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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_536_Библиотеки_им_академика_М_И_Перельмана.pdf
Laparoscopic Roux-En-Y Gastric Bypass
J. Caetano Marchesini and Natan Zundel
29
29.1 Introduction
Laparoscopic gastric bypass is one of the most frequent
bariatric procedures performed in the world. Nowadays,
only sleeve gastrectomy is more used than this technique.
Wittgrove and Clark [1] published their initial results on
laparoscopic gastric bypass in 1994 and many centers have
chosen this technique like the gold standard procedure for
bariatric patients [2], but there is no a uniform way to perform this procedure and each surgical team has its own
specific surgical steps. There are different types of gastrojejunal anastomosis [3], different length of the alimentary
limb, antecolic or retrocolic route for the Roux limb, and
different approaches [4].
All of these techniques have been shown to produce successful outcomes when performed by experienced surgeons.
Outcomes are very good, with a % reduction in excess body
mass index that significantly improved over time and a
highly significant decrease in obesity-related comorbid disease that persisted at 10 years of follow-up [5].
Electronic supplementary material The online version of this
chapter (https://doi.org/10.1007/978-3-030-55176-6_29) contains
supplementary material, which is available to authorized users.
J. C. Marchesini
Department of Endoscopy, Medical School of Mario Covas
Hospitaland Bariatric Surgery of SirioLibanés Hospital, Sao
Paulo, Brazil
N. Zundel
Department of Surgery, FIU Herbert Wertheim College of
Medicine, Jackson North Medical Center, 17038 North Dixie Hwy
Beach, Miami, FL 33160, USA
e-mail: drnazuma99@yahoo.com
29.2 Description of the Surgical Technique (Video 29.1)
1. Patient, surgical team and trocar position
The patient is taken to the operation table in the supine
position with the legs together, monitored, placed under
general anesthesia and submitted to skin preparation.
Drapes are placed for delimitation of the surgical field.
The patient is placed in a semi-sitting position, with the
back raised at an approximate angle of 45°. This position
decreases the distance between the trocars and the esophagogastric junction, the deeper part of the operative field.
This generally avoids the need of long instruments. The
patient’s position will be changed to horizontal in the
intestinal operating time, back into semi-sitting during
the gastrojejunal anastomosis and finally again in horizontal for closure of the Petersen’s space.
The surgeon stands on the right side of the patient
together with the first assistant, who handles the camera. The second assistant and the scrub nurse stay on
the left side (Fig. 29.1).
Trocars are placed as follows (Fig. 29.1):
– A 10 mm trocar in the umbilicus for the camera
– Two 5 mm trocars are then placed in the epigastrium,
in a subcostal position, near the xiphoid process 4 cm
from midline. The right trocar is used for the surgeon’s
left hand and the left trocar is used for liver retraction
with a grasper, fixed on the diaphragm near the esopha-
geal hiatus.
– Another 10 mm trocar is inserted in the left subcostal
margin near the anterior axillary line. This will be used
by the second assistant to manipulate instruments to aid
the procedure and, if necessary, to place an abdominal
drain at the end of the operation.
– Two other 13 mm trocars are placed bilaterally in the
midclavicular lines. The distance to the costal margin
depends on the patient’s abdominal shape.
© Springer Nature Switzerland AG 2021
M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery,
https://doi.org/10.1007/978-3-030-55176-6_29
229
230 J. C. Marchesini and N. Zundel
Fig. 29.1 Position of surgical team (a), patient (a) and trocar’s (b) placement
Fig. 29.2 Dissection of the lesser gastric curvature. Close (a) and schematic view (b)
2. Dissection of the lesser gastric curvature (Fig. 29.2)
The first surgical step is to place a subhepatic clamp for
retraction anchored in right crura. The operation itself
begins with dissection of the lesser gastric curvature,
next to the third distal vessel of the esophagogastric
junction above the “crow’s foot”.
