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21 Multimodal Analgesia inBariatric Surgery
8. Ong CK, Seymour RA, Lirk P, Merry AF. Combining paracetamol (acetaminophen) with
nonsteroidal antiinammatory drugs: a qualitative systematic review of analgesic efcacy
for acute postoperative pain. Anesth Analg. 2010;110(4):1170–9. https://doi.org/10.1213/
ANE.0b013e3181cf9281.
9. Wick EC, Grant MC, Wu CL. Postoperative multimodal analgesia pain management with
nonopioid analgesics and techniques: a review. JAMA Surg. 2017;152(7):691–7. https://doi.
org/10.1001/jamasurg.2017.0898.
217
Chapter 22
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Anatomical Considerations
AlminoCardosoRamos andEduardoLemosDeSouzaBastos
22.1 Introduction
Even with all the literature support for biliopancreatic diversion with duodenal
switch plus sleeve gastrectomy (BPD-DS) and its variant, the single anastomosis
duodeno-ileal bypass with sleeve gastrectomy (SADI-S), as the most effective procedure among all the bariatric surgical techniques, inducing weight loss and achieving metabolic improvement, these surgical modalities have very few worldwide
acceptation with less than 1% of the worldwide weight loss surgery preference [1–
3]. This low acceptance could be associated with the hypoabsorptive nature of the
procedure with high risks in terms of serious nutritional complications, including
anemia and hypoproteinemia, and also the major surgical complexity of the surgery,
involving steps in all the four different abdominal quadrants with duodenal dissection, division, and anastomosis, steps considered as very challenging for the majority of the bariatric surgeons. The complete knowledge about surgical anatomy of the
stomach, duodenum, jejunum, and ileum is absolutely important in preparation and
training for reaching optimum results with duodenal switch-style bariatric procedures. In this chapter, we will highlight the most important anatomical considerations in order to be well prepared for the most complex bariatric/metabolic
technical alternative.
A. C. Ramos (*)
Gastro-Obeso-Center—Advanced Institute for Metabolic Optimization, São Paulo, Brazil
E. L. D. S. Bastos
Division of Gastrointestinal Surgery, Marilia Medicine School, Marilia, Brazil
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
A. Teixeira et al. (eds.), Duodenal Switch and Its Derivatives in Bariatric and
Metabolic Surgery, https://doi.org/10.1007/978-3-031-25828-2_22
219
220
A. C. Ramos and E. L. D. S. Bastos
22.2 Sleeve Gastrectomy
In general, the majority of the surgeons start the BPD-DS and SADI-S by the sleeve
part of the procedure with the stomach approach being the rst target of the surgery.
The stomach is a bag-shaped muscular, highly vascularized food reservoir organ
with a great capacity of distension that can assume different sizes and shapes, from
time to time, depending on the volume and kind of content (liquids or solid food),
the posture or position (standing, sitting, or lying down), and the fullness state of the
digestive organ [4, 5]. The stomach has a content capacity of about 60–90mL when
empty and totally relaxed but can expand to hold more than 1L of food, and in great
stretch situations, the gastric capacity can achieve up to 4L of content [6, 7]. The
fundus involves the superior third segment of the stomach, including the cardia and
the esophagogastric angle (His angle), representing the stomach portion with maximum capacity dilation to accumulate food and also the most important place in
production of the major hormone of hunger, the ghrelin [8]. Then there is a tubular
right curved part of the stomach, the body, leading to the nal triangular shape portion, the antrum, orientated to the right, starting at the level of the incisura angularis
and nishing in the pyloric channel with the pyloric sphincter [9–11].
Surgeons will start the sleeve gastrectomy part of the BPD-DS or SADI-S by
dissection and exposing the esophagogastric angle or dividing the vessels of the
greater curve looking for having access for the tubular gastric resection. Considering
the rst choice, the esophagus comes from the thorax and enters the abdomen passing through the right crus of the diaphragm, via the esophageal hiatus, and has a
small 2–3cm abdominal length portion, nishing in the esophagogastric junction,
the cardia [12, 13]. In this abdominal course, it is covered with the peritoneum of
the greater sac anteriorly and on its left side, and it is covered with the lesser sac
peritoneum on the right posterior side [9]. In the case of starting the sleeve by this
upper part, the surgeon will open this peritoneum with electrocauterization or bipolar or ultrasonic energy exposing all the left lateral part of the right crus. Some surgeons will also remove the fat pad, a landmark in the top of the fundus, just close to
the esophagogastric junction, while some don’t [14–17].
