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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5193_Библиотеки_им_академика_М_И_Перельмана.pdf
198
Fig. 17.5 Initial view of
the abdomen
Fig. 17.6 Left lobe of the
live retracted using a liver
Hammock using barbed
suture
H. Takla
Fig. 17.7 Identication of
landmarks at the GE
junction
Fig. 17.8 Identifying the
phreno-esophageal
ligament and looking for a
hiatal hernia
17 Robotic Roux-en-Y Gastric Bypass
199
• The next step is to create the gastric pouch. We usually use a few landmarks to
ensure creation of a properly sized gastric pouch. The rst method is to measure
about 5cm vertically from the GE junction, which is the point where the trans-
verse re of the stapler is started to create the pouch transverse staple line.
Another landmark that can be used is just above or at the second crossing vein
seen on the anterior wall of the stomach (Fig.17.9).
• There are a couple of techniques to dissect the lesser curve of the stomach and to
be able to create the gastric pouch transverse staple line, either a perigastric dis-
section, which is the method preferred in our practice, versus division of lesser
omentum including the left gastric vessels and nerve of Latarjet. We generally
prefer the perigastric method as it theoretically preserves more blood supply to
the pouch and nerve supply, which could potentially help with emptying. As
shown by Van Wezenbeek etal. in 2016, the omental transection technique may
also increase the risk of leaks, bleeding, and abscess formation (Figs. 17.10
and 17.11).
• Careful dissection is carried out along the lesser curve dividing all the medial and
posterior vessels to the lesser curve of the stomach using a bipolar energy device.
Hand-over-hand blunt dissection helps create a tunnel until reaching the lesser
sac. Care should be taken in the presence of posterior adhesions between the
posterior wall of the stomach and the retroperitoneal fat as this could potentially
risk injury to the pancreas or splenic artery. Once the lesser sac is entered, the
Fig. 17.9 Starting the
perigastric dissection
above or at the second
crossing vein
Fig. 17.10 Dividing all
the small branches at the
lesser curve
200
Fig. 17.11 Identifying the
retrogastric tunnel into the
lesser sac
Fig. 17.12 Insertion of
the stapler into the
retrogastric tunnel
H. Takla
stapler is used to create a 50mm transverse staple line to allow for a two-layered
18–20mm anastomosis. The bougie is introduced by anesthesia and advanced to
create a longer anterior wall of the pouch than the posterior wall to give room to
create an anastomosis along the anterior wall of the gastric pouch (Figs.17.12
and 17.13).
• Subsequently, the vertical retrogastric tunnel is created with a vertical trajectory
toward the GE junction, careful division of retrogastric fat using a bipolar energy
device is done taking care not to injure the pancreas, splenic artery and properly
dividing the posterior short gastrics to avoid any traction injury to these vessels
(Fig.17.14).
• The pouch vertical staple line is then created usually using two ring of the
60mm robotic stapler with blue or white loads depending on the thickness of the
stomach tissue (Figs.17.15, 17.16, 17.17 and 17.18).
• We routinely check the blood supply of the pouch by asking anesthesia to
give 7.5mg of Intravenous Indocyanine green.For the most part, pouches are
usually well vascularized (Fig. 17.19); however, this becomes even more
important in revisional procedures where some of the gastric blood supply
may have been already interrupted previously.
• The next step is to create the gastrojejunal anastomosis. Our routine practice is to
perform an antecolic antegastric two-layered hand-sewn gastrojejunostomy
using the omega loop technique.
17 Robotic Roux-en-Y Gastric Bypass
Fig. 17.13 Transverse
staple re to create the
gastric pouch
Fig. 17.14 Vertical
retrogastric dissection
201
Fig. 17.15 Vertical staple
re to create the gastric
pouch along the bougie
• The greater omentum is reected cephalad, and we usually split the greater
omentum until reaching the anti-mesenteric border of the transverse colon; this
allows the Roux limb to reach the pouch in an antecolic-antegastric fashion with-
out undue tension.
• Occasionally with shortened thick small bowel mesentery, a retrocolic-
retrogastric Roux limb is necessary, but in our experience this is a rare occurrence.
• The ligament of Trietz is then identied, and then we use the tip up grasper
robotic instrument to assist in counting 70–85cm of biliopancreatic limb. As
noted in several studies, the length of the BP limb is an important contributor to
202
Fig. 17.16 Second
vertical staple re
Fig. 17.17 Final staple
re to separate the gastric
pouch from the gastric
remnant
H. Takla
Fig. 17.18 Completed
gastric pouch
the malabsorptive function of the procedure. In our practice, we do vary the BP
limb length slightly based on BMI.One crucial step here is to ensure that the BP
limb connecting to the ligament of Trietz stays on the right side of the screen
(patient’s left upper quadrant), especially when using the omega loop technique
that we routinely use in our practice. This step ensures that a Roux en-O congu-
ration does not occur (Figs.17.20, 17.21, 17.22 and 17.23).
