Live laparoscopic antecolic and antegastric gastric bypass for morbid obesity

Authors

Abstract

Gastric bypass is the most frequently performed bariatric surgery. It provides long-term and consistent weight loss. This video shows a laparoscopic gastric bypass in a 49-year-old woman with a BMI of 42.

Keywords

Obesity surgery, gastric bypass, circular gastrojejunostomy

Media type

Duration

22'54''

Publication

2011-01

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Audio

Subtitles

E-publication

WeBSurg.com, Jan 2011;11(01).
URL: http://www.websurg.com/doi-vd01en2958.htm

Live laparoscopic antecolic and antegastric gastric bypass for morbid obesity

1. Introduction 00'20''

This is the case of a 49-year-old woman with a BMI of 42. In her past medical history, a laparoscopic hysterectomy was performed 4 years ago and an epigastric hernia repair quite in her youth. We placed the trocars and I just want to show you the usual placement of trocars in gastric bypass.

2. Trocar placement 00'48''

The first trocar that we put inside is the optical trocar. It is one handbreadth and a half under the xiphoid process. It is an open laparoscopy that we perform all the time. After that, we put a 5mm trocar in the epigastric area in order to retract the liver. On each side, we put on the left hypochondrium a second retraction trocar. It is also a 5mm one. It is placed very deep in the left hypochondrium. Two 12mm trocars on each side on the mid-clavicular line. 12 mm trocars for working on the stomach. One trocar is placed quite lateral to the umbilicus. It is placed to work at the lower part of the abdomen to make the jejunojejunostomy. The gastric bypass that we will perform today has a particularity in this patient. There is quite no omentum under the colon and you see that the colon is totally free, and the cavity with just some fat at the lower part of the colon, but not really the omentum as we can see it usually. First step, if we have the omentum, is to open it to create a way to put up the limb going to the gastric jejunostomy, and we push upwards the colon. I will ask my assistant to push up the colon here and we will try to find the Treitz’s angle. You have just to lift the transverse colon to keep here in the mesentery.

3. Measuring the biliary limb 02'37''

Without taking any bowel, you will see here the out coming of the angle of Treitz very easily. So, at this moment, we will measure the biliary limb and we will measure 70cm for this biliary limb. As you see, we have a little landmark here, 5mm from the tip of the instrument, and this will help us for measuring. I will put all the small bowel of the biliary limb in the left hypochondrium to avoid any trouble after that with rotating and twisting of the limbs. We have 70cm. I will ask my assistant to take at this moment the limb here.

4. Biliary limb fixation 03'20''

I will put a little stitch here for fixing this landmark on the remnant of the stomach. Here you see the stomach. I will keep very close to the pylorus here just to make this landmark here. And I will fix the stitch that will be situated between the biliary and the common limb, here on the stomach. The stitch will be cut before the gastrojejunostomy. Here you see that the biliary limb will stay fixed to the stomach and it is very easy after that to find it again. It is fixed. We will cut the threads. We will put a little landmark just to be sure that we know which limb will be the biliary one. After that, we will cut this part here, and this will be the bowel that will be put on the stomach here.

5. Measuring the alimentary limb 04'15''

We will measure the alimentary limb. It is a 150cm limb. You see that all the bowel is put on the right region of the abdomen, so we have no crossing of the different limbs during the work we are performing. I will ask my assistant to take the bowel here and, again, I will put a stitch to fix together the alimentary limb and the biliary limb. This is the alimentary one, this is the biliary one, and this will be the common limb here. We will put first a stitch here in the biliary limb, 2 to 3cm from the stitch we put on the stomach, and we fix together the alimentary and the biliary limb here.