The greater curve of the stomach starts at the level of the apex of the fundus running distally along the left border of the body of the stomach and the inferior border
of the antrum and pylorus in a convex trajectory. The lesser curvature starts at the
right of the cardia as a continuation of the right border of the abdominal esophagus
and runs along the right side of the body and the antrum in a concave trajectory
including the incisura angularis in the middle [10, 11]. The blood supply of the
stomach is very rich, with many vessels overlapping. The lesser curve is supplied by
the left gastric artery, coming straight from the celiac trunk and the right gastric
artery, a branch from the hepatic artery. The greater curve is supplied by the right
gastroepiploic artery arising from the gastroduodenal artery and the left gastroepiploic artery and the short gastric arteries originating from the splenic artery making
an extensive arcade. This arcade gives off multiple small arteries to the body and
antrum of the stomach. This excellent collateral blood supply of the stomach allows
the surgeon to ligate much of the arterial supply without any risk of ischemia [18].
22 Anatomical Considerations
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221
These vascular branches will be divided just close to the gastric wall using bipolar or harmonic energy releasing the greater curve for the tubular gastrectomy with
linear 60mm cartridge stapling. In general, the surgeon will look for the thinnest
point in the gastric connection with the omentum to start the dissection. There is no
necessity for using metallic clips. Once we open, we will reach the retrogastric
space, the bursa omentalis or lesser sac, behind the stomach and in front of the pancreas. Now surgeons will take the decision about progressing with the division at
rst up till the esophagogastric angle, ligating all the short vessels, or moving down
up to the pylorus or vice versa (Fig.22.1). Few peritoneal bands may be identied
between the posterior surface of the stomach and the anterior surface of the pancreas, and these adhesions should be removed. With all the greater curve released,
the stapling of the stomach can be initiated (Fig.22.2). It is important to have clear
differences of gastric wall thickness according to the different portions of the stomach that will become progressively thicker from the fundus to the antrum and from
greater to smaller curve. The average thickness is 1.7mm, 2.4mm, and 3.1mm in
the fundus, body, and antrum, respectively, and will orientate the choice of the color
of the cartridge based on the range diameter for closing the staples [19, 20].
Fig. 22.1 Division of the
greater curve:
gastroepiploic vessels
arcade
Fig. 22.2 Stapling of the
stomach creating the
gastric sleeve
222
A. C. Ramos and E. L. D. S. Bastos
Sleeve gastrectomy was initially proposed as part of the BPD-DS, named parietal
gastrectomy, with the objective of reducing acid gastric production to decrease the
possibility of peptic complications of the procedure such as the anastomotic ulcer.
The esophagus is covered with nonkeratinized stratied squamous epithelium,
which changes into columnar epithelium in the stomach. The columnar cells in all
of the stomach secrete mucin; the main zymogenic cells in the fundus secrete
protein- digesting pre-enzyme pepsinogen; the parietal oxyntic cells in the body of
the stomach secrete acid and intrinsic factor; and the G cells in the antrum secrete
gastrin that can stimulate parietal cells in acid production [21–25].
The celiac trunk arises from the anterior surface of the abdominal aorta at the
level of the rst lumbar vertebrae. It has a short length, about 1cm long, and trifurcates into the common hepatic artery (CHA), the splenic artery (SA), and the left
gastric artery (LGA). The LGA runs toward the lesser curvature of the stomach and
divides into an ascending branch (vascularizing the abdominal segment of the
esophagus) and a descending branch for the proximal stomach. The CHA runs
toward the right on the superior margin of the pancreas and gives off the gastroduodenal artery (GDA), which runs down behind the rst part of the duodenum. After
giving off the GDA, the CHA continues as the proper or common hepatic artery
(CHA) [10–16].
The right gastric artery (RGA), a branch from CHA, runs along the lesser curvature from right to left and joins the descending branch of the LGA to form an arcade
along the lesser curvature between the two leaves of the peritoneum of the lesser
omentum. This arcade gives off multiple small arteries to the antrum and body of
the stomach [10–16].
The greater curvature arcade is formed by the RGEA and the LGEA providing
several omental (epiploic) branches to supply the highly vascularized greater omentum. The splenic artery also gives off three to ve short gastric arteries that run in
the gastro-splenic (gastro-lienal) ligament and supply the upper part of the greater
curvature and the gastric fundus, sometimes collectively referred to as the vasa
brevia. Few small posterior gastric arteries may arise from the splenic artery. The
stomach has a vast network of vessels in its submucosa [10–16].
