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Typical procedure for laparoscopic gastric bypass: gastrojejunostomy with circular stapler

Authors

Abstract

Gastric bypass is the most frequently performed bariatric surgery nowadays. This video clearly shows all steps of this procedure.

Classification

live recorded

Keywords

laparoscopic gastric bypass, gastrojejunostomy, circular stapler

Media type

Duration

27'00''

Publication

2011-10

Popular

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Audio

Subtitles

E-publication

WeBSurg.com, Oct 2011;11(10).
URL: http://www.websurg.com/doi-vd01en3362.htm

Typical procedure for laparoscopic gastric bypass: gastrojejunostomy with circular stapler

1. Introduction 00'19''

This is the case of a 40–year-old lady with a BMI of 53. It is a superobese patient and we will try to perform a gastric bypass. As for trocar placement, you can see just one handbreadth and a half under the xiphoid process, we have the optical trocar and on each side, we have two 12mm trocars to work in the upper part of the abdomen. Quite lateral to the umbilicus here, I have a 12mm trocar that will help work in the lower part of the abdomen to perform the jejunojejunostomy. At least, in the really left part of the abdomen of the patient, you cannot see very easily here. It’s a 5mm trocar for my assistant that will help me to present the tissue and here at the epigastric area, I have a 5mm trocar for the introduction of the liver retractor at the end of the operation when we’ll do the gastrojejunostomy.

2. Greater omentum division 01'27''

The first step is to divide the omentum to create a way to put up the alimentary limb up to the stomach and after that, we have to lift the transverse colon and the meso of the transverse colon. Here you see the angle very nicely.

3. Biliary limb measurement 01'52''

And with a measuring device that is a grasper with a landmark at 5mm from the tip, we will measure the biliary limb. The biliary limb is the first that we have to measure. So I’m at 75cm here and I will ask my assistant to take the bowel at this moment here. In this obese patient, it is difficult to have a lot of trocars inside and we will use some little tricks to help us for the presentation and the stability of what we are doing.

4. Limb fixation 02'28''

Here I want to fix this limb at the stomach wall and I’ll take a stitch. That stitch is just the landmark between the biliary limb and the beginning of the alimentary limb. After that, we will cut the bowel here and this part will go up to the stomach. Here I will fix that part on the anterior aspect of the stomach. This stitch will be removed at the end of the procedure. This is a temporary stitch just for presenting purposes. It’s an external knot that I perform here. It’s quite easier. That is a device that was invented by Joel Leroy so you can ask him how it works. Very gently, I will fix not too close this part of bowel to the stomach wall. We have to remove it afterwards.

5. Biliary limb marking 03'26''

I just want to make a little drawing at this point just to be sure that we know what is what, if we have some trouble, this is the biliary limb and so I draw a little blue landmark on this biliary limb.

6. Alimentary limb measurement 03'45''

After that, we have to measure the alimentary limb, and I will measure 1 meter and 50. And you see here I put all the bowel in the right part of the abdomen, so I will have sufficient place to perform the jejunojejunostomy. I will ask my assistant to take the bowel here and I will put a stitch between the alimentary limb and the biliary limb just at the upper part of the jejunojejunostomy.

7. Jejunojejunostomy 04'26''

So I will prepare the jejunojejunostomy, it’s just a stitch here on the biliary limb. There is no doubt since I have the blue drawing here, not too much tissue but enough and after that even with the same device, I will put the 2 limbs together. My assistant keeps his grasper in place just to avoid too many movements of the stitch and you see he’ll take a part of the knot with the grasper. We can remove the lateral grasper and we’ll bring up the bowel here at the upper part of the abdomen. So just remember here we have the beginning of the alimentary limb—see the stitch on the stomach here. This is the end of the alimentary limb that is coming down. This is the common limb and here in the deepness, the biliary limb. And so we’ll perform the anastomosis here. First of all, I will make 2 little openings in the bowel here. I check where I am from the meso just with the hook, I try to open the small bowel and I make my way inside to be sure that I’m not in a submucosal way. The second one will be here just close. And after that, I will use the GIA linear stapler to perform the jejunojejunostomy. I will introduce the first jaw and the first branch inside the bowel here and then I will bring up like a trouser the second part and I will ask my assistant to take here the bowel as close as possible to the opening of the bowel, and I take the other bowel and I’ll pull gently to push the GIA inside. If you can introduce all the GIA, it’s better. If you can’t, it’s not a problem, it’s a 60mm long GIA so the most important thing is that you have the 2 borders here on the same line and so we can fire. When this is done, you see I close the stapler before retrieving it out. So we just have to close the 2 openings and I introduce monofilament absorbable suture (it’s a 3/0 one). We’re calibrating the tail. I introduce a second stitch and you’ll see one further advantage to this first stitch is the extramucosal and it will help me with the first stitch to adjust the orientation of the anastomosis. If I go a little bit too much to the right side, I will have the round ligament in my way. See if you don’t put this first stitch here, you’re in trouble when you want to finish, when you’re at the end of the running suture and here you see very nicely what you have to see. I will finish my running suture by taking this. OK that’s done. The jejunojejunostomy is done and I will have to close the defect we have in the lower part of the mesentery.