6. Jejunojejunostomy 05'04''

When this is done, we will begin with the jejunojejunostomy. We pull up the two limbs here. Here you have the stomach, and the first stitch is put here. This is the alimentary limb. This is the end of the alimentary limb that has come down and we put it a little bit on the side. This is the part following the alimentary limb that will be the common one after the jejunojejunostomy that we will perform here. This is the biliary limb. You see the small drain we did here. We will use the hook to make the opening to introduce the GIA stapler. We do the same on the other side. We will use a 60mm stapler, white cartridge, to perform the jejunojejunostomy. You see, now we are introducing each branch of the GIA stapler inside the bowel. For the second site, I pull up this limb and I put it on like a trouser. I will ask my assistant to take the bowel here very largely to avoid making any injury to the bowel at this time. You see, very gently, I pull up and I can perform the jejunojejunostomy. I open the stapler. I just drag a little bit inside and close it before taking it out in order to avoid increasing the opening of the bowel. We come inside with the needles. I will close it with one running suture. I can make some additional stitches with the needle on this side if I need it. Just with the stitch I put, I can change the orientation of the hole and have a better presentation of the lips of the closing, calibrating the tail of the stitch. The two instruments come together to take the end of this thread, really the end, to avoid having too much tissue on the end. I close it. I take again this part. I close it with the grasper and we put three or four additional knots for closing the first stitch here. This is the last stitch we have to perform here in the running suture. We close the running suture very slowly. I will cut the two threads I am taking out. You see the two threads here. I will take them out. And we have to close the mesenteric defect. It is on this side. You see it very nicely here.

7. Mesenteric defect closure 08'13''

This is the mesenteric defect that you will have to close. If you do not do that, you have chances to have an internal hernia. This was a little trick to avoid making the first knot. Inside you see the little loop here and so we do not need to perform the first knot. We go into deepness here to be sure that the defect is well closed. The danger or one of the possible mistakes here is to go in straight here. You need to go inside the little hole you have here. You see very nicely the vessels here. We will try to avoid them. The last stitch takes a part of the bowel very gently here in order to close totally the defect at the lower part. We will have a second defect, which is Petersen’s space. I will show you at the end of the procedure. See the loop. Before we go up, we have just to control this stitch here to be sure that you have no opening due to the traction. If you have, you have to put one stitch here. This is an absorbable suture, so this is not a big problem. At this moment, we will ask the anesthesiologist to put the legs down and so we will lift the left lobe of the liver. Here we are lucky, the left lobe is not so huge, but sometimes it is going up to the spleen. We will go to the lesser curvature and we will look for the vessels we have here. The first artery seems to be here and usually we are between the second and the third artery. Here you see that the second artery is quite large and here is the vision. We will make, I think, a little large approach, I do not know, we will have to see.

8. Entering the lesser sac 10'18''

I try to keep all the vessels here in place on the lesser curvature to have a good vascularization. I will just try to dissect between 2 of the branches of that second branch of the gastric artery. So just with the graspers, I will try to open the space we have behind the stomach here. I will try to do it under view control. You see, I am quite in the lesser sac here. You need to avoid injuries to the posterior aspect of the stomach. The lesser sac is here. But you see we have an artery at the lesser sac here that is a big artery, so I will just take a look how I can handle with that big artery here. It’s a 30-degree scope that we use here and I will put inside.

9. Gastric pouch division 11'35''

I ask the anesthesiologist to remove the nasogastric tube and we ask a second time to be sure that it’s OK and we will begin to cut the horizontal part of the stomach here with a blue cartridge, 60mm. When you have a bleeding, sometimes it’s very useful to find the lesser sac because when you are in the lesser sac, after that you have more space and it’s easier to perform your hemostasis. And my assistant will take the staple line quite on its last few centimetres here just in the corner and I will adapt the staple line. It’s a blue cartridge also and we will gently to make our pouch here. See that the second cartridge is a 60mm one. Usually, we use 2 to 3 cartridges to complete the pouch and you see very gently we are looking for the left crus and the posterior aspect of the stomach and you see the grasper coming out here. And so we will continue and finish the pouch here. You can see the tip of the stapler here and so that’s perfect. See it’s totally divided. This is the left crus. We were very far from the spleen and so the next step will be some bipolar cautery just to remove and stop the oozing that we have here. We’re just preparing the posterior aspect of the stomach that will be the region of the anastomosis and here I just need to make an additional bipolar cautery because I have some little vessels on the posterior aspect of the lesser curvature. This region is really vascularized and hemorrhage can be a major concern here. That’s perfect.

10. Staple line oversewing 14'02''

We oversew the 2 staple lines here. That allows for a better hemostasis here.

