrocolic, let’s go back, come back this way, all the way round, sealed up, up and round, and that’s it. So did we get all our stuff out, all of our drains, all of our stitches, all of whatever we left in behind. That’ll be done for us, we don’t generally use leak test. Thank you for another wonderful demonstration as usual.

Username
Password
	Remember me (needs cookies)