The left gastric (coronary) vein drains into the portal vein at its formation (by the
union of the splenic and superior mesenteric veins). The right gastric and right
gastro- omental veins drain into the portal vein. The left gastro-omental vein drains
into the splenic vein, as do the short gastric veins [10–16].
The esophageal plexus of vagus (parasympathetic) nerves lies in the posterior
mediastinum below the hila of the lungs. It divides into two vagal trunks that enter
the abdomen along with the esophagus through the esophageal hiatus in the left
dome of the diaphragm. The right (posterior) vagus is behind and to the right of the
intra-abdominal esophagus, whereas the left vagus is in front of the intra-abdominal
esophagus [10–16].
22 Anatomical Considerations
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223
22.3 Duodenal Approach
The small bowel is the intestinal part placed between the stomach and the colon
including three different portions, duodenum, jejunum, and ileum. Talking about the
technical steps for BPD-DS and SADI-S, the duodenal dissection looks to be the
major anatomic barrier for increasing the international acceptance for these DS bariatric model surgical procedures. Surgeons are a little afraid of working in an area
with big vessels, pancreas, and common bile duct (CBD), for duodenal dissection
and division (Fig.22.3), nishing the surgery with a manual duodeno-ileal anastomosis [26].
The duodenum corresponds to the shortest part of the small intestine with about
25cm and can be divided into four segments: superior, descending, horizontal, and
ascending in a “C” shape. The rst superior part, or bulb with 5cm, is connected to
the undersurface of the liver by the hepatoduodenal ligament, which contains the
proper hepatic artery, portal vein, and common bile duct (CBD); the quadrate lobe
of the liver and gallbladder are in front, and the CBD, portal vein, and GDA are
behind. The second descending part, or the “C” connection loop with 8–10cm,
which has a double, upper and lower, exure, is related to the transverse mesocolon
and colon in front and the right kidney and inferior vena cava (IVC) behind; the
head of the pancreas lies in the concavity of the duodenal “C.” The third horizontal
part with 5–7cm runs from right to left in front of the IVC and aorta, with the superior mesenteric vessels, the vein on the right and the artery on the left, anteriorly.
The fourth ascending part with 2.5cm will continue as the jejunum. The duodenojejunal junction or exure is an abrupt turn at the level of the second lumbar vertebrae and can be identied during surgery just to the right of the inferior mesenteric
vein (IMV). It is attached posteriorly by the suspensory muscle of the duodenum or
the ligament of Treitz [27, 28]. The GDA, a branch of the CHA, runs down behind
the rst part of the duodenum in front of the neck of the pancreas and gives off the
posterior superior pancreaticoduodenal artery (PSPDA) before it divides into the
right gastroepiploic (gastro-omental) artery (RGEA) and the anterior superior pancreaticoduodenal artery (ASPDA) [27, 28].
Fig. 22.3 Retroduodenal
dissection close to the
gastroduodenal artery
(GDA)
224
Fig. 22.4 Duodenal
division
A. C. Ramos and E. L. D. S. Bastos
Once dissected and divided, the rst part of the duodenum is mobile and can be
used for the duodeno-ileal anastomosis (Fig.22.4). Duodenal dissection starts in the
duodenocolic ligament moving posteriorly in the retroduodenal space having the
pancreas behind. This space is a vascular crossing in between the posterior surface
of the duodenum and anterior to the pancreas. Next the opposite side in the duodenal hepatic ligament will be opened. Inferior limit will be the gastroduodenal artery
[29, 30]. A thin tape can be used to repair and mobilize the duodenum. In this part
of the procedure, some surgeons will prefer to divide the right gastric artery in order
to reach a better mobilization of the divided duodenal limb. This can be done in
between clips or simply by using bipolar or harmonic energy. Now, the duodenum
can be transected with linear stapling trying to keep the largest segment as possible
(Fig.22.4). This distal part of the duodenum will be anastomosed to the ileum by
manual suture or using linear staple [31, 32].
22.4 Jejunum andIleum
In continuity with the duodenum, jejunum and ileum are a 4–12-m-long (average
6–7m) convoluted tube occupying the center of the abdomen and the pelvis, surrounded on the two sides by the right and left colon and above by the transverse
colon. The ileum continues into the large intestine (cecum) at the ileocecal junction
[33, 34].
The jejunum constitutes about two fths of the proximal small intestine, and the
ileum makes the distal three fths. No clear demarcation can be noted between the
jejunum and ileum; however, there are some references which can help to distinguish the jejunum from the ileum. The jejunum has a thicker wall and a wider lumen
than the ileum and mainly occupies the left upper and central abdomen. Mesenteric
fat is less abundant in the mesentery of the jejunum, and vessels in the mesentery
are, therefore, well seen [31–34].
