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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_670_Библиотеки_им_академика_М_И_Перельмана
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92 Atlas of Gastrointestinal Surgery: The Stomach
Esophagus
Body and tail
of pancreas
retracted
The spleen, tail, and body of
the pancreas are mobilized out
Spleen
7
Post.
stomach
GIST
Splenic a.
Splenic v.
divided
of the retroperitoneum. The
splenic vein is dissected free
from the posterior aspect of
the pancreas at the same level
the splenic artery had been
divided. The splenic vein is
doubly clamped, divided, and
ligated (7).
TA
stapler
Spleen
Often in performing a total gastrectomy the specimen is left
attached to the esophagus until the reconstruction has
been started. In this instance, however, expo-
sure is made easier, and the operative
procedure facilitated, by dividing
the esophagus at this juncture.
The TA stapler is placed across
the distal esophagus, and a
linen-shod clamp is placed
across the proximal stomach
(8). The stapler is fired and
the gastroesophageal junction is
Esophagus
Stomach
Leiomyosarcoma
divided with a scalpel.
8
Resection of a Large Gastrointestinal Stromal Tumor (GIST) 93
Esophagus
Stomach
L. gastric vessels
9
Duodenum
Splenic a.
Pancreas
Omentum
GIST
A row of interlocking horizontal mattress sutures of 3-0 synthetic absorbable material are placed in the pancreas proximal
to the point of division, and the pancreas is divided with the electrocautery (9). At this point the specimen is free of all
surrounding structures, it is removed from the operative field.
The closure of the resected end of the pancreas is reinforced with a series of figure-of-8 sutures of 3-0 synthetic
absorbable material. When the pancreatic duct can be identified, a separate figure-of-8 suture is placed for closure (inset).
Gastric reconstruction is performed as previously described in this atlas. A Roux-en-Y jejunal loop is constructed and
brought up in an antecolic position. An end-to-side esophagojejunostomy is performed with two layers of interrupted
3-0 silk, approximately 10 cm from the end of the jejunal loop. In this instance a small cuff of proximal stomach has been
left on the distal esophagus. This makes the anastomosis easier and more secure. A pouch is created by a long side-to-
side anastomosis between the afferent and efferent limbs of the Roux-en-Y loop. This side-to-side anastomosis is performed
94 Atlas of Gastrointestinal Surgery: The Stomach
with an inner continuous layer of 3-0 synthetic absorbable suture material and an outer layer of interrupted 3-0 silk. The
length of the side-to-side anastomosis is approximately 10 cm. Enteric continuity is reestablished by an end-to-side jejuno-
jejunostomy, performed with an inner continuous suture of 3-0 synthetic absorbable material and an outer layer of
interrupted 3-0 silk sutures. The length of the Roux-en-Y loop should be approximately 60 cm, measured from the new
reservoir (10). The pancreatic closure is drained with a closed suction silastic drain.
Duodenum
Liver
Esophagus
Stomach
Jejunum
Pancreas
oversewn
Pancreas
10
New
pouch
Transverse
colon
End-to-side
jejunojejonstomy
BARIATRIC PROCEDURES
The morbid obesity epidemic continues to spread throughout industrialized nations. Medical therapy that can cause sus-
tained significant weight loss may be years away. Bariatric surgery continues to be the only proven method to achieve sus-
tained weight loss in the majority of patients. Currently, the four most common bariatric operations in the United States
are Roux-en-Y gastric bypass (1), adjustable gastric band (2), vertical sleeve gastrectomy (3), and duodenal switch with
biliopancreatic diversion (4).
Roux-en-Y Gastric Bypass
1
Adjustable Gastric Band
2
Duodenal Switch with
Biliopancreatic Diversion
Vertical Sleeve Gastrectomy
3
4
96 Atlas of Gastrointestinal Surgery: Stomach
These operations are now done laparoscopically at most bariatric centers in the United States. Roux-en-Y gastric bypass
and duodenal switch with biliopancreatic diversion both have malabsorption as integral components to weight loss.
Adjustable gastric band and vertical sleeve gastrectomy are both restrictive operations with no malabsorption. On average,
patients with a high body mass index tend to do better with an operation that includes malabsorption.
Indications
The National Institutes of Health Consensus Development Conference Statement for Gastrointestional Surgery for Severe
Obesity was issued in 1991 and is still regarded as the starting point for criteria to accept patients in a surgical weight-
loss program. Patients are considered morbidly obese and candidates for surgery if they have a body mass index of at least
35 kg/m
2
with an obesity-related comorbidity or greater than 40 kg/m2. It is recommended that patients should have tried
dieting in the past before surgical therapy is considered as a treatment option.
When evaluating a potential patient for bariatric surgery, a multidisciplinary team should be employed. This team should
include a dietitian and mental health professional who are both familiar with bariatric surgery. Their purpose is to obtain a
past dietary and behavioral eating history, discuss postoperative dietary expectations, and decide if they are an appropri-
ate patient for the type of surgery they have chosen. Patients who currently have known drug or alcohol addictions are not
considered for surgical therapy. Support for the surgery from family members and friends is important.
At this time there is not enough evidence to support surgery in patients who cannot ambulate and are bedridden. These
patients are also at greater risk of postoperative complications, and therefore the benefits may not outweigh the risks.
