Tips and tricks for gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass

This video demonstrates the use of a EEA circular stapler in performing the gastro-jejunal anastomosis during the gastric bypass surgery. The surgeon demonstrates the preparation of the anvil, the transoral intubation, and introduction of the shaft. This video is intended to provide basic instruction as to the use of this specific technique.

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Tips and tricks for gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass

Authors

M Vix, M Simone, F Rubino, J Marescaux

Abstract

This video demonstrates the use of a EEA circular stapler in performing the gastro-jejunal anastomosis during the gastric bypass surgery. The surgeon demonstrates the preparation of the anvil, the transoral intubation, and introduction of the shaft. This video is intended to provide basic instruction as to the use of this specific technique.

Classification

tips and tricks

Keywords

gastrojejunostomy, Roux-en-Y gastric bypass, laparoscopy, EEA stapler

Media type

Surgical video

Duration

08'00''

Publication

2006-07

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Subtitles

E-publication

WeBSurg.com, Jul 2006;6(07).
URL: http://www.websurg.com/doi-vd01en1981.htm

Tips and tricks for gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass

1. Creation of gastric pouch 00'01''

In this video we show how to prepare a circular stapler before performing a GJ anastomosis for the bypass. Normally we use a 25 circular stapler. We perform a GI anastomosis between the gastric pouch and the alimentary limb. The stapler that we use is not adapted for this procedure so we show how to prepare the anvil before the anastomosis. The 1st step is to perform the gastric pouch. A very small incision of the lesser omentum is performed just close to the gastric wall in between the first 2 vascular arcades or just below the 2nd one. Some people suggest that the limit for the 1st linear stapler is at 5cm from the LES. We take great care to minimize the incision of the lesser omentum to avoid any devascularization or injury of the gastric wall. Cautery is only used to make a small opening and all the dissection is then performed in a blunt fashion with a fenestrated grasper. The right hand pushes the stomach wall upwards and to the left whereas the grasper on the left hand basically makes the path towards the lesser sac. When the lesser sac is entered, the 60mm linear stapler is placed across to divide the stomach horizontally.

2. Preparation of the anvil 01'26''

The circular anvil is prepared before by the surgeon. The spring of the anvil is taken away and then a Prolene suture is threaded through the tip of the anvil in order to then secure it to the NG tube. You can see here the spring being removed. And then after this, the plate inside is flattened. We can now see the orientation of the stitch. A nasogastric tube is then secured to the tip of the anvil using a suture. The final configuration can be seen here. When the tip of the NG tube is seen through the gastric wall, a small opening is made.

3. Positioning of the anvil on the pouch 02'21''

We like to make this opening as small as possible just in after engaging the tip of the NG tube, and when the anesthetist pushes the tube, the gastrotomy will actually be shaped by the tube itself so that it maintains the same size as the NG tube. The NG tube is pulled and removed and its distal end is freed from the anvil. We make sure that the anvil is flipped back to its original 90 degree position, and here we can see a purse-string being placed around the anvil.

4. Fashioning of the alimentary limb 03'09''

The alimentary limb is identified and the enterotomy is performed just on the staple line. The circular stapler is introduced through a small enlargement of the incision at the site of the 12mm trocar in the left flank. A wound protector is placed to both ensure protection of the abdominal wall and maintain the pneumoperitoneum by wrapping the plastic wings around the shaft of the stapler. The stapler is advanced for 5 to 6cm in the bowel and tension is made in order to ensure that the wide trocar tip exits rapidly and sharply, hence perforating the antimesenteric border of the bowel. Following this, the anvil is identified in the gastric pouch and it is then joined with the stapler. We then verify the position, bring the 2 ends of the stapler together, and fire. We now verify that both of the rings are intact proximal and distal, and then remove the stapling gun. The enterotomy is closed with one fire of 60mm linear stapler and the excess bowel is removed after placing it into a plastic bag.

5. Closure of enterotomy 04'27''

We always place a stay suture on the right-hand side of the gastroenteral anastomosis and perform a routine methylene blue test to check for leaks.