Laparoscopic gastric bypass

This video demonstrates a Roux-en-Y gastric bypass using the EEA stapler to accomplish the gastrojejunostomy. The Roux limb is brought up anterior to the transverse colon. The surgeon uses a 150 cm alimentary limb.The jejuno-jejunal anastomosis is performed with a GIA stapler.

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Laparoscopic gastric bypass

Authors

J Himpens, J Marescaux

Abstract

This video demonstrates a Roux-en-Y gastric bypass using the EEA stapler to accomplish the gastrojejunostomy. The Roux limb is brought up anterior to the transverse colon. The surgeon uses a 150 cm alimentary limb.The jejuno-jejunal anastomosis is performed with a GIA stapler.

Classification

routine cases

Keywords

morbid obesity,operation,laparoscopy,gastric bypass,anastomosis,stomach

Media type

Surgical video

Duration

15'00''

Publication

2002-08

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E-publication

WeBSurg.com, Aug 2002;2(08).
URL: http://www.websurg.com/doi-vd01en1343e.htm

Laparoscopic gastric bypass

1. Trocar placement and stomach dissection 00'19''

There are 5 trocars used and their placement and configuration is similar to that used for a Nissen fundoplication. As we enter the abdominal cavity, the first location of dissection is the crus. Here you have the edge of the stomach and you want to avoid having redundance of the fundus. Here’s the esophagus. Now we head for the lesser curve and the level of dissection is simple. You have one vessel here, a 2nd vessel here, a 3rd vessel here and I usually start at the level of the 3rd vessel. Just by scoring the peritoneum. At this stage, you can ask your cameraman to incline your 30 degree angle scope from lateral to medial. At that level, do you try to enter the lesser sac? Sometimes you do, sometimes you don’t. It depends on the level of the reflection. The size of the opening that you’re doing there is just to introduce the GIA, not larger? Exactly. I use a blue load posteriorly, sometimes with the other end, you can perforate the stomach. So it’s nice and smooth. To have the right direction and to aim towards the pillar so that there’s a transverse transection, usually there is a little bleeder at the edge, and you see you aim towards the left pillar. You really want to aim for the crus. You see it’s completely separated.

2. Jejunostomy 03'13''

In the 2 holes opposite the spring, I insert a Prolene together with the needle. I’m going to remove the spring and push down the knife. You hear a click. And then you can flip the head of the anvil. Then you put the anvil in it and the NG tube, we use a different type of NG tube and then you will stitch the anvil through the NG tube so that while introducing it, the head stays put. Now you give the NG tube to the anesthetist and you have to introduce it through the mouth, this end first. In this particular case, the anesthetist was unable to pass the NG tube. Occasionally this happens and in situations such as this, we can take the NG tube and pass it through one of the trocar sites and introduce it from the gastric remnant anteriorly retrograde through the esophagus and the anesthetist can then take it through the patient’s mouth. The anvil can be sutured to the end of the NG tube in this fashion and then reintroduced in a traditional fashion. It’s a tube designed by Cook and that they use for endotracheal tube exchange, slippery when wet. Now let’s try to find a hole. Now the NG tube is out through the mouth and now Dr. Alle is going to stitch it. Now we’re ready to cut. Now remember this trick: if your NG tube for some reason is not stiff enough, it’s very helpful. Now when that hole is pretty big, be sure that you don’t pull out the anvil. I’d like to add a little purse-string now. Usually you don’t need to do this but with the hole being that big, I think that’s safe to use this purse-string. Now we can let that go. Leave it alone. And now we’re ready for the 2nd part of the operation.

3. Bowel mobilization 07'14''

I’ll go and first divide the omentum. So we put the patient in a flatter position and we go for the edge of the omentum. So I divide the omentum because I do an antecolic Roux-en-Y construction and if you do it transmesocolic, I think it’s more difficult and more dangerous and I think most people came to that conclusion. Now let’s go dig for the angle of Treitz. For that, you lift the transverse colon. Pull this. So here’s the angle of Treitz. Try to make sure that your biliary limb is always to the left of the patient to the right of the screen and never lose it. I think exposure at this point is absolutely critical: can you explain to us how you are achieving the exposure you have right now? First of all, you put the patient a bit more horizontal. You go look for the angle of Treitz and then you just lift the real loop of bowel and you make sure that this is going towards the angle of Treitz. Now I don’t measure the biliary limb because you must get a loop that you can lift easily towards the gastric remnant, which is right there. Be careful because it’s very easy to make a hole, you see here, that’s a serosal tear. So be careful doing that. Then you ask your assistant to hold the biliary side, which is here. I’m holding the digestive side. And the idea is not to transect the bowel completely.

4. Anastomosis 09'40''

Now I’m ready to dilate the opening of the 12mm trocar on the mid-clavicular line. Now we have our hole in the bowel. Here’s my stitch so I know that I’m in the right direction. I take out the little white trocar. And now we’re ready to perform the anastomosis. We can appreciate it’s well vascularized. I’m ready to fire. Let’s have a look first if it’s not twisted, not kinked. It looks OK. The gastro-enterostomy is done. Let’s have a look at what we did. The gastro-enterostomy is a gastric pouch. Here it is. That’s the distal stomach. This will be the biliary limb. This is the alimentary limb. Now I want to measure just about between 100 and 150cm for the alimentary limb. To do that, here’s a little trick. You take a Steristrip, so from here to here, it’s 5cm. Why not 10 here? Because otherwise you’ve to pull and you’re going to make holes in the small bowel. Here’s the anastomosis. This is about 5, about 10, 15, 20, 35, 40, 45, and just about 150, somewhere between 100 and 150. Again you ask your assistant to hold it here. So he holds the distal part and I’m holding the proximal part. Again I ask for a stitch, anti-mesenterically right here. We make a hole here and you make a hole in the other one, which is right here because you put a stitch there. And you see that pulling on the stitch, it’s right in so that’s a white cartridge and you don’t want to have bleeding. You’re going to have a nice and long anastomosis. And now we’re ready to close the anastomosis with a running suture. This is a 2/0 silk suture. I use Vicryl and it looks so much easier. I don’t think with this type of nice and long anastomosis, you don’t need to put the so-called anti-obstruction stitch. I need to cut the bowel here now, the bowel there and I’m done. In order to do that, I need to make a window in the mesentery. I try to stay as close as possible to the bowel wall. I think I’ll need a white stapler. Make sure you don’t go too far because the anastomosis is there. And now we’re going to just transect the bowel. This should be the last firing. There is a little bleeding there, it’s probably the meso.

5. Drain placement 15'16''

To check the anastomosis, you put the patient horizontally. We put some water here and ask the anesthetist to insufflate 15cc of air while I compress here the alimentary limb and we see there are no bubbles.