Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

Stomach pouch

Anvil

Cutting away jejunal excess

Mating together

circular stapler

and anvil Jejunal Roux end excess

Circular stapler

FIGURE 34–27

FIGURE 34–26

Pouch

One seromuscular suture

FIGURE 34–28

Esophagogastric junction/ esophageal hiatus

Midline incision

MC

FIGURE 34–29

Left gastric artery

Hepatogastric ligament

Stomach

FIGURE 34–30

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2. DISSECTION

A table-mounted body wall retractor such as the Bookwalter model facilitates exposure.

The omentum is divided in the midline all the way to and for a short distance along the transverse colon using the ultrasonic shears. This will allow placement of the Roux limb anterior to the colon and stomach with less tension. Adhesions to the abdominal wall may need to be divided first (Figure 34-31).

The ligament of Treitz is identified, and the jejunum is divided approximately 40 cm distal to it. An opening is made in the transverse mesocolon if a retrocolic approach is favored (Figure 34-32).

The mesentery of the distal aspect of the divided jejunum is incised next to the bowel wall to provide additional mobility of the Roux limb. Any ischemia area created by this maneuver will be trimmed during one of the final steps.

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 large enough to accommodate the end of the stapler (Figure 34-33).

Creating omental window

FIGURE 34–31

Ligament of Treitz

Biliopancreatic limb

Opening created in mesocolon

3 0

c m

Roux limb

FIGURE 34–32

Ligament of Treitz

Creating enterotomies

FIGURE 34–33

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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 firing of the 60-mm stapler or two successive firings of the 45-mm stapler is used here (Figure 34-34).

The resulting enterotomy is closed with one firing of the 60-mm or two firings of the 45-mm linear stapler using the 2.5-mm stapler loads (Figure 34-35).

A seromuscular stitch of 2-0 silk is placed at the left side of the anastomosis. The mesenteric defect is closed from the right side 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 34-36).

The jejunojejunostomy is inspected for adequacy of the lumen and hemostasis of the suture and staple lines. The patient is turned to the reverse Trendelenburg position.

Creating a jejunojejunal anastomosis

Enterotomy stapled closed

Arrow going through mesentery defect

A

Anastomosis

complete

B

Closure of mesentery defect

B

FIGURE 34–36

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The peritoneum overlying the left crus of the diaphragm at the angle of His is disrupted and spread open to expose the diaphragmatic muscle. Blunt dissection with a finger is used to enlarge this space posterior to the stomach and along the crus. A thin veil of peritoneum is left between the stomach and spleen (Figure 34-37).

A balloon-tipped orogastric tube is placed in the stomach to size the pouch. 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 pulled back into the esophagus. One must be continuously aware of the position of all tubes in the esophagus, because stapling across the tubes requires a difficult and lengthy revision (Figure 34-38).

The cautery or ultrasonic shears is 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, can cause troublesome bleeding. Therefore this dissection should be performed slowly and meticulously, with a delicate combination of sweeping and judicious use of energy sources (Figure 34-39).

Entering phrenogastric ligament at angle of His

FIGURE 34–37

Inflated balloon at esophagogastric junction

Line of transection

FIGURE 34–38

Opening in phrenogastric ligament at angle of His

Entering lesser sac

FIGURE 34–39

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An articulating 45-mm linear cutting stapler loaded with 3.5-mm staples is angled, placed, and fired transversely across the lesser curvature approximately 4 cm distal to the esophagogastric junction at the site identified by the balloon to begin creation of the pouch (Figure 34-40).

A gastrotomy is made near the greater curvature of the stomach. The anvil of a 25-mm end-to-end stapler is loaded with the spike that has a 2-0 polyester suture knotted through its eye. The anvil is placed through the gastrotomy. The suture is threaded downward through the eye of the 5-mm articulating dissector (Figure 34-41).

Stapling transversely across lesser curvature

FIGURE 34–40

Trocar (spike) with 2-0 polyester suture

Circular staple anvil

Gastrotomy

Laparascopic band passer

FIGURE 34–41