The ileum has a thinner wall and a smaller lumen than the jejunum and mainly
occupies the central and right lower abdomen and pelvis. Mesenteric fat is abundant
in the mesentery of the ileum, and vessels in the mesentery are, therefore, not well
22 Anatomical Considerations
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225
seen. The mesentery is a double fold of peritoneum attached to the posterior abdominal wall. It is fan-shaped with a root of about 15cm which covers the entire length
of the jejunum and ileum. Between the two leaves of the mesentery are the mesenteric vessels and lymph nodes [31–34].
The superior mesenteric artery (SMA) is the main artery of the small intestine; it
comes off as the second branch from the anterior surface of the abdominal aorta
1cm below the celiac trunk, behind the neck of the pancreas. From there, it descends
in front of the uncinate process of the pancreas and the third horizontal part of the
duodenum to enter the small intestine mesentery. Multiple jejunal and ileal branches
arise from the left side of the SMA.They anastomose with each other to form a
series of loops or arcades from which arise the terminal (end) branches, called vasa
recta, which supply the jejunum and ileum and lie between the two leaves of the
small intestine mesentery. Jejunum has fewer (two to three) series of arcades, and
the vasa recta are longer. The ileum has more (four to ve) series of arcades, and the
vasa recta are shorter [31–34].
From the right side of the SMA arise ileocolic, right colic, and middle colic arteries.
The ileocolic artery or one of its branches gives off the appendicular artery. The ileal
branch of the ileocolic artery anastomoses with the terminal ileal branch of the
SMA.The left branch of the middle colic artery anastomoses with the ascending branch
of the left colic artery (which in itself is a branch of the inferior mesenteric artery).
Jejunal, ileal, ileocolic, right colic, and middle colic arteries are accompanied by
the same named veins, which drain into the SMV [31–34].
The superior mesenteric vein (SMV) lies to the right of the SMA in front of the
uncinate process of the pancreas and the third part of the duodenum. The union of
the vertical SMV and the horizontal splenic vein forms the portal vein (PV) behind
the neck of the pancreas. The inferior mesenteric vein (IMV) lies to the immediate
left of the duodenojejunal (DJ) exure and joins the junction of the splenic vein
(SV) and SMV.The PV runs up (superiorly) behind the rst part of the duodenum
in the hepatoduodenal ligament (HDL) behind (posterior to) the bile duct on the
right and the proper hepatic artery (HA) on the left. The portal venous system (SV,
SMV, and PV) has no valves [31–34].
From the point of view of nutritional balance and nutrient’s absorption, the proximal jejunum and distal ileum are more important; the distal jejunum and proximal
ileum (mid-small bowel) can be more easily sacriced or bypassed without much
disturbance of absorption and risk of malnutrition [34]. Also, in this kind of surgery,
keeping the rst part of duodenum in alimentary bowel transit will collaborate in
improving micronutrient nutritional balance.
Once we have nished sleeve gastrectomy and duodenal division, the next step
of the surgery will be identifying the ileocecal valve and progress carefully mobilizing and counting the length of the total alimentary limb length for BPD-DS or common channel in the case of the SADI-S technique, proceeding with the subsequent
duodeno-ileal anastomosis (Fig.22.5) that will nish this procedure or moving with
ensuing ileal section and jejunoileal anastomosis in the case of BPD-DS [14–17].
Suture of the intestinal mesenteric gaps to avoid internal hernia occurrence would
be the closing step of the procedure.
226
Fig. 22.5 Duodeno-ileal
anastomosis
A. C. Ramos and E. L. D. S. Bastos
22.5 Summary
BPD-DS or SADI-S is considered the most complex bariatric/metabolic technique.
Surgeons more frequently will start the procedure by the gastric approach with the
greater curve liberation for proceeding the tubular gastrectomy. Next will be duodenal dissection, and it is considered very important to have an adequate anatomic
knowledge of the region mostly over vascular supply, pancreas, and biliary tract.
This is not an easy approach for most surgeons. After duodenum dissection and
division, the surgical working eld will change for the right inferior abdominal
quadrant to ileocecal identication and ileal measurement dening the length of the
limbs. The last part will be proceeding with the gastrointestinal tract reconstruction
by duodeno-ileostomy that will complete a SADI-S procedure or move with the
nal part of the BPD-DS, the jejunoileal anastomosis.
Key Learning Points
The knowledge and adequate mastery of anatomic relations involving the stomach,
duodenum, jejunum, and ileum are essential to practice a safe and effective BPD-DS
or SADI-S.
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