Laparoscopic gastric bypass using infrared

WebSurg is a free virtual surgical university, accessible worldwide through the Internet. Our goal is to provide surgeons, scientific societies and the medical industry with the first online continuing medical education in laparoscopic surgery and information on the latest developments in laparoscopic surgery, including NOTES and robotics.

Create account

Browse the WORLD

Virtual University

Google translate

Summary
Chapters
Your comments
Ask the Experts

You need to log in to watch this media!

Click here to log in.

Laparoscopic gastric bypass using infrared

Authors

M Vix, J Marescaux

Keywords

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

Media type

Surgical video

Duration

11'00''

Publication

2002-12

Popular

Favorites

Favorites Media

Audio

Subtitles

E-publication

WeBSurg.com, Dec 2002;2(12).
URL: http://www.websurg.com/doi-vd01en1357e.htm

Laparoscopic gastric bypass using infrared

1. Trocar placement 00'13''

We use a total of 6 trocars for this procedure, and as you can see, we arrange them similar to the trocar positioning for a hiatal hernia repair.

2. Creation of gastric pouch 00'26''

The 1st step of the procedure is creating a proximal gastric pouch of 25cc. This is accomplished by inserting an orogastric tube with a 25cc balloon, which is pulled proximally against the hiatus and the lesser omentum is opened between the 1st and 2nd gastric pedicles. We begin our dissection here as shown and we continue a posterior dissection between the 2 pedicles. This region is chosen because it is a theoretically avascular plane and as you can see, we have no bleeding in this region. We are creating a window now for placement of our Endo-GIA stapler to define the limits of the proximal pouch. We continue with our retrogastric dissection towards the left crus. You can see here that we’ve just come through on the other side and we have room for our stapler. Our schematic representation shows our dissection line behind the stomach. Next, the stapler is inserted into this region we have dissected for the 1st portion. The second line of division is then directly cephalad. You can see here we are inserting our Endo-GIA stapler and this is a horizontal trajectory. Once the stapler is fired, we have our 1st bite. The next step is to make sure we have an open channel proceeding cephalad, then we place the Endo-GIA stapler from the other side orientated in a cephalad direction and make our second line of division. Oftentimes, this will require more than one staple firing. Thus we have a proximal gastric pouch.

3. Gastrojejunal anastomosis 03'11''

The next portion of the procedure is to select a division of the small bowel. We’d like to go between 30 and 50cm from the ligament of Treitz and bring up the distal portion of small bowel to anastomose to our proximal gastric pouch shown here. To create a proximal anastomosis, we prefer to use a circular stapling device. We see here the anvil from the circular stapling device. We pass a heavy Prolene stitch through the distal portion of the anvil and then remove the spring so that the head of the anvil rotates freely. This requires a little bit of inferior pressure in order to remove the spring. You can see now that the head rotates freely. The next portion is to take the nasogastric tube, transect it with heavy scissors, and fit the pin portion of the anvil into the nasogastric tube. This will be later passed down through the oropharynx by the anesthesiologist. In order to keep the unit together, we actually suture through the nasogastric tube around the pin of the anvil shown here and tie the Prolene. This gives us some more secure system. Next we pass the nasogastric tube with anvil over to the anesthesiologist who passes the nasogastric tube through the mouth down into our proximal stomach. The incision is made in the staple line and the end of the nasogastric tube is pulled all way through until the anvil catches in the proximal stomach. The nasogastric tube is removed. You can see here the proximal stomach. We’ve actually placed the illuminated stent within the NG tube in order to easily identify it. We locate the tip here just adjacent to our staple line, and then we open this region making a small incision with the Harmonic scalpel. This is done through trocar B. Once our gastric pouch is opened, we then pass the nasogastric tube through this incision. It’s very easy to see the tip of the nasogastric tube because of the infrared stent we’ve used. We pull it all the way through until the anvil, which is attached to the back, catches in the proximal stomach. Prolene sutures are divided using the Harmonic scalpel and then the vibrating jaw of the Harmonic scalpel is used to cut the plastic in the nasogastric tube and remove it from the anvil pin. Next, we take a pre-measured plastic tape, introduce it into the abdomen, and use this to measure for our proximal division. The measurement begins at the ligament of Treitz. Once we have found our distal division point, we create a mesenteric window; we divide the bowel. The incision is then made in the distal portions of bowel and the circular stapling device is placed into the incision shown here. The pin is then deployed, plastic portion removed. You can see now we’ve passed our Endo-GIA stapler through our trocar and we divide the bowel at the level of our mesenteric window. We do a 2nd firing of the vascular load to allow for mobility and further division of the mesentery. Now that our distal segment is mobile, we make an enterotomy using the scissors and we will place our circular stapling device into this portion of the bowel. The circular stapler will be used to perform our gastrojejunal anastomosis. You can see here our circular stapling device passed through trocar D directly through the abdominal wall, placed into the jejunum. Our pin is deployed, the plastic portion removed. At this point, the anvil and the pin are mated in a 90 degree angle and the device is fired to create the anastomosis. Your can see our stapler is passed through the abdominal wall here, our pin and anvil have been mated. We are closing the device or fire it and remove the anvil along with the 2 rings of jejunum and stomach shown here. Next we use the aid of a wound protector to maintain our pneumoperitoneum. Via occluding of this wound protector, we can maintain the pneumoperitoneum and reintroduce the trocar like so and then tie it into position. Next we have to close the area where we passed the end to end stapler. This is accomplished with an Endo-GIA. After closing the enterotomy, the bowel is clamped and either a methylene blue or an air test is performed. You see here we’re passing an Endo-GIA to close the enterotomy that was created in the small bowel. This device is then fired, which will create a staple line here and close the enterotomy. Next we need to occlude the bowel and perform an air test; we clamp down on our bowel segment and with the NG tube, a small amount of air is insufflated and the air is retained so we know that we have no anastomotic leaks.

4. Enteroenterostomy 09'36''

Next we need to create our distal anastomosis, which is usually between 100 and 150cm from our proximal anastomosis. We do a side-to-side functional anastomosis. We make 2 small enterotomies approximately 8mm in length for each segment of bowel. A distal entero-enterostomy is created with the stapling device and then the remaining defect is closed with a running suture. At this point, you can see we are positioning our 2 arms of the bowel side by side. We make our 1st enterotomy as seen in the inset here and next our 2nd enterotomy, and we use the Endo-scissors with coagulation and try to minimize our bleeding from the bowel wall. Once we are into the lumen of the bowel, we introduce the Endo-GIA stapler. In this case, we use a vascular load because of the increased vascularity of the small bowel mucosa. The stapler is clamped and then fired to create a generous anastomosis. The stapler is removed and now we will begin to hand-sew our remaining defect. We go from proximal to distal in order to facilitate the suture line and as you can see here, our segments of bowel are quite vascularized, there is some oozing from the submucosa. We use a single layer of braided absorbable suture to close the final defect.