Laparoscopic Roux-en-Y gastric bypass after open Nissen fundoplication

Although laparoscopic revision of antireflux procedures when performing a RYGB is feasible, it presents some technical problems such as dissection of Nissen wrap and identification of anatomical landmarks. This is the case of a 50-year-old female patient who underwent a laparoscopic converted to open Nissen fundoplication 10 years ago. Her gastroesophageal reflux was healed. However, she put on weight. Her current BMI is 45. The patient asks for a bariatric procedure.

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Laparoscopic Roux-en-Y gastric bypass after open Nissen fundoplication

Authors

M Vix, B Dallemagne, F Costantino, J Marescaux

Abstract

Although laparoscopic revision of antireflux procedures when performing a RYGB is feasible, it presents some technical problems such as dissection of Nissen wrap and identification of anatomical landmarks. This is the case of a 50-year-old female patient who underwent a laparoscopic converted to open Nissen fundoplication 10 years ago. Her gastroesophageal reflux was healed. However, she put on weight. Her current BMI is 45. The patient asks for a bariatric procedure.

Keywords

Laparoscopic Roux-en-Y gastric bypass after open Nissen fundoplication

Media type

Surgical video

Duration

35'00''

Publication

2010-07

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E-publication

WeBSurg.com, Jul 2010;10(07).
URL: http://www.websurg.com/doi-vd01en3018.htm

Laparoscopic Roux-en-Y gastric bypass after open Nissen fundoplication

1. Clinical case presentation 00'18''

This is the case of a 50-year-old female patient who underwent a laparoscopic converted to open Nissen fundoplication 10 years ago. Her gastroesophageal reflux was healed. However, she put on weight. Her current BMI is 45. The patient asks for a bariatric procedure. Her preoperative workup shows no abnormality.

2. Trocar insertion 00'48''

The first port is placed in the left flank in order to avoid adhesions on the midline. Here you can observe that the introduction of the different ports is uneasy. The omentum adheres considerably to the abdominal wall and forms adhesions to the bowel and colonic walls. At this stage, it is essential to find the plane between the omentum and the peritoneum in order not to leave the omentum on the wall. This dissection plane is searched by using either scissors, the Ligasure® vessel-sealing device or the hook in order to obtain the finest dissection possible and to free the operating space as much as possible out of comfort.

3. Adhesions dissection 01'50''

A few adhesions are taken down around the round ligament. Here the remaining adhesions on the midline are further freed. All adhesions will be resected in order to perform the laparoscopic gastric bypass in excellent conditions. Once all parieto-omental adhesions have been freed and all necessary trocars have been placed, the superior region can be accessed and the dissection can be initiated between the liver and the stomach. Once again, the dense adhesions must be taken down in order to regain the most normal anatomy possible.

4. Inferior gastric portion dissection 02'34''

The dissection is started at the inferior portion of the stomach in order to well comprehend the anatomy before approaching the superior gastric portion where the Nissen fundoplication had been performed. Here all adhesions are removed using the hook and paying attention not to accidentally enter the Glisson’s capsule and not to open the gastric serosa. It is sometimes uneasy to understand the nature of the tissue that is grasped by the forceps, whether or not it is an adhesion or it is some omental tissue at the level of the greater curvature. This may account for the discontinued dissection in order to identify all anatomical structures in the area. Dissection is carried on more and more cranially.

5. Cardia area dissection 03'47''

Here it reaches underneath the left liver, very close to the cardia. It looks like the region where the Nissen wrap can be found will be approached. The dissection is carried on cautiously. It stands to reason that the vascularization of the superior gastric pouch should be preserved as much as possible.

6. Liver dissection 04'30''

The lower surface of the liver is dissected. A few effractions to the Glisson’s capsule can be observed. These should be kept to a minimum in order to avoid a blood suffusion that would impair the operative field. The procedure is carried on in a stepwise fashion and begins to run smoothly. A few fixation stitches of the Nissen wrap are found. At this moment, it is essential to understand the anatomy of the Nissen pouch.

