Laparoscopic gastric bypass after failed Mason procedure

This video shows a redo gastric bypass in a patient who had previously failed to lose weight after a Mason procedure. The correction of the culprit gastrogastric fistula is demonstrated as well as the performance of the subsequent 'gold standard' operation. This video shows a re-do gastric bypass in a patient who had previously failed to lose weight after a Mason procedure. The correction of the gastrogastric fistula is demonstrated as well as the performance of the subsequent “gold standard” operation. Once the fistula is fully isolated, the authors divide it using a 60mm Endo-GIA. The video shows the tract of the fistula has completely skeletonized. The gastrogastric fistula is clearly visible.

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Laparoscopic gastric bypass after failed Mason procedure

Authors

M Vix, D Varela, J Marescaux

Abstract

This video shows a redo gastric bypass in a patient who had previously failed to lose weight after a Mason procedure. The correction of the culprit gastrogastric fistula is demonstrated as well as the performance of the subsequent 'gold standard' operation.
This video shows a re-do gastric bypass in a patient who had previously failed to lose weight after a Mason procedure. The correction of the gastrogastric fistula is demonstrated as well as the performance of the subsequent “gold standard” operation. Once the fistula is fully isolated, the authors divide it using a 60mm Endo-GIA. The video shows the tract of the fistula has completely skeletonized. The gastrogastric fistula is clearly visible.

Keywords

redo gastric bypass, Mason procedure, skeletonization of gastrogastric fistula

Media type

Surgical video

Duration

14'50''

Publication

2007-12

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E-publication

WeBSurg.com, Dec 2007;7(12).
URL: http://www.websurg.com/doi-vd01en2216.htm

Laparoscopic gastric bypass after failed Mason procedure

1. Case presentation remnant 00'08''

This video shows the case of a patient operated previously according to the “Mason” technique for morbid obesity. Unfortunately, the patient’s case had been a complete failure with weight gain despite a strict diet management postoperatively. We suspected a gastro-gastric fistula might be at the root of this. The procedure begins by thorough exploration of the abdominal cavity. We locate the adhesions between the liver and the stomach that indicate the previous surgery and we continue by freeing these adhesions using monopolar coagulation. Evident in the video is the tension that these adhesions are under. We then elevate the stomach’s greater curvature and locate a further band of tissue around the stomach.

2. Mobilization of the stomach 01'00''

Here we can see the adhesions between the ‘Masonized’ stomach and the remaining stomach. All these adhesions need to be dissected in order to obtain an adequate working space and the dissection is continued up to the angle of His. Further dissection needs to be performed at the inferior level of the Masonized stomach to find the passage into the lesser sac. Here we can see the lesser sac has begun to be entered into. And in this way, we complete the dissection of the angle of His, which will allow us to obtain a better exposure of the operative field. Here we can see further and quite extensive adhesiolysis is necessary. Evident here as you can see, is the gastro-gastric fistula.

3. Skeletonization of gastrogastric fistula 03'17''

Once the fistula has been fully isolated, we will be able to divide it using a 60mm Endo-GIA. You can see here that the fistula’s tract has been completely skeletonized. Here you can see clearly the gastro-gastric fistula. This is divided using a 60mm Endo-GIA.

4. Gastrogastric fistula transection 05'50''

We now proceed with the opening of the lesser sac on the gastric pouch. As a standard, we aim to do this between the second and the third gastric vessels.

5. Creation of gastric pouch for bypass 06'21''

This demonstrates the path of the stapler and again a 60mm linear Endo-GIA stapler is used to create the gastric pouch. As a safety measure, we prefer to resect the whole of the excluded stomach. This means that the fistula’s remnant will also be fully resected.

6. Placement of anvil of circular stapler 07'05''

We perform the gastrostomy using monopolar cautery and extract the tip of the anvil using monofilament sutures. This will allow us to tailor a cuff at the level of the anastomosis. You can see here that the strut of the anvil is snugged into the gastrotomy and a purse-string suture is encircled around it to ensure that it is fixed into position.

7. Oversewing of staple lines 07'40''

As always, we place a running suture along the suture line of the excluded stomach. The suture we use for this is a 2/0 monofilament. Once this is achieved, we proceed down to the submesocolic area to find the extremities of the greater omentum.

8. Construction of Roux limbs for gastric bypass 08'27''

Retraction of these will make it easier to divide the greater omentum at its mid-point and this will allow us to expose the duodenum correctly. The duodenal limb is measured as you can see. After measuring a limb length of 150cm, this is then fixed up to the anterior wall of the stomach. The proximal limb is marked and a further 75cm of the limb is measured to determine the place of the jejunal anastomosis. A stay-suture is used to fix the two limbs of bowel together. As is our usual practice, we perform the side-to-side jejuno-jejunal anastomosis using a 60mm linear stapler. The stapler entry site is then oversewn. The placement of the stay suture at the lower end of the enterotomy site helps greatly to provide traction on the bowel. The mesenteric defect between the loops is also closed. You can see that the running suture is extended up to include the serosa of the bowel. The procedure then continues with division of the Roux-en-Y loop again by linear stapler. This limb will be anastomosed to the gastric pouch using a circular stapler. Here you can see the strut of the anvil and the gastric pouch being mated with the circular stapler in the jejunal limb. The circular stapler entry site is again resected using a linear stapler. The resected specimens are extracted with an endobag. The gastrojejunal anastomosis is supported using absorbable sutures. The last step of the procedure is closure of Petersen’s space. Finally, you can see here a trick showing how trocar openings may be re-approximated with the help of a Berci needle.