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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 cautery or 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
(Figures 34-42 and 34-43).
Gastrotomy
Anvil
Band passer
FIGURE 34–42
Angled dissector
Bovie used to create gastrotomy
3 8 0 S E C T I O N I V • TH E A B D O M E N
Once the anvil is in position, the original gastrotomy is closed with the linear stapler containing 3.5-mm staples (Figure 34-44).
The 60-mm linear stapler with 3.5-mm staple height is applied to the stomach paralleling the lesser curve. Downward traction on the suture on the anvil facilitates proper placement. Before firing the stapler, the orogastric tube is advanced until it can be certain that it is visible within the pouch and not within the main body of the stomach or caught by the stapler. This is repeated until the surgeon is certain the pouch has been completely separated from the main body of the stomach (Figure 34-45).
The spike is removed and discarded (Figure 34-46).
The jejunal Roux limb is opened longitudinally on its end (Figure 34-47).
The circular stapler is placed into the lumen of the Roux limb (Figure 34-48).
Closing gastrotomy with stapler
FIGURE 34–44
Begin completion
of pouch with stapler
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Stomach pouch
Applying a one-quarter turn, trocar is removed from anvil
Open staple line
FIGURE 34–46
FIGURE 34–47
Inserting circular stapler into Roux limb lumen
3 8 2 S E C T I O N I V • TH E A B D O M E N
Once past the demarcated segment, the stapler is opened to pierce the antimesenteric border (Figure 34-49).
The stapler and anvil are mated together, and the instrument is closed and fired. The stapler is partially opened and removed (Figure 34-50).
Piercing through antimesenteric border of jejunum
Anvil
Mating together circular stapler and anvil
Circular stapler
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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 (Figure 34-51).
A seromuscular stitch of 2-0 Vicryl is placed at the right side of the gastrojejunostomy
(Figure 34-52).
The leak check and placement of the closed suction drain complete the operation.
Stomach pouch
Cutting away jejunal excess
Pouch
One seromuscular suture
FIGURE 34–51
3 8 4 S E C T I O N I V • TH E A B D O M E N
3. CLOSURE
Interrupted #2 Vicryl sutures are used to close the abdominal fascia, and the skin is closed with staples after thorough irrigation.
STEP 4: POSTOPERATIVE CONSIDERATIONS
Telemetry and pulse oximetry monitoring should be strongly considered for several hours postoperatively in these high-risk patients.
Ambulation within the first 2 hours of emergence from anesthesia should help prevent venous thrombosis. Patients appropriately educated preoperatively will be anxious to get up out of bed.
STEP 5: PEARLS AND PITFALLS
A thorough preoperative educational program is the best way to achieve the lowest risk of perioperative complications and highest patient compliance.
Venous thrombosis and gastrointestinal leaks are among the most lethal perioperative complications, and surveillance for them is important.
Despite prophylaxis with ambulation, sequential compression devices, and low-molecular- weight heparin, the risks of deep venous thrombosis and pulmonary embolism are still significant.
Intraoperatively, a simple and quick way to test the integrity of the gastrojejunostomy is to occlude the Roux limb with an atraumatic instrument, flood the upper abdomen with saline, and inject boluses of air through the orogastric tube. Bubbles of air when present
should be traced to their source to reinforce the staple line with Vicryl sutures. This procedure can also be performed with methylene blue injection through the orogastric tube.
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Another way to detect leaks in the early postoperative period is to place a closed suction drain at the gastrojejunostomy under the left lateral segment of the liver. This also helps protect against the progression of gastrojejunal leaks to peritonitis and abscess.
Finally, consideration should be given to a contrast swallow with fluoroscopy before allowing any oral intake to screen for early postoperative leaks.
SELECTED REFERENCE
1. Brolin RE: The antiobstruction stitch in stapled Roux-en-Y enteroenterostomy. Am J Surg 1995;169: 355-357.
C H A P T E R 35
LAPAROSCOPIC PLACEMENT
OF ADJUSTABLE GASTRIC BAND (PARS FLACCIDA APPROACH)
Michael D. Trahan
STEP 1: SURGICAL ANATOMY
Experience with the anatomy and a surgical procedure of the esophagogastric junction is a prerequisite to a successful gastric banding operation (see Figure 34-1).