7. Calibration tube insertion 05'12''

A calibration tube is placed in order to identify the cardia.

8. Fundoplication right border identification 05'38''

The right border of the fundoplication is identified and a dissection is carried out cautiously in order not to remove the vascular network supplying the right border of the stomach. It looks like we can reach underneath the fundoplication by following the anterior aspect of the stomach. The nature of the tissue that has been grasped by the upper forceps is difficult to identify. A dissection is performed. In order to avoid any gastric fistulas, this bridge will not be divided with the scissors, but using the Endo-GIA linear stapler. Consequently, any effraction of the digestive lumen will be avoided. This maneuver allows for an easier dissection of the anterior aspect of the stomach. However, there are still numerous adhesions and the identification of a normal anatomy is uneasy. An omental adhesion is taken down and it looks as if the beginning of the upper gastric pouch can be seen by passing posteriorly to the stomach. The dissection is performed cautiously in order not to open the gastric serosa. The left-side grasper is used to hold the right portion of the fundoplication. Several attempts to approach the esophagus are made in order to place it on a loop. It looks like the tissue that has been divided by the Endo-GIA linear stapler was simply adherent and that there was no real gastric pouch at this place.

9. Lesser sac opening 08'47''

In order to precisely define the situation, the lesser sac is opened. This maneuver allows to visualize the posterior aspect of the stomach. A gastrolysis of the upper part of the stomach is performed in order to regain a normal anatomy.

10. Short gastric vessels division 09'24''

The short gastrics are divided. The first objective is to undo the Nissen wrap before dividing the stomach to prepare the gastric bypass procedure. The upper portion of the stomach is reached.

11. Left crus identification 09'50''

The left crus is being identified. Attempts to visualize the posterior and superior aspect of the stomach are made. However, adhesions block access to this route. Here the right internal portion of the stomach has been accessed. A few omental adhesions are resected but this route will not be further used in order not to restrict the vascularization of the lesser curvature. Access is made posteriorly to take down the adhesions situated in the lesser sac between the stomach and the pancreas. Here a complete access route has been created and the dissection is then continued towards the esophagus. This dissection is carried out slowly and cautiously as the identification of anatomical structures is far from easy.

12. Posterior wrap dissection 11'42''

The dissection is continued further at this place. The dissection of the posterior portion of the wrap allows to skeletonize the right crus and the left crus to the right of the stomach. The esophagus is therefore skeletonized. Attempts to find the left crus are made from the left side. The objective is to place the esophagus on a loop in order to manipulate and identify it more easily and to safely achieve the dissection in correct and safe conditions. The loop that has been passed posteriorly to the esophagus allows to check for the integrity of the esophagus and to work on the posterior adhesions. At this stage of the procedure, it is discovered that the Nissen wrap was not complete; there was already a partial slippage of this wrap posteriorly to the stomach. The tissue that had been divided with the Endo-GIA linear stapler was just fibroid. From then onwards, an external and lateral upper polar gastrectomy is decided upon in order to clarify the operative field.

13. Upper gastric dissection 13'28''

Only the internal and medial portion will be left in contact to the esophagus. It will be used to perform the gastric bypass. A complete gastrolysis is therefore carried out until the angle of His and the posterior portion of the stomach can be tilted at this moment. A complete dissection of the upper portion of the gastric pouch is carried out.

14. Stomach transection 13'55''

Once this upper portion has been totally freed, the stomach is transected. It will be a complete transection since the external and lateral portion of the gastric pouch will be resected. The medial portion will be used for the gastric pouch of the bypass procedure. Two applications of the Endo-GIA linear stapler will be necessary. A loop is passed in this region in order to make sure that the entire stomach has been divided and that no bridge has been left between the upper and the lower portion of the stomach. Since the stomach has a thicker wall here, an Endo-GIA linear stapler with green cartridges is used. The loop is withdrawn at this moment and a complete transection of the stomach is achieved. A stitch to ensure air tightness is tied at the very internal portion of the staple line. These two staple lines will then be covered by an absorbable running suture.