3. Transverse gastric section (Fig. 29.3)
A space between the neurovascular bundle and the wall
of the stomach is created, along which the first stapler
will be inserted.
This first transverse firing is done with a purple or gold
45 mm load, with the stapler inserted by the 13 mm
trocar in the right side of the patient.
4. Vertical gastric section
The operation continues with vertical firings toward the
His angle. To do this step, a 32 Fr Fouchet bougie is
introduced into the stomach to be used as a guide for
the vertical staples (Fig. 29.4). At this point, we must
not apply too much tension of the stomach on the
bougie.
Fig. 29.3 Transverse section of the stomach. Close (a) and schematic view (b)
Fig. 29.4 A 32 Fr bougie
into the stomach
23129 Laparoscopic Roux-En-Y Gastric Bypass
The stapler is inserted in the 13 mm trocar on the left
side of the patient. Purple loads of 45 or 60 mm are
used for these staplings. The vertical stapling should finish approximately 2 cm from the esophagus (Fig. 29.5).
5. Reinforcement suture (Fig. 29.6)
After reviewing hemostasis, over sewing or not the staple
line is done depending on the intensity of local bleeding.
6. Intestinal operating time position
For the intestinal operating time, an optional 5 mm
trocar can be inserted, between the umbilical and the
13 mm trocar in the right side of the patient, forming
a triangular image (Fig. 21.1). This extra trocar gives
more ergonomy to the surgeon’s arms, avoiding fatigue
in procedures that are longer than usual.
232 J. C. Marchesini and N. Zundel
Fig. 29.5 Vertical gastric section. Close (a, b) and schematic view (c)
7. Transection of the small intestine
Using graspers through the 13 and 5 mm right-side trocars for the surgeon’s hands, and the left side 13 mm
for one hand of the assistant, the inframesocolic area is
exposed to identify the angle of Treitz.
At 120 cm of the angle of Treitz, the transection of
the small intestine is performed with a white load.
The stapler is inserted in the 13 mm right-side trocar
(Fig. 29.7).
8. Jejunum-jejunal anastomosis
From this point, we count 100 cm from the distal segment of the intestinal transection for the preparation of
the alimentary limb and establishing the location of the
Roux-en-Y enteroanastomosis.
To avoid confusion, the biliopancreatic limb should be
positioned toward the angle of Treitz and the alimentary limb by the patient’s right side with the mesentery
exposed open. This facilitates the lifting of the alimentary limb to the gastrojejunal anastomosis at the end of
the enteroanastomosis. The mesenteric space is easily
exposed in this position.
Both the biliopancreatic and the alimentary limbs are
positioned side by side in an isoperistaltic manner. Two
orifices are made to insert the stapler and the anastomosis is performed with 45 mm white loads (Fig. 29.8).
The remaining orifice is closed by means of a continuous suture with 3-0 PDStm thread (Fig. 29.9).
Fig. 29.6 Reinforcement
suture
23329 Laparoscopic Roux-En-Y Gastric Bypass
Fig. 29.7 Transection of the small bowel. Close (a) and schematic view (b)
9. Suture anchoring the alimentary limb to the gastric
pouch (Fig. 29.10)
To make the gastrojejunal anastomosis, we lift the alimentary limb parallel to the gastric pouch, where it is
anchored using a 3-0 Ethibondtm suture in the stapling
line, approximately 5 cm above the distal end of the
gastric pouch.
10. Gastrojejunal anastomosis
Through small orifices, made in the gastric pouch and
the alimentary limb with electrocautery or ultrasonic
scissors, the stapler with a 45 mm purple or gold load
is inserted (Fig. 29.11).
The staple firing is made anterior to the section line
of the gastric pouch. The hole which results from the
234 J. C. Marchesini and N. Zundel
Fig. 29.8 Jejunum-jejunal anastomosis. Close (a) and schematic view (b)
Fig. 29.9 Close the orifice. Close (a) and schematic view (b)
stapler introduction is closed with double-layer suturing using the same 3-0 PDS™ thread (Fig. 29.11).