• The loop of jejunum is then brought up into the upper abdomen with the BP limb
on the right side of the screen and the Roux limb on the left side of the screen;
the loop is then attached to the transverse staple line of the pouch to create the
outer (second) layer of the anastomosis. This is done using a 3/0 slowly
17 Robotic Roux-en-Y Gastric Bypass
Fig. 17.19 ICG used to
check the blood supply of
the gastric pouch
Fig. 17.20 Identifying the
ligament of Treitz
203
Fig. 17.21 Conrming
the duodenojejunal
junction
Fig. 17.22 Identifying the
direction of the BP and
Roux limbs to avoid
Roux-en-O conguration
204
Fig. 17.23 Counting the
BP limb length using the
tip up grasper
Fig. 17.24 Attaching the
omega loop to the
transverse pouch staple
line using 3/0 absorbable
suture
H. Takla
absorbable barbed suture. This is locked at the left corner of the pouch and left in
place to be used for the anterior second layer (Fig.17.24).
• A gastrotomy is then performed using the cut function on the monopolar scissors
over the bougie. We try to measure the length of the gastrotomy and enterotomy,
which is usually about 2cm that allows sufcient anastomosis caliber and mini-
mize the risk of stricture (Fig.17.25).
• Once the gastrotomy and enterotomy are completed, we then start performing a
hand-sewn anastomosis using a 3/0 slowly absorbable barbed suture starting at
the left corner, then progressing to the posterior layer and the anterior layer.
Subsequently, we then use the previous 3/0 suture to complete and anterior sec-
ond layer moving from the left of the anastomosis to the right (Fig.17.26).
• After the anastomosis is constructed, we then use the bougie to test for a leak; we
usually have anesthesia move the bougie to mid pouch and inject 20cc of water
mixed with 7cc of ICG to test for a leak, and we then follow that with 20cc of
air to ensure that the anastomosis is air tight as well. This uid is then suctioned
and the bougie is removed (Fig.17.27).
• Next the biliopancreatic limb is divided using a 60mm robotic stapler; the line
of division is aligned with the vertical staple line of the pouch to avoid Candy
Cane syndrome (Figs.17.28, 17.29 and 17.30).
• The next step is to count the Roux limb, which we usually use 130–150cm
length Roux limb depending on the BMI.We usually use a ruler to count and
ensure that the length is as accurate as possible (Fig.17.31). The counting is
17 Robotic Roux-en-Y Gastric Bypass
Fig. 17.25 2cm
gastrotomy and enterotomy
are created
Fig. 17.26 Inner layer of
the anastomosis is created
using 3/0 absorbable suture
205
Fig. 17.27 Second
anterior layer of the
anastomosis is then placed
Fig. 17.28 A window
created in mesentery of
biliopancreatic limb
206
Fig. 17.29 BP limb
divided using the robotic
stapler
Fig. 17.30 Completed
division of BP limb to
separate the omega loop
into alimentary and BP
limbs
H. Takla
usually done in a counterclockwise fashion. After reaching the point where the
Roux limb will be anastomosed to the BP limb, an enterotomy is made in the
Roux limb, Another enterotomy is made in the BP limb just distal to the staple
line; a side-to-side Jejunojejunostomy is then created using a 60mm robotic
stapler (Figs.17.32, 17.33 and 17.34).
• We then place a simple interrupted suture at the posterior corner of the anasto-
mosis to allow for traction on the anastomosis to distract the enterotomy to the
right and allow easy closure of common enterotomy (Fig.17.35).
• The common enterotomy channel is then closed using a running 3/0 slowly
absorbable barbed suture in two layers (Fig.17.36).
• Subsequently, the anastomosis is distracted to the left upper quadrant and the
mesenteric defect behind the jejunojejunostomy is closed using a running 2/0
ethibond suture. Care should be taken to avoid excessive angulation of the Roux
limb going into the jejunojejunostomy during this step (Figs.17.37 and 17.38).
• The nal step is to close the pseudo-Peterson space behind the Roux limb by
suturing the mesentery of the Roux limb to the transverse mesocolon using a
permanent suture as well (Figs.17.39 and 17.40).
• We routinely perform upper endoscopy to ensure patency of the anastomosis and
inspect for any bleeding in the gastric pouch or at the gastrojejunostomy
(Fig.17.41).
• The procedure is then concluded.
17 Robotic Roux-en-Y Gastric Bypass
Fig. 17.31 The Roux
limb is then counted
Fig. 17.32 After making
enterotomies, a side-toside jejunojejunostomy is
created
207
Fig. 17.33 The stapler is
rotated slightly to allow
antemesenteric borders of
the bowel to be
anastomosed
Fig. 17.34 The staple line
is inspected for bleeding