C H A P T E R 34 • Roux-en-Y Gastric Bypass (Open and Laparoscopic) |
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The jejunum is followed for approximately 100 cm for a standard length gastric bypass. Here a small enterotomy is made on the antimesenteric border. Another small enterotomy is made at the antimesenteric corner of the proximal blind end of the jejunum. The enterotomies are only the length of the jaws of the ultrasonic shears (Figure 34-8).
With a jaw of the 2.5-mm stapler height linear cutter inserted though each of the enterotomies, the stapler is fired to create the anastomosis. Either one 60-mm stapler or two successive firings of the 45-mm stapler is used here (Figure 34-9).
Ligament
of Treitz
Roux limb is 100 cm
from initial jejunal
transection to 30 cm anastomosis
FIGURE 34–8
Stapling to create anastomosis
3 6 0 S E C T I O N I V • TH E A B D O M E N
The resulting enterotomy is closed with one 60-mm or two firings of the 45-mm linear stapler using the 2.5-mm stapler loads (Figure 34-10).
A seromuscular stitch of 2-0 silk is placed at the left side of the anastomosis, and the mesenteric defect is closed on the right side of the anastomosis with a running 2-0 silk suture, starting at the base of the defect and ending with a seromuscular bite of each portion of jejunum. This seromuscular bite is reported to decrease the risk of anastomotic obstruction
(Figure 34-11).
The jejunojejunostomy is inspected for adequacy of the lumen and hemostasis of the suture and staple lines. The Roux limb is held in place as the omentum and colon are swept back downward. The patient is turned to the reverse Trendelenburg position. The telescope is exchanged for a 45-degree long scope. A table-mounted retractor is clamped to the bed.
The 5- or 10-mm Fisher or Nathanson liver retractor is positioned to elevate the liver by direct insertion through the abdominal wall to the left of the midline in the epigastrium. This insertion site should be just at the caudal extent of the left lateral lobe. No attempt should be made to incise the lateral liver attachments. The retractor is secured to the table mount
(Figure 34-12).
Stapling enterotomies
3 6 2 S E C T I O N I V • TH E A B D O M E N
The peritoneum overlying the left crus of the diaphragm at the angle of His is disrupted bluntly and spread open to expose the diaphragmatic muscle. An articulating right-angled instrument is used to create a space by blunt dissection posterior to the stomach and along the crus. A thin veil of peritoneum is left between the stomach and spleen (Figure 34-13).
A balloon-tipped orogastric tube is placed in the stomach to guide the pouch creation. The balloon is inflated to 20 mL and pulled back snuggly to the esophagogastric junction. Once the line of transection is identified, the balloon is deflated and the tube is pulled back into the esophagus. One must always be certain of the position of any esophageal tube, because stapling across the tubes can result in a difficult and lengthy revision (Figure 34-14).
Phrenogastric ligament entered with dissector
FIGURE 34–13
Inflated balloon at esophagogastric junction
Line of
transection
C H A P T E R 34 • Roux-en-Y Gastric Bypass (Open and Laparoscopic) |
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The assistant grasps the stomach in two places along the lesser curvature above and below the site of transection. The ultrasonic shears are used to carefully incise the peritoneum and underlying fat of the gastrohepatic ligament to enter the lesser sac without injuring the wall of the stomach, the vagus branches, or the vasculature of the pouch. There are a number of small veins that, when not entirely sealed with the shears, can cause troublesome bleeding. Therefore this dissection should be performed slowly and meticulously with a delicate combination of sweeping and sharp dissection with the ultrasonic device (Figure 34-15).
An articulating 45-mm linear cutting stapler loaded with 3.5-mm staples is angled, placed, and fired transversely across the lesser curvature approximately 3 to 4 cm distal to the esophagogastric junction at the site identified by the balloon to begin creation of the pouch (see Figure 34-15).
Stapling transversely across lesser curve
FIGURE 34–15
3 6 4 S E C T I O N I V • TH E A B D O M E N
A gastrotomy is made near the greater curvature of the stomach. The 12-mm port is removed from the left upper quadrant, and this incision is dilated sequentially up to 26 mm with Hegar dilators. The anvil of a 25-mm end-to-end stapler is loaded with the spike possessing a 2-0 polyester suture knotted through its eye. Using the 12-mm port facilitates insertion of the anvil into the peritoneal cavity (Figure 34-16).
