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Typical demonstration of a laparoscopic Roux-en-Y gastric bypass

Authors

Abstract

This video shows how to perform laparoscopic Roux-en-Y bypass in a standardised fashion. Every step is clearly shown and explained.

Keywords

laparoscopy, Roux-en-Y gastric bypass, morbid obesity, RYGBP

Media type

Duration

31'09''

Publication

2008-05

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Audio

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E-publication

WeBSurg.com, May 2008;8(05).
URL: http://www.websurg.com/doi-vd01en2334.htm

Typical demonstration of a laparoscopic Roux-en-Y gastric bypass

1. Trocar positioning 00'08''

For the position of the trocars, here you see the outside view. The costal margin is here, the first incision we have made is one and a half handbreadths under the xiphoid appendix because the umbilicus in obese patients is not always in the same place, so the xiphoid appendix is a better landmark. I will do an open laparoscopy and we put a 12mm trocar here in this place. Then one 5mm trocar at the very left of the patient, in the middle between the scope and this 5mm trocar we have inserted a 12mm trocar. In this trocar, we will insert the round stapler to do the gastrojejunostomy and this trocar will allow us to continue the stapling. The stapling will begin here from the right, you see a 12mm trocar on the right side, a 5mm trocar very high, which is used for exposure of the small bowel and retracting the liver, and an additional 12mm trocar quite lateral to the umbilicus is used for all the lower operation under the mesocolon, to measure the limbs and for the jejunojejunostomy.

2. Operation begins with division of omentum 01'49''

The first step is to make a way to the omentum to bring the loop up, I take the omentum up and I always try to work in the upper half of the abdomen. I bring the omentum over the transverse colon and I will begin to cut here the omentum. I use the Ligasure, it is an Atlas 10mm and it is perfect for cutting into the omentum. Here I have dissected and divided the omentum and so I am on the transverse colon, I will bring the transverse colon high in order to discover the Treitz angle.

3. Identification of ligament of Treitz 03'15''

You see that just by bringing the colon up, without searching for anything, I see here the Treitz angle. I will begin to measure the biliary limb.

4. Measurement (75cm), ligation and marking of biliary limb 03'30''

To do that, I have a little landmark on my grasper, it is 5mm from the tip of the instrument and that will allow us to make a good measure. I measured 75cm, I will ask my assistant on the right to take this part of the bowel, this is the biliary limb, and I put all the duodenojejunal part on the right side of the screen. I put one stitch here to fix this limb on the stomach, that is the point that will help us to expose the bowel very easily here. This stitch is the landmark between the biliary and the alimentary limbs. I will fix it quite close to the pylorus, I will perform there an external knot. We will cut this stitch. I put a little blue mark there to be sure that I will recognize the biliary limb and avoid placing the bad limb on the stomach afterwards. The second step is the measurement of the alimentary limb, so we will cut towards here and this part will go to the stomach to make the gastrojejunostomy.

5. Measurement of alimentary limb (150cm) 05'42''

I measure the alimentary limb, it will have a length of 150cm. All of the alimentary limb is in the right region of the abdomen. We ask the assistant to take again this landmark and I will put a stitch between the biliary and the alimentary limb in order to make the jejunojejunostomy that is the root of the Roux-en-Y. This will be the upper part of the jejunojejunostomy. I will ask my second assistant to put the grasper through the epigastric trocar and to take this stitch. We bring this limb here high there. I put the stitch on the stomach here, this is the biliary limb, this is the end of the alimentary limb, you see it very clearly there. I have here the beginning of the common limb and we will do the anastomosis between these two parts of small bowel.

6. Jejunojejunal anastomosis 07'38''

I put a hole here in the duodenal part, I take the jejunal part, place a hole inside too, and I will perform the stapling to make the jejunojejunostomy. First, I put the white part in the bowel there, I bring the second limb like a trousers there, put it inside this way and I ask my assistant to place a little traction on this limb. I have performed here the jejunojejunostomy, I close the stapler before releasing so I don’t increase the hole that I have to close with stitches at this moment. The first stitch I will put will be on the lower part of the hole that I have to close. That I think is very important to see the ending point of the running suture that I will do afterwards. Calibrating the hand of the thread. After that, I take a 20cm thread to make the running suture, this stitch allows me to see very well the point where I have to put my needle in the upper part and to make the first stitch for this running suture from high to low. This is a 20cm long thread. We perform the running suture and I take this stitch also to stretch. Sometimes you are able to go through at the same time; if not, you do it in two times. I do not have to pull on my stitches each time. I close here the first part of the running suture; you see that the first stitch I put helped me to close my running suture there. The closing with sutures here is good, here I have the mesenteric defect between the Roux-en-Y limb and I will have to close that. It is important to close it to avoid internal hernias, when this patient has some abdominal pains and you can’t find reasons for them, do an exploratory laparoscopy to check the closure of these defects.

7. Closure of mesenteric defect 11'52''

There is a little trick so I don’t have to do the first knot, I prepare a stitch with a loop, and you can go with your needle through the loop, you have knots to do that. It is large enough to avoid the leakage. I will use the same trick afterwards for oversewing the staple line of the stomach. Here there are some big vessels and you have to try to avoid them off the mesentery. At the end, I put a stitch between the 2 parts of small bowel. I will stretch this running suture here. We have to check carefully if we haven’t made a hole by pulling on these two parts; if not, you can put a stitch there. The route is done, we will go to the upper part of the stomach, and we will put a liver retractor in the epigastric port. Gastric bypass is not a very malabsorptive procedure, duodenal switch or Scopinaro procedures are more malabsorptive ones; if you do that, you have to reduce the length of the limbs after having a very good psychiatric evaluation of the patient.