STEP 2: PREOPERATIVE CONSIDERATIONS
The standard indications for a bariatric operation include either a body mass index of at least 40 kg/m2 or a body mass index of at least 35 kg/m2 with significant associated medical illness. Potential patients must also have tried multiple dietary, activity, and lifestyle modification programs. They should be free of substance abuse and be psychologically stable so that they can make an intelligent decision regarding the risks of the operation and the need to dramatically alter their lifestyles. The indications for banding are the same as the indications for gastric bypass.
Bariatric operations should not be offered unless a dedicated team is in place for the thorough preoperative evaluation and close long-term follow-up that are required for every patient.
Banding is considered the safest of all the bariatric operations.
Twenty percent to 40% of patients getting an adjustable gastric band will need to have a hiatal hernia repair. Small but significant hiatal hernias can be missed on preoperative studies. These are often not diagnosed until the intraoperative test, so the surgeon must be prepared for this inevitable situation.
Patients should receive prophylaxis against wound infection with an intravenous cephalosporin and against venous thrombosis with sequential compression devices and low- molecular-weight heparin before induction of anesthesia.
386
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Each incision site is preemptively anesthetized with local anesthetic injection.
General anesthesia is required for this operation. An anesthesia team specially trained and equipped for the morbidly obese patient is necessary.
There are currently two devices with approval from the U.S. Food and Drug Administration (FDA) for use in the United States. There are several others being used internationally. The techniques for insertion may differ slightly, but the principles are the same.
Use of the devices requires a formal education and official proctoring process before the bands are made available to the surgeon. This description is not meant to substitute for that qualification process.
STEP 3: OPERATIVE STEPS
1.INCISIONS
Five small incisions are made as diagrammed. Initial entry is made using a 5-mm optically guided bladeless trocar at the left costal margin in the midclavicular line—this will be the main telescope port. The peritoneal cavity is insufflated and the remaining ports are placed under direct internal visualization. The liver retractor is inserted near the xiphoid process. A 5-mm trocar is placed on either side of the midline to be used as the surgeon’s working ports. A 15-mm trocar is placed below the left costal margin near the anterior axillary line. The assistant will use this port to expose the esophagogastric area (Figure 35-1).
Assistant
MC
388 |
S E C T I O N I V • TH E A B D O M E N |
2. DISSECTION
The orogastric calibration tube is inserted and watched as it enters the stomach. The balloon is inflated with 15 mL of air or water. The tube is pulled back to identify and test the integrity of the esophagogastric junction. If the balloon slips up into the mediastinum, a hiatal repair should be performed, usually by mobilization of the anterior aspect of the distal esophagus and suturing the anterior aspect of the hiatus. A larger hiatal hernia may require a posterior repair. Once the balloon confirms adequate hiatal repair, it is deflated, and the tube is removed.
The pars flaccida is the clear membrane covering the caudate lobe and running between the lesser curvature of the stomach and the liver. This membrane is bluntly opened (Figure 35-2).
The assistant grasps the fat along the lesser curvature and retracts it to the patient’s left. This maneuver exposes the right crus of the diaphragm, which should be carefully distinguished from the inferior vena cava. The peritoneum covering the fat just anterior to the lower aspect of the right crus is bluntly opened just enough to allow passage of the 5-mm articulating dissector. The dissector is placed through this opening and should pass without the slightest resistance behind the stomach aiming toward the angle of His (Figure 35-3).
The band is selected and prepared according to the manufacturer’s specifications. The band and tubing are inserted through the 15-mm trocar by grasping the tip of the band buckle and pushing the device through the trocar with the band first. The grasper then releases the band, and the tubing is gently grasped and fed through the trocar, as well. The tip of the tubing is grasped before inserting the tubing all the way through the trocar. The tip of the tube is grasped by the retrogastric grasper or, if using a band passer, fed through the eye at the tip of the instrument (Figure 35-4).
Opening pars flaccida
15 mL fluid insufflated in intragastric balloon
