Laparoscopic gastric bypass for a young woman with a BMI of 44

This video presents the key steps to a gastric bypass procedure. This video is recommended for advanced laparoscopic surgeons.

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Laparoscopic   gastric   bypass   for   a   young   woman   with   a   BMI   of   44

Authors
D Varela, J Marescaux
Abstract
This video presents the key steps to a gastric bypass procedure. This video is recommended for advanced laparoscopic surgeons.
Classification
basic techniques
Keywords
laparoscopy, gastric bypass, young woman, BMI of 44, morbid obesity
Media type
Duration
16'30''
Publication
2008-10
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en
E-publication
WeBSurg.com, Oct 2008;8(10).
URL: http://www.websurg.com/doi-vd01en2389.htm

Laparoscopic   gastric   bypass   for   a   young   woman   with   a   BMI   of   44

1. Determining the length of the limbs 00'24''
For the first part of the gastric bypass procedure, we work in the lower abdomen. In order to do this, all the fatty tissue of the greater omentum and the transverse colon are retracted cephalad. The assistant holds the transverse colon with the atraumatic grasper located in the left upper quadrant. Adhesions to the jejunum are taken down in order to clearly identify the ligament of Treitz. This is performed with the monopolar hook and scissors. The duodenojejunal limb is prepared by measuring 30 to 50cm distal to the ligament. To achieve this, a 5cm mark is placed at the tip of the right-hand grasper. A stay suture is placed between the bowel and the stomach to mark this site. A Prolene 2.0 is preferred. The proximal portion of this limb is the biliopancreatic limb; it is marked with methylene blue in order to make it easily recognizable and avoid any errors during the re-anastomosis. Subsequently, the length of the Roux limb is measured starting from the suture we have just placed, approximately 100 to 150cm long. The limb is orderly measured and placed on the right side of the abdomen. The assistant fixes a grasper onto the limb once the desired length is reached in order to mark the site of the entero-enterostomy. This anchoring stitch between the limbs helps to stabilize them while the anastomosis is being performed. A small incision is made at the tip of the duodenojejunal limb on the anti-mesenteric border. For this, the tip of the hook coagulator is ideal. Once the colotomy is performed, the hook is advanced into the lumen to verify its position and avoid a submucosal dissection. A second incision is made on the gastrojejunal limb. Adequate traction is essential to perform a neat colotomy, that is to avoid tearing the tissues. The entero-enterostomy is performed with a linear stapler (white cartridge) introduced through a 12mm trocar located in the left anterior mid-clavicular line. I prefer to place the left lateral limb first and then the medial limb. An anchoring suture is placed in the inferior border of the anastomosis. This suture facilitates bowel manipulation and subsequently minimizes the risk of tears. The stapler insertion site is closed using Vicryl 2.0 in a continuous suture. In all cases, the mesenteric defect is closed with a running suture. We used a Prolene suture, starting from the bottom and continuing cephalad.
2. Gastric pouch preparation 06'18''
The liver retractor is now introduced through the 5mm trocar situated in the right upper quadrant. The left lobe is retracted laterally to visualize the hiatus. We begin the dissection between the 2nd and 3rd vascular arcades of the lesser curvature using monopolar coagulation. The objective is to open the lesser omentum and dissect 3 to 4cm of the posterior gastric wall. This is achieved with the alternating blunt dissection of 2 atraumatic graspers. Following this, a linear stapler (blue cartridge) is introduced and fired perpendicular to the axis of the esophagus. The second resection is pursued cephalad towards the angle of His and along the posterior gastric wall. Generally, 3 to 4 staplers are needed to complete the gastric resection. A grasper is passed behind the gastric wall to ensure the right exit site of the stapler. Pulling laterally both gastric walls makes it easier to visualize the resection line. A running suture is performed on the gastric remnant to achieve a better hemostasis. Two clips are applied at the end of the suture to lock it. The anvil is passed through the esophagus attached to an orogastric tube. This tube is then extracted through the stomach until the center rod of the anvil appears. The monofilament suture is cut and the anvil is freed from the orogastric tube. A running suture is the performed around the anvil. A Prolene 2.0 is used. The stay suture between the stomach and the biliary limb is cut. The end of the Roux limb is opened using monopolar coagulation. The left lateral trocar site is then enlarged and dilated in order to insert a protective plastic cover used to avoid contaminating the abdominal wall during the removal of the stapler. The stapler is introduced 10cm into the open end of the Roux limb. The spike of the anvil shaft perforates the small bowel and it is then removed from the abdomen by the surgeon’s left side grasper.