8. Creation of gastric pouch 14'21''

Here we are on the upper part of the abdomen, I will give this part of the stomach to my assistant. It is very important at the beginning to open the angle between the left crus and the stomach. I open just in between the fat and the stomach to the anterior part first that authorizes the pneumatization of the tissue there and after that, I will go to the left crus here. It is important to do that because that is the end of the channel that you will do in the lesser sac and when you begin by doing that, the outcome of the staple line will be easier, the dissection will be easier. Sometimes the spleen is very close to the stomach and you can have some injury of very short gastrics, I take only the stomach, I don’t remove the fat because I think that all the adhesions are on the stomach, the fat comes if you pull too much. At the beginning of my experience, I would try to remove all the fat you see out of the screen, today I don’t do that, I just try to dissect the posterior aspect of the cardia as wide as possible here. Here it’s enough, we are quite on the posterior aspect of the stomach. Now we need to find the gastric pouch, you see here the esophagogastric junction, there is a first vessel going to the stomach here, the second branch is here. I usually try to do it between the second and the third branch, it depends on the distance you have between those 2 branches. I think I can open just in between, this region is very vascularized so we go very carefully because when you don’t see very well, you can have some injuries of the stomach wall. Once the peritoneal sheet is opened, I use blunt dissection with graspers to go inside the lesser sac, I make just the hole necessary to put the first line of staples. You see by transparency the lesser sac. The lesser sac is opened and so I have the space to put my staple line inside. You see here the grasper inside the lesser sac. After that, I pull it a little bit up to keep the vascularization and I put a first line of staples to divide the pouch. You see the lesser sac here, you must be sure that you are on the lesser sac. After that, we will have to go up to the cardia. If you are not comfortable here, you can use a calibration tube that the anesthesiologist will put in to be sure that you don’t cut a part of the esophagus. You see here that we are going in the right direction. Second staple line and we will try to find the dissection I did. So you see this will be the direction of my last staple line. We have two lengths of 60 GIA to make the pouch, the staple line is totally regular and we have no angles in the staple line. Here is the first angle between the horizontal and the vertical one. I will oversaw that staple line, the oversewing is important to avoid using the hemorrhage coming from the staple line and to reduce the risk of leakage due to angles in the staple line. You see here the gastric pouch, and on it, you see the staple lines and the angle between the horizontal and vertical ones is here. I ask my assistant to grab this line and I will make a little hole in the gastric pouch in order to take out the nasogastric tube. The hole is done, I check carefully the wall of the stomach. The anesthesiologist puts the nasogastric tube in, it is an orogastric tube.

9. Preparation of gastric side of gastrojejunal anastomosis 22'34''

When I pull the gastric tube outside, the anesthesiologist brings it outside and when the anvil is completely in the mouth, we bring the head of the patient back so the anvil goes down very easily in the abdomen. We cut the string that was put in to prepare, I pull on the knot here to remove this part and we remove the orogastric tube. It is important to check the orientation of the table of the anvil, we pull it a bit to bring it at a 90 degree angle. We remove the thread we used to put it into position, I pull a purse-string around to make sure I will have a very good doughnut of gastric wall.I hope I don’t break the thread when I close the knot, we will clean the camera. We remove the liver retractor. This is the stitch between the bowel and the stomach, and here is the upper stitch from the anastomosis. We try to go between 2 vascular lines.

10. Division of jejunum (to separate alimentary from biliary limb) 25'25''

We will use the white GIA cartridge. I increase the opening in the mesentery to avoid too much traction. We open the alimentary limb to help introduce the round stapler. There is a large opening of the bowel there, we will introduce the round stapler and to do that, we increase a little the opening to be able to introduce the head of the round stapler.

11. Preparation of jejunal side of gastrojejunal anastomosis 26'57''

The bowel that was transected, I will give a grasper to my second assistant, giving one part of the limb here to the grasper is important to give it the good angle. At this moment, we cut the stitch between the stomach and the bowel, and we free this limb. The assistant at my right takes the bowel here very firmly. You see here the round stapler coming, and we introduce it inside the alimentary limb. It is inside, we pull it up and look on the side.

12. Construction of gastrojejunal anastomosis 28'15''

I remove the white part and immediately I have to take it out. With little retraction of the liver, we go back and you see here we have the anvil. We bring the anvil to the round stapler. The head tilts and comes to the right position, I open it a little again to check the position and close again and fire. Just wait a minute with compression of the staple line and after that, I will remove it and we will check the doughnuts. I remove the head and inside I will check the doughnuts, the jejunal part and the gastric doughnut here, seems to be perfect there.

13. Closure of stapler entry site 30'10''

I put a trocar in, we have to close the entrance of the round stapler, white cartridge I used for the small bowel. I just have to lift to put it here, and you see I have a very nice part here. It is closed, the procedure is finished, and we just have to remove immediately a part of bowel we cut outside. Very good example of how to organize an operation and perform it with all the care and attention.

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