11. Stomach opening 14'12''

So at this moment we will open the stomach in order to push down the anvil of the GIA. To do so, we always open at the same point: it’s just in the corner between the 1st and the 2nd staple line here. And after that we will ask the anesthesiologist to push down a gastric tube.

12. Gastric tube insertion 14'38''

That’s a nice exercise, it’s not easy to perform because the mouth of a lot of superobese patients is very small and the opening is not very easy. You have a lot of teeth in the way and they are under the drapes. See the orogastric tube comes out very easily because if you put that through the nose, it’s difficult to push down the anvil. So the anvil is going down. It’s from the manufacturer. It’s the Covidien OrVil® probe and so you just have to cut the 2 little threads here at the lower part of this anvil. After that, you pull and we can remove this tube outside of the abdomen and you see the anvil is in place so you can remove here the thread that was placed to keep the anvil tilted and we will perform a purse-string around the out coming of the anvil. This is just to be sure that we have nice donuts when we perform the gastrojejunostomy. You need to avoid taking the tip of the anvil because this is a part of the mechanism, you see, there’s some little opening here and when you decrease this opening, it’s quite difficult to put the anvil in the stapler behind this purse-string. We take the needle out. See each time when you pull, there is a counter-traction with the stapler inside and we will close the purse-string. And at this moment, we will remove the liver retractor.

13. Gastrojejunal anastomosis 16'35''

Here you can see the stitch we placed on the stomach. Here we see on the side the anastomosis and I will ask my assistant to take the bowel here and so you see just with the grasper, we will open here a little window behind under the bowel in order to cut it with a GIA stapler. See the window is created and I will use the white stapler, 60mm. This is done and we will use the Ligasure® device just to increase the opening of the meso here to have a better freedom of the limb that will go up to the stomach. OK, that’s enough. Usually you see a very nice beating here on the arteries and we will open the small bowel here. I will ask my assistant to take the upper part here, just the real upper corner and so just with cautery, we will open very easily. And I will use a 25 round stapler and I introduce it inside the abdomen. We will cut the bowel that will climb to the stomach. There is a little trick too. See we will take some bowel and so the direction will be good for introduction. See it’s easy. See the stapler comes out so we can reduce at this moment the traction we have and after that, we will come back and take the white part and we introduce the anvil. The yellow part is covered by the anvil and I will close it. When that is closed, we come back to be sure that we have no twist and so on and we will perform the anastomosis. We will open the stapler and immediately we will check the donuts. Here you have the bowel part that is perfect of course, and on the other side you have the gastric part that is totally round. It’s not disrupted. That’s perfect too so we can close the stapler. So a lot of material is needed for that but it works quite easily. Be sure that we close really the opening. Perfect. We introduce the bag inside. We put the specimen inside. The bag is retrieved immediately because we have no other specimen to remove and so of course we don’t forget it. We will put 2 stitches on each side of the anastomosis. Here you see the introduction of the thread. The image is not perfect and we check on that. See we’ve just a stitch on each side of the anastomosis. And we have to put a 2nd stitch here to suspend the anastomosis.

14. Closure of Petersen\'s space 21'00''

We will close the Petersen’s space. This is the alimentary limb that is coming down from the gastrojejunostomy and we will push this on the side to see really the colon, here the stomach, the gastrocolic ligament and we see the colon here. So we will push up the colon here and here you can see very nicely Petersen’s space. This is the alimentary limb that is going up. This is the mesentery from the alimentary limb and here you see this is the mesocolon that you see very nicely and the hole is here. We have to close that hole here. And you have to remember that you have this opening here that you close but that we open and we re-operate some patients for bowel incarceration through this hole and when you have that, you can have a lot of bowel that is going through this hole coming from the right or from the left side. It doesn’t make any difference and sometimes you have quite the totality of the small bowel that is going through the hole. We close it with a non-absorbable suture very gently because you remember that here we have the mesocolon and we also have some vessels inside. We’ll close it. The purse-string that I put here because the hole is quite round and so it’s easier to close it in just one motion. An important thing afterward is to put again the alimentary limb in a straight position. We release the colon and here you see the alimentary limb, which has to go on the other side.

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