The anvil is placed through the gastrotomy using an anvil grasper. The suture is threaded downward through the eye of a 5-mm articulating dissector (Figure 34-17).
The articulating dissector is placed through the gastrotomy and flexed so that its tip tents up the stomach at the staple line near the lesser curve. The ultrasonic dissector is activated while touching the tip of the articulating dissector to create a gastrotomy only big enough to pass the articulating dissector through it. The suture is then grasped, and once it is pulled through the tiny gastrotomy, the articulating dissector is straightened and removed (see Figure 34-17).
Anvil of circular stapler
Trocar used to insert anvil into abdomen
Anvil
Clamp keeping tension on suture
A B
FIGURE 34–16
Gastrotomy
Anvil
Band passer
C H A P T E R 34 • Roux-en-Y Gastric Bypass (Open and Laparoscopic) |
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The surgeon pulls the suture across the field to the patient’s right while holding the stomach at the crotch of the staple line until the anvil trocar passes through the gastrotomy. Once the anvil is in position, the original gastrotomy is closed with the linear stapler containing 3.5-mm staples. Either one firing of the 60-mm or two firings of the 45-mm stapler is usually required (Figure 34-18).
Harmonic scalpel creating gastrotomy
A
Angled dissector and anvil
Grasper to pull suture of anvil through gastrotomy
B
FIGURE 34–18
3 6 6 S E C T I O N I V • TH E A B D O M E N
The 60-mm linear stapler with 3.5-mm staple height is applied to the stomach paralleling the lesser curve through the 12-mm port on the left side. Downward pulling of the suture von the anvil facilitates proper placement. Before firing, the surgeon advances the orogastric tube until he or she can be certain that the tube is visible within the pouch and not within the main body of the stomach or caught by the stapler (Figure 34-19).
The 10-mm articulating dissector is placed through port two. Its tip is passed behind the stomach and flexed into the space created at the angle of His. Gentle side-to-side manipulation enlarges this opening. The assistant holds this instrument while the articulating 45-mm linear stapler loaded with 3.5-mm staples completes the division of the stomach, again confirming placement of the stapler by manipulation of the orogastric tube (Figures 34-20 and 34-21).
The anvil trocar can now be removed. It is helpful to note that a 90-degree rotation of the blue spike with a right-angled dissector while the anvil is held steady with an anvil grasper or other grasping instrument simplifies the detachment. The anvil grasper is applied to the anvil above the springs (Figure 34-22).
Closing gastrotomy with stapler
FIGURE 34–19
C H A P T E R 34 • Roux-en-Y Gastric Bypass (Open and Laparoscopic) |
367 |
Completion
of pouch with stapler
Stapler
FIGURE 34–20 completing pouch
FIGURE 34–21
Stomach pouch
Applying a one-quarter turn, trocar is removed from anvil
3 6 8 S E C T I O N I V • TH E A B D O M E N
The jejunal Roux limb is opened longitudinally on its end (Figure 34-23). The 12-mm port is removed again, and the circular stapler is placed through the dilated port site and into the lumen of the Roux limb. Once past the demarcated segment, the stapler is opened to pierce the antimesenteric border. Traction must be maintained on the bowel proximal and distal to the end of the stapler to keep the bowel from slipping off of the stapler trocar
(Figures 34-24 and 34-25).
The stapler and anvil are mated together, and the instrument is closed and fired. The stapler is partially opened and removed. The redundant open segment of jejunum is trimmed and sealed by first incising the mesentery and then applying the linear stapler with 2.5-mm staples. Before firing the stapler, the orogastric tube should be passed through the gastrojejunostomy for the subsequent leak check. A seromuscular stitch of 2-0 Vicryl is placed at the right side of the gastrojejunostomy (Figures 34-26, 34-27, and 34-28).
A test for leaks and placement of a closed suction drain completes the procedure.
Open staple line
Inserting circular stapler into Roux limb lumen
FIGURE 34–23
Piercing through antimesenteric border of jejunum