Despite the controversies, the choice of the anastomotic technique should depend for the most part, based
on present evidence, on the surgeon’s preferences and
expertise [7, 8].
The choice of the antecolic route for the roux limb is
based on the consideration of internal hernias. Two
reviews of internal hernias after laparoscopic gastric
bypass found that the retrocolic window was the most
common site of symptomatic herniation [9, 10]. Antecolic
placement of the Roux limb avoids creation of a retrocolic defect. Only on rare occasion, such as when a Roux
limb has poor mobility and would create anastomotic tension at the gastrojejunostomy, do we prefer the retrocolic
route for the Roux limb to reach the gastric pouch.
Fig. 29.10 Suture anchoring the alimentary limb to the gastric pouch. Close (a) and schematic view (b)
23529 Laparoscopic Roux-En-Y Gastric Bypass
Fig. 29.11 Gastrojejunal anastomosis. Close (a) and schematic view (b, c)
11. Close the spaces (Fig. 29.12)
The mesenteric defects are closed with 2-0 Ethibond™. The
Roux-en-Y enteroanastomosis defect is closed at the end of
the procedure, if this was not done earlier. This step can be
left to the end to decrease the tension at the time of the gastrojejunal anastomosis. The closing of the Petersen’s space
is done with 2-0 Ethibond™.
Upon completion of the procedure, hemostasis and
methylene blue test are performed to detect possible leakage through the suture lines. The use of a Penrose drain or
similar is optional, and classic criteria are followed. Its use
is not a routine.
236 J. C. Marchesini and N. Zundel
Fig. 29.12 Close the spaces.
Final view
References
1. Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopic gastric
bypass, Roux-en-Y: preliminary report of five cases. Obes Surg.
1994;4(4):353–7.
2. Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide
2011. Obes Surg. 2013;23(4):427–36.
3. Higa KD, Boone KB, Ho T, Davies OG. Laparoscopic Roux-en-Y
gastric bypass for morbid obesity: technique and preliminary
results of our first 400 patients. Arch Surg 2000;135:1029–33; discussion 1033–1034.
4. Marchesini JC, Marchesini JB, Baretta GA, Castro GR, Sadowski
JA, Sobottka WH, Feistler R. Laparoscopic Roux-en-Y gastric
bypass with single transumbilical incision–GelPoint
Cir Dig. 2013;26(1):83–4.
5. Mehaffey JH, LaPar DJ, Clement KC, Turrentine FE, Miller MS,
Hallowell PT, Schirmer BD. 10-Year outcomes after Roux-en-Y
gastric bypass. Ann Surg. 2016;264(1):121–6.
®
. Arq Bras
6. Higa KD, Ho T, Boone KB. LaparoscopicRoux-en-Ygastric
bypass: technique and 3-year follow-up. J Laparoendosc Adv Surg
Tech A. 2001;11:377–82.
7. Champion JK, Williams MD. Prospective randomized comparison
of linear staplers during laparoscopic Roux-en-Y gastric bypass.
Obes Surg. 2003;13:855–9; discussion 860.
8. Korenkov M, Goh P, Yucel N, Troidl H. Laparoscopic gastric
bypass for morbid obesity with linear gastroenterostomy. Obes
Surg. 2003;13:360–3.
9. Higa KD, Ho T, Boone KB. Internal hernias after laparoscopic
Roux- en-Y gastric bypass: Incidence, treatment and prevention.
Obes Surg. 2003;13:350–4.
10. Champion JK, Williams M. Small bowel obstruction and internal
hernias after laparoscopic Roux-en-Y gastric bypass. Obes Surg.
2003;13:596–600.
Laparoscopic Sleeve Gastrectomy
Michel Gagner
30
30.1 Introduction
The sleeve gastrectomy is a restrictive and hormonal procedure, in which stomach is reduced to a vertical tube with
a volume less than 2100 mL. A metabolic action has been
described in relation to this technique, due to the resection
of the greater gastric curvature and the fundus also alters the
hormonal milieu of the gut, in particular decreasing ghrelin
production [1] with effect in hunger and satiety [2, 3].