8. Mesenteric defect closure 09'18''

Here you see this is the alimentary limb and the common limb, and here we have a hole that is the defect we have in the mesentery. So we have to close that. I will use also a running suture, it’s a non-absorbable monofilament suture. We put a little loop at the end of this thread and that allows us to avoid doing the first stitch and we’ll close here this mesenteric defect. Remember that one of my assistants is holding the first stitch I perform to stretch the two limbs and here we’ll have to finish. And we’ll go at this upper part, just at this stitch to be sure that the traction we put on the 2 limbs is not too big. It’s OK here.

9. Alimentary limb division 10'25''

What we can do immediately is to cut the alimentary limb and we’ll make a little opening here close to the anastomosis just by opening the meso here, and we’ll use a white cartridge, 60mm, GIA. So I’ll just increase the opening in the meso that I have to decrease traction I’ll have on the alimentary limb when the gastrojejunostomy is done, and I use the Ligasure® for 2 or 3 openings here in the meso. So the lower part is prepared. We have to go to the upper part and to do a dissection of the stomach and the stomach pouch. For that, we’ll use a liver retractor. So we’re changing the patient’s position. The patient was quite horizontal and so we’ll have a tilt up to 30 degrees. The patient is strapped to the table so she can’t fall down. I will help my assistant to gently put the liver retractor in place. OK, that’s done. Let’s take a look at the anatomy here. Even in an obese patient here, you can see segment I of the liver, the pars flaccida of the omentum is here, and this is what we’re opening when we’re performing a gastric band—that would be the opening here. So we’ll move up at the upper part of the abdomen. This is the spleen.

10. Cardia dissection 12'14''

We need to see the left crus and here you see there’s a little fat pad and the first step will be to remove this fat pad in order to discover the left crus here. I just open the peritoneal sheet as you see. I try to avoid having some burns on the stomach wall. I think it’s important to have a clear view here. It’s quite the anterior part of the esophagus, you see the left crus that is appearing here. I use the 10mm Ligasure® because of the heaviness of the omentum and I will take it out immediately. We are going to begin with the gastric pouch. We have to see at the upper part where the vessels are because it’s a problem of vascularization. The first vessel is here, the second there, and I think that we will begin just here in between.

11. Retrogastric channel 13'15''

I will use the hook to open the peritoneal sheet just in front of the region where I want to make my retrogastric channel. It’s a very short opening and when the peritoneal sheet is opened, we’ll use a grasper and I’ll go behind the stomach, and very gently you see under direct view, I will open the space I have just behind the stomach. See I try to see the landmark between the stomach and between the fat to be sure that I’m not going inside the wall of the stomach. I think I’m here in the lesser sac or quite close to the lesser sac. I have to use a little bit more than one trocar, and you see that the lesser sac is opened here.

12. Gastric pouch creation 14'05''

And after that, I will begin to cut the stomach. I introduce the GIA. It’s a 60 blue cartridge and you see very easily, I’m introducing the GIA behind the stomach. You heard I asked the anesthesiologist to remove the nasogastric tube. All the time you have to remember: check the staple line before you remove your instruments. See my grasper is coming out on the other side. See the retrogastric channel is here. See my grasper here so I’ll use one stapler more. We check where we are. We check the direction.

13. Staple line oversewing 15'15''

I oversew the staple line that can reinforce but that’s not really the purpose of that but that makes a very good hemostasis of the staple line. See that even when you take a blue cartridge, you have some oozing, and one of the dangers is that you have some hemorrhage after the operation. Here I use a V-loc™ just to avoid making the knot at the end of the running suture. There’s also a little loop at the end of this thread. We see the spleen but we were not very close to it. See that all the vascularization of the spleen is kept in place. It’s not totally mandatory but I said I prefer it and so that’s a very good training to handle the needle inside in a quite difficult area. So the first running suture is quite finished. See always the same position of the needle on the needle driver. I think we’ll stop here, and thanks to the little tees you see on the V-loc™, I don’t have to make any knot. The suture will stay in place. We just have to keep 1cm of thread here. OK, we’ll do the second staple line, which is a little bit shorter because we have to stop 1cm before the corner between the two first staple lines, which means the horizontal one, the first vertical one.

