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Laparoscopic sleeve gastrectomy converted to gastric bypass

This video demonstrates the performance of a gastric bypass in a patient who already had had a sleeve gastrectomy performed previously.

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Laparoscopic sleeve gastrectomy converted to gastric bypass

作者群

M Vix, D Varela, J Marescaux

摘要

This video demonstrates the performance of a gastric bypass in a patient who already had had a sleeve gastrectomy performed previously.

關鍵字

gastric bypass, sleeve gastrectomy, laparoscopy, conversion

媒體類型

手術影片

期間

11'13''

刊物

2008-03

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Mar 2008;8(03).
URL: http://www.websurg.com/doi-vd01en2251.htm

Laparoscopic sleeve gastrectomy converted to gastric bypass

1. Complex case history 00'15''

This is the case of a 46-year-old woman with a surgical history of 2 prior caesarean sections, a cholecystectomy and a gastric banding placed because of a BMI of 47. In 2005, a barium swallow showed a normal placed cardia with no stenosis or hiatal hernia. A biopsied lesion in the greater curvature revealed an endocrine, carcinoid-type lesion. For this reason, a gastric sleeve resection was decided upon. Pathological examination reported diffuse micro-nodular endocrine hyperplasia with intestinal metaplasia. Postoperative barium swallow showed a tubular stomach with irregular contours. The passage of contrast wass uneventful and no fistula was observed. By 2007, the patient had lost a bit of weight

2. Case begins with adhesiolysis 01'05''

but her BMI remained at 40. Preoperative work-up studies were normal and therefore revisional bypass was decided upon. In order to identify where the previous sleeve gastrectomy resection had started, we measured a length of 6cm proximal to the pylorus. You can see that we are still able to identify the sutures that have been placed on the staple line. On this side of the sleeve, there are some adhesions to the staple line and the left hepatic lobe, and we prefer to free these with the aid of the Ligasure.

3. Lesser curvature dissection and entry into lesser sac 02'04''

Now the first step of the procedure proper is the creation of a gastric pouch. The line of division begins between the first and second vascular arcade along the lesser curvature, and to perform this dissection, we prefer to use the hook cautery. Dissection is carried out on the right edge of the stomach with the aid of 2 atraumatic graspers. The lesser sac is opened and the posterior gastric surface is dissected. The linear stapler is introduced cautiously into the previous dissected space and is placed perpendicular to the axis of the esophagus.

4. Gastric transection 02'58''

The stomach is retracted caudad, and the gastric tube removed and the stapler fired. Two additional applications are necessary to completely divide the remainder of the stomach. The resected stomach is then placed in a retrieval bag.

5. Placement of circular stapler anvil 03'23''

Next, an incision a few millimetres long is made over the staple line on the gastric pouch. The anesthesiologist pushes an orogastric tube with an anvil attached to it. This anvil is passed down the esophagus and into the proximal gastric pouch. Once the orogastric tube is in the abdominal cavity, it is retrieved outside and the anvil is freed. A running suture is placed around the anvil at the gastric pouch.

6. Creation of duodenojejunal limb 04'12''

Having completed the preparation of the gastric pouch, we now prepare the entero-enterostomy. To do this, the ligament of Treitz is identified with a minimal manipulation of the small bowel. We aim to measure 50cm distal to the ligament. The duodenal jejunal limb is then fixed to the greater curvature of the stomach and it is marked to avoid any errors during the re-anastomoses.

7. Roux limb measurement 05'06''

From this landmark onwards, we measure 150cm distally to obtain the Roux limb. An anchoring suture is placed between the limbs to mark the site of the entero-enterostomy.

8. Jejunojejunal anastomosis 05'31''

A small incision is made with the tip of the cautery hook on the antimesenteric border of the duodenojejunal limb and the gastrojejunal limb. The entero-enterostomy is then performed with a 60mm linear stapler. Following this, the stapler insertion sites are closed using continuous sutures.

9. Closure of mesentery 06'35''

Closure of the mesenteric defect is essential and to do this, continuous suturing is performed. Approximately 50cm from the ligament of Treitz, the small bowel is divided with a linear stapler for future anastomosis to the stomach.

10. Jejunal transection 07'47''

The stapled tip of this Roux limb is opened using a hook cautery. First however, a hemostatic suture is performed along the gastric pouch in order to invaginate the staple line.

11. Gastrojejunal anastomosis 08'49''

The head of the circular stapler is introduced 5 to 10cm into the open end of the Roux limb. The spike of the anvil shaft perforates the small bowel at its antimesenteric side. The Roux limb is then brought to a supramesocolic position. The circular stapler is then fired and loosened and removed from the limb. Immediately, the integrity of the donuts is checked. A linear stapler is then used to close the Roux limb. The resected portion of jejunum can then be placed into an Endo-bag. A single suture is placed on each side of the anastomosis to protect it. Petersen’s space is then closed to prevent the duodenojejunal limb from becoming occluded or strangulated. A drain is left adjacent to the gastrojejunal anastomosis and it can be removed after 24 or 48 hours. A water soluble contrast examination performed on postoperative day one confirms the absence of anastomotic leakage.