This technique was described at the beginning like a first
stage of duodenal switch in high-risk patients [4–6]. After
evaluating the results of this procedure alone a lot of surgical teams decided to perform this technique like a definitive
bariatric procedure.
Nowadays, it is the most common bariatric procedure
performed around the world. It’s very important to do a
correct selection of the patients and make a safe procedure
based in expert recommendations [7].
Long-term results are excellent with a correct weight
loss and comorbidities curation rates. Complications are
infrequent. Stenosis, reflux, bleeding and leaks are the most
common complications and an expert multidisciplinary
group is necessary to treat them successfully.
Electronic supplementary material The online version of this
chapter (https://doi.org/10.1007/978-3-030-55176-6_30) contains
supplementary material, which is available to authorized users.
M. Gagner (*)
Department of Surgery, Hopital du Sacre Coeur, 315 Place
D’Youville, #191, Montreal, QC H2Y 0A4, Canada
e-mail: gagner.michel@cliniquemichelgagner.com
30.2 Description of the Surgical Technique (Video 30.1)
1. Patient, surgical team and trocar position
The patient is placed in supine position with legs
apart and both arms in abduction. The surgeon stands
between patient’s legs, assistant with the camera on
the right side of the patient and the first stay on the
patient’s left side (French position).
Trocars are placed as follows:
– A 10 mm trocar in the umbilicus for the camera (30°).
– A 5 mm trocar in the epigastrium, near the xiphoid pro-
cess. It is used for liver retraction.
– A 5 mm trocar in the right upper quadrant, for the sur-
geon’s left hand.
– A 12 mm trocar in the left upper quadrant, for the sur-
geon’s right hand.
– A 5 mm trocar laterally in the left abdomen, for the
assistant.
2. Exposure of the surgical field
First of all, a liver retractor is placed and an evaluation
of the stomach and hiatus is performed (Fig. 30.1).
3. Dissection of the greater gastric curvature (Fig. 30.2)
In this step, dissection of the greater curvature starts in
the antrum and it continues to the angle of His crani-
ally. Distally the dissection ends close to the pylorus.
4. Short gastric vessels section (Fig. 30.3)
Carefully short gastric vessels are divided. Sometimes
a dilated fundus make this dissection difficult. To
obtain a correct view in order to avoid bleeding in this
area surgeon and assistant both have to make a careful
traction of the fundus to the left.
5. Dissection of the angle of His (Fig. 30.4)
Cranially the dissection continues to the angle of His.
It’s very important to remove all adherences of the pos-
terior wall of the stomach in order to make a correct
dissection of the left crus and the angle of His.
© Springer Nature Switzerland AG 2021
M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery,
https://doi.org/10.1007/978-3-030-55176-6_30
237
238 M. Gagner
6. Section of the stomach (Fig. 30.5)
After total mobilization of the greater gastric curva-
ture, a Fouche tube (36Fr) is placed into the stomach
lumen. The tube is located in the lesser curvature. Then
sequential stapler firings along this inserted bougie are
used to create a sleeve gastrectomy. The staplers used
in this part of the operation are 60 mm/4.8 mm, cov-
ered with bioabsorbable material to prevent bleeding
and to diminish the rate of leakage.
7. Stitch at the proximal end of the first section (Fig. 30.6)
After the first stapler firing, a X stitch is performed at
the end of the section, near to the piylorus.
8. Gastric section (Fig. 30.7)
The section of the stomach is now performed following
Fig. 30.1 Exposure of the surgical field.
the bougie to the angle of His.
9. Stitch at the end of the section near to the angle of His
(Fig. 30.8)
Fig. 30.2 Dissection of the greater gastric curvature. Close (a, b) and schematic view (c)
Fig. 30.3 Short gastric
vessels section. Close (a) and
schematic view (b)