15. Pouch freeing 15'33''

The vertical portion of the stomach is then divided in order to release the pouch to be used to perform the gastric bypass procedure. This gastric pouch is slightly longer in order to preserve an appropriate vascularization. Two lengths of the 60mm Endo-GIA are normally used to complete the division of this pouch. Here, three and a half lengths will be used. This gastric pouch will be totally separated from the upper portion of the stomach. A few posterior adhesions are still fixed. The resected gastric pouch is completely freed and will be placed in a bag. This pouch is shelved in the lower portion of the abdomen and a running suture is placed to bury the staple line, preserving only the angle between the horizontal and vertical portions of the gastric pouch. The horizontal portion of this staple line is buried in a similar way.

16. Burying suture 17'39''

Once the two burying sutures have been placed, the distal staple line is also buried in order to avoid bleeding or prevent leakage on this staple line. Once all staple lines have been buried, a purse-string is fashioned around the angular portion of the upper gastric pouch. It can be observed that the staple lines cross at this place, delimitating small zones where the vascular supply is poor. The lowermost tip will be resected on this purse-string. When the purse-string has been fashioned, the stomach is opened by resecting the lowermost part. The crossing of the staple lines is therefore completely eliminated.

17. Anvil introduction 18'43''

An orogastric tube is then introduced into the esophagus bringing the anvil of a circular stapler to its uppermost end. A methylene blue test had been carried out beforehand in order to control the patency of the gastric pouch. The purse-string is tightened on the exit of the anvil. Once the diaphragmatic crura have been sutured by a stitch of non-absorbable thread, the lower part of the procedure can be approached, namely the gastrojejunal bypass. In order not to generate too important dysphagias, only one stitch is placed. The lower part of the procedure on the small bowel is begun. A few omento-mesenteric adhesions are taken down.

18. Biliary loop 20'24''

The duodenojejunal flexure (Treitz’ angle) is searched for and a 75cm biliary loop is measured. This loop is attached to the distal gastric stump in order to prepare the anastomosis at the foot of the loop.

19. Alimentary loop 21'08''

A 150cm alimentary loop is measured and the fixation of the alimentary loop to the biliary loop allows to prepare the Roux-en-Y anastomosis.

20. Jejuno-jejunal anastomosis 21'26''

The jejunojejunal anastomosis is performed using a 60mm Endo-GIA linear stapler, white cartridge. The linear stapler’s introduction site is closed with a running suture of PDS 3/0 material.

21. Mesenteric defect closure 21'59''

The next operative step consists in the closure of the mesenteric defect at the foot of the loop using a non-absorbable thread. A small loop formed at the thread’s extremity allows not to tie the initial knot. This closure should prevent internal hernias in the mesentery of the foot of the loop from occurring.

22. Gastro-jejunal anastomosis 22'41''

The anastomosis at the foot of the loop is therefore carried out. The digestive loop still needs to be mounted on the gastric stump and the gastrojejunal anastomosis needs to be performed. A mesenteric opening is created and the jejunum is divided using a single application of the 60mm Endo-GIA linear stapler, white cartridge. This loop is opened in order to introduce the head of a PCEEA circular stapler easily. The head of a PCEEA circular stapler is introduced into the jejunal lumen. The spike of the stapler is taken out and connected to the anvil previously introduced. The gastrojejunal anastomosis is therefore completed. As soon as the anastomosis has been finalized, the stapler is removed. The doughnuts are immediately controlled. They are in good conditions thanks to the purse-string placed on the upper portion of the stomach. The circular stapler’s introduction site is closed using a single application of the 60mm Endo-GIA linear stapler, white cartridge. The bowel specimen is placed in the bag. Two suspension stitches are placed on the anastomosis using an absorbable thread on each side of the gastrojejunal anastomosis.

23. Petersen’s space closure 24'45''

The final step of the procedure consists in the closure of the Petersen’s space using a non-absorbable thread, fashioning a purse-string closure of the orifice. The main difficulties in this procedure have been the dissection of Nissen wrap and the identification of anatomical landmarks. The rest of the procedure has been quite easy.