14. Gastric pouch opening and anvil insertion 17'20''

Here you have the crossing point between the horizontal and the vertical line and so I’ll use the hook to make an opening here and then we’ll ask the anesthesiologist to bring down the anvil of the circular stapler. The anvil is prepared by the manufacturer. At the beginning, we tilt the head of the anvil ourselves but the manufacturer has brought that to the market, and you’ll see that we bring down. We’re in the mouth with the anvil. The most difficult moment here is when you’re going through the throat with the anvil. You need to have your head a little bit tilted behind backwards. Sometimes the anvil stops there. If the head is not brought backward enough, and so I have just to see to open this little thread. I will remove the anvil from the orogastric tube. Don’t take that opening here with your jaws but just the white part here and tilt the anvil. The anvil’s head is just here behind. And we’ll do a purse-string around this opening. I think it’s quite important to do that purse-string to be sure that you have very good donuts and no leakage in your gastrojejunostomy. See the anvil is not totally tilted but we will bring it to tilt totally at the end of the procedure when we’re doing the gastrojejunostomy. So just to be sure that the anvil will tilt, see I take the white part here—that’s very important, and I push gently the stomach wall upwards. This way I check the purse-string I made. It seems to be good. So we go down; we can remove the liver retractor, and we will go down to the bowel. I just adapt a little bit the position.

15. Small bowel opening 20'18''

The position is straight, no reverse Trendelenburg, and we will open the staple line. You’ll see the assistant will take the upper part of the staple line here--this very short part of the corner. I take the lower corner, and I come with the hook, and you will see that the opening usually is very easy. At this moment, we have to increase one of the scars.

16. Circular stapler introduction 20'54''

We open here the fat just to give more freedom when making the dissection on the other side so we go to the other side, and with the help of the S-shaped retractors, I will dissect the subcutaneous area. See that we are quite close to the fascia here and after the fascia, you have to open a little bit the muscular layer. We introduced, what Joel used, that drape here inside and let’s introduced the circular stapler, protecting. Here’s the circular stapler that we will introduce here and we close here the drape around the round stapler. So we’re inside, you see here the drape and the stapler that is inside. We need to cut the stitch we put just at the beginning. And I will give my assistant a part of small bowel here to change the direction of the small bowel to help the introduction of the round stapler. I check if my opening is large enough—I think so. I will try to introduce the round stapler inside.

17. Gastrojejunal anastomosis 22'50''

That is sometimes challenging. You understand why we changed the direction, you see, of the limb for helping purposes. We take a look on the side and I’ll push the tip of the stapler out. See we did no injury on the bowel here. It’s very important to see it. After that, my assistant will pull up the liver. That is one of the most difficult moments because you have a lot of things to do and you need all your hands with a very good precision of the view. I heard a little click, which means that my stapler is closed. I have just to see. Here I have a green landmark I’ll try to show you. It’s here, see. The stapler is closed. I will fire. Be sure that you have really closed the stapler and then we’ll look. We’ll stay here for one minute with a compression of the anastomosis in order to decrease the hemorrhage rate of the staple lines from the gastrojejunostomy. Here’s a little click and so I’m sure that it’s opened. See here the anvil is coming out, and here you’re able to immediately see what the quality of the donuts is. This is the part of the bowel that is of course round and not interrupted, and that is the part of the stomach, and you see thanks to the purse-string, I don’t have any trouble with that donut. That is the first check you have to perform to be sure that your donut is not interrupted, and then we have to check to be sure that we have no immediate leakage on our staple line. So I can remove the circular stapler. I put again the trocar inside. We pull and we close again the drape.

18. Closure of small bowel opening 25'52''

Now we need to close the opening. We will use the Ligasure® to increase a little bit, to remove the fat in order to avoid too big staple lines for closing purposes, and I will use a white cartridge, 60mm stapler, and we’ll have a look—here you can see the anastomosis. We will close. We introduce a bag to avoid contamination. So I check the 2 staple lines of the last firing of staples on the gastrojejunostomy.

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