Patients with end-stage heart failure or respiratory failure are also at high risk of morbidity and mortality. Surgery is not nec-
essarily contraindicated for them, but weight loss may not be the solution to their desperate attempt to correct heart or
lung disease. Cirrhotic patients may be at higher risk from surgery, but certainly may benefit from weight loss. Patients who
are morbidly obese may be rejected as a liver or kidney transplant candidate, and therefore patients with early-stage cir-
rhosis or chronic renal insufficiency may benefit from bariatric surgery-induced weight loss. There currently are not enough
data about cirrhotic patients to determine who is an appropriate candidate for weight loss surgery and who is too late in
their disease course to benefit from the procedure.
Open Roux-en-Y Gastric Bypass
On the morning of surgery the patient is injected subcutaneously with low-molecular-weight heparin to prevent venous throm-
boembolic complications. A peripheral IV is placed and a second-generation cephalosporin or equivalent is administered intra-
venously. The patient is placed on the operating room table in the supine position with a footboard. Sequential compression
devices are placed on the lower extremities. General anesthesia is initiated and then a urinary catheter is inserted. The anes-
thesiologist inserts, applies suction to, and then immediately removes the orogastric tube before starting the operation.
An upper midline incision is made starting at the xiphoid process. The
deep subcutaneous fat layer is divided using the electrocautery and with
bilateral traction down to the midline linea alba. A fixed retractor sys-
tem is necessary to help retract the liver, which is often massively
enlarged, and to allow access to the gastroesophageal junction.
98 Atlas of Gastrointestinal Surgery: Stomach
We start the case with creation of the Roux
Stomach
Mesentery
Omentum
limb and the small intestinal anastomosis. The
jejunum is measured approximately 40 to
75 cm distal to the ligament of Trietz, where
there is usually a long enough section of
mesentery that will eventually allow a tension-
free anastomosis of the Roux limb to the gastric
pouch. The jejunum is transected at this point
(1a and 1b) with a linear stapler loaded with a
60 mm length white cartridge. The mesentery is divid-
ed and a stay suture is placed on the Roux limb. A site is
selected on the Roux limb, 75cm distal to the stapled end,
which represents where the stapled side-to-side jejunojejunos-
tomy will be constructed (1c). If the patient’s body mass
index is over 50 kg/m
2
, then the length of the Roux
Roux limb
can be extended up to 150 cm if desired.
Biliopancreatic limb
Jejunum transected
with stapler
1a
Roux limb
Open Roux-en-Y Gastric Bypass 99
Stomach
Biliopancreatic limb
Biliopancreatic limb
Divided
jejunum
Roux limb
1b 1c
The 75 cm mark of the Roux limb is tacked to the proximal
jejunum (biliopancreatic end) using a stay suture.
The anastomosis is performed with a linear stapler loaded
with a 60 mm length white cartridge inserted
through small enterotomies made below the
Jejunojejunostomy
Stay suture
Proximal jejunum
(biliopancreatic)
stay suture (2).
Roux limb
Stapled side-to-side
jejunojejunostomy
2
100 Atlas of Gastrointestinal Surgery: Stomach
Enterotomy closed
Stay sutures
Biliopancreatic
limb
Antiobstuction
suture
3
The enterotomy
is closed by firing a
linear stapler loaded
with a 60 mm length blue
cartridge placed under the
stay sutures at each end of the
opening (3). An unzippering stitch is
Unzippering
suture
Roux limb
placed in the crotch of the stapled anastomosis and an antiobstruction stitch is placed to keep the Roux
limb from kinking at the jejunojejunostomy. The mesenteric defect is closed. Clips or sutures are placed on
the staple line if there is any bleeding.
The patient is placed in reverse Trendelenburg with a footboard in place. The distal esophagus is then
mobilized bluntly and encircled with a Penrose drain that is placed under traction by attaching it to the
retractor bar. This helps to bring the proximal stomach anterior and aids in exposure for stapling the pouch.
The gastrohepatic omentum is entered bluntly next to the caudate lobe. There may be an aberrant left hepat-
ic artery in 25% of patients that should be protected. The phrenoesophageal ligament is incised to open
up a space at the angle of His, exposing the anterior and lateral distal esophagus. One should avoid a low
dissection laterally, which can lead to an injury of the short gastric vessels. The dissection around the distal
Open Roux-en-Y Gastric Bypass 101
esophagus is aided by having a nasogastric tube in place until it is necessary to staple. Division of the neu-
rovascular bundle on the lesser curvature of the stomach just distal to the left gastric vein is accomplished
using a linear stapler loaded with a grey staple cartridge. The anesthetist must remove the nasogastric tube
and the temperature probe from the esophagus prior to
stapling. Multiple linear staplers loaded with 60 mm
blue cartridges are used to transect the stomach into
a small 15 to 20 mL proximal gastric pouch. The
first transection is started on the lesser curve side
and divides the stomach horizontally, just distal to
the left gastric vein. This is followed by sequen-
tial vertical stapling until completion at the angle
of His (4). It is important to retract the posterior
fundus downward and bring the stapler around
the tissue at the angle of His to avoid mak-
ing a large fundal pouch.
The Roux limb is then brought up, in
a retrocolic position, to the gastric pouch
through a defect in the transverse
mesocolon made by blunt dissec-
tion just to the left of the mid-
dle colic artery. The retro-
colic, retrogastric tunnel is
Gastrohepatic
omentum
Caudate
lobe
Pouch
Stomach
expanded so that the
Roux limb is not con-
stricted at the level of
the mesocolon.
Neurovascular
bundle
4
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