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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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102 Atlas of Gastrointestinal Surgery: Stomach
Gastric
pouch
Inner layer of
posterior row
A two-layer hand sewn anasto-
mosis is created with the posterior
interrupted silk Lembert sutures
placed first. The gastric pouch
and jejunum are opened for
approximately 10 to 12 mm
Roux limb
(retrocolic)
Stomach
A 32 French blunt-end bougie is placed through the anasto-
and an inner continuous locking
layer of synthetic absorbable
suture is placed for the inner pos-
terior layer (5).
5
Completed Gastric Bypass
Gastric pouch
Roux limb
(retrocolic and
retrogastric)
Stomach
mosis, and the inner layer is completed anteriorly with a running
Connell suture. The anterior outer row of interrupted silk Lembert
sutures is placed to finish the anastomosis (6), and the bougie is
removed. A 18 French nasogastric tube is then guided carefully
through the anastomosis, which is then tested with 30 mL of
methylene blue. The Penrose drain around the esophagus should be
released intermittently when placing the bougie, and then the nasogas-
tric tube, to avoid injury.
The mesenteric defects are then closed at the transverse mesocolon and
behind the Roux limb to prevent an internal hernia. The fascia is closed
with a running suture, the subcutaneous tissues are irrigated with anti-
biotic solution, and the skin is closed with staples (6).
Transverse colon
Biliopancreatic
limb
Side-to-side
jejunojejunostomy
6
Laparoscopic 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 immediately removes an orogastric tube before starting the operation.
Initial access to the peritoneal cavity is gained by making a skin incision in the left upper quadrant and inserting a
12 mm trocar under direct vision with a 0° laparoscope inserted inside of it. The trocar insertion site is located just below
the ribs and in most instances approximately 18 to 22 cm away from the tip of the xiphoid process. Pneumoperitoneum
is then created with a high flow insufflator with an air warmer. The 45° angled viewing laparoscope is then inserted and
the additional four trocars (two additional 12 mm trocars and two 5mm trocars) are placed under direct vision. One of
the two 5 mm trocars is placed below the left upper quadrant 12 mm trocar, slightly more lateral and far enough away
(usually the breadth of a hand) to not interfere with the upper trocar. The right-side trocars are both placed in the right
Camera
upper quadrant, approximately at the midclavicular line. The 5 mm
trocar is placed just below the ribs; the 12 mm trocar just
above the horizontal plane of the umbilicus. The
12 mm supraumbilical trocar is placed and used
as the camera port (1).
The omentum and transverse colon are
first retracted cephalad until the transverse
mesocolon is visualized. Anterior retraction
of the mesocolon allows visualization of
the jejunum at the ligament of Trietz. The
jejunum is then transected with a linear sta-
pler loaded with a 60 mm length white
cartridge approximately 40 to 75 cm dis-
tal to the ligament of Trietz (2). At this
1
point, the mesentery is usually long enough
104 Atlas of Gastrointestinal Surgery: Stomach
that the Roux limb can reach to the gastric pouch in an antecolic position without tension. The jejunal mesentery is divid-
ed with ultrasonic shears. A stay suture is placed on the Roux limb, and then a site on the jejunum is selected, 60 to
75 cm distal, which represents the site where the subsequent jejunojejunostomy will be constructed. If the patient’s body
mass index is over 50 kg/m
Duodenum
2
, the length of the Roux limb can be extended up to 150 cm if desired.
Stomach
Transverse colon
Omentum
Transverse
mesocolon
Jejunum transected
with stapler
Biliopancreatic limb
Roux
limb
Proximal
jejunum
Mesentery
2
Stomach
Laparoscopic Roux-en-Y Gastric Bypass 105
The 60 to 75 cm mark of the Roux limb is then
tacked to the proximal jejunum (biliopancreatic
limb) using a stay suture (3).
3
The jejunojejunal anasto-
Roux limb
Biliopancreatic limb
Biliopancreatic limb
Stapled side-to-side
jejunojejunostomy
mosis is performed with the
linear stapler loaded with a
60 mm length white car-
tridge inserted through small
enterotomies made with the
ultrasonic shears below the
stay suture (4).
Roux
limb
4
106 Atlas of Gastrointestinal Surgery: Stomach
5
The enterotomy is closed by firing a linear
Enterotomy
closed
Biliopancreatic
limb
Roux
limb
stapler loaded with a 60 mm length blue
cartridge placed under the stay sutures
at each end of the opening (5).
Unzippering
suture
An unzippering suture is placed in the
crotch of the stapled anastomosis and an antiob-
struction suture is placed to keep the Roux limb from
kinking at the jejunojejunostomy. The mesenteric defect
is closed with a running suture (6). Clips or sutures are
placed on the staple line if there is any bleeding.
6
Laparoscopic Roux-en-Y Gastric Bypass 107
Next the patient is placed in a steep reverse
Trendelenburg position. The legs and feet are checked to
make sure they are still straight and on the footboard.
The left lateral segment of the liver is retracted with a
fixed retractor, through a subxiphoid 4 mm punc-
Left gastric v.
Bare area
Liver
Pouch
Neurovascular
bundle divided
Stomach
ture, which is held in position with a movable arm
attached to the table. The peritoneal attach-
ments at the angle of His are dissected to
expose the left crus. The lesser sac is
entered through the bare area of the
gastrohepatic ligament.
7
Split omentum
Division of the neu-
Transverse colon
rovascular bundle on the
lesser curvature of the stomach,
just distal to the left gastric vein, is
performed using a linear stapler loaded
with a grey staple cartridge. Multiple firings
of the linear stapler loaded with blue staple cartridges are used to transect the stomach, creating a small, 15 to 20 mL
proximal gastric pouch. The first line of transection is horizontal, followed by sequential vertical stapling up to the angle of
His. It is important to retract the posterior fundus downward and bring the stapler around the tissue at the angle of His
to avoid making a large fundal pouch. This is prevented by placing an articulating dissector posterior to the gastric pouch
at the level of the angle of His, and retracting the fundus in a caudal direction while stapling the stomach (7).
108 Atlas of Gastrointestinal Surgery: Stomach
Gastric pouch
Roux limb
(antecolic and
antegastric)
Omentum
Ileum
Stomach
Omentum
Biliopancreatic
limb
The stomach staple lines on both sides are
inspected for adequate staple formation,
bleeding, and ischemia. In 5 to 10% of
patients the left lateral segment of the liver
is so large that the angle of His cannot be
adequately visualized before gastric tran-
section. In these cases we use a 40
French bougie inserted transorally into
the stomach along the lesser curvature,
and then staple along side of it. After
each stapled transaction we dissect pos-
terior until we reach the angle of His.
The Roux limb is brought up in an
Side-to-side
jejunojejunostomy
8
antecolic position, taking care to avoid a
twist in the mesentery (8). Alternatively, it
may be necessary to use a retrocolic, retrogas-
tric approach when a short mesentery would
put too much tension on the anastomsis.
Laparoscopic Roux-en-Y Gastric Bypass 109
Gastric
pouch
The Roux limb is tacked to
the gastric pouch approximately where
the first and second gastric staple lines inter-
sect. A small enterotomy is made below the
stay suture in the Roux limb and a similar
size gastrotomy in the pouch. The linear
stapler loaded with a 45 mm length
blue staple cartridge is inserted
two-thirds of its full length,
and fired, creating a 30 mm
Roux limb
Stapled
gastrojejunostomy
9
gastrojejunostomy (9).
110 Atlas of Gastrointestinal Surgery: Stomach
A stay suture is placed at
the lower edge of the
enterotomy and it is used to
retract the anastomosis to
the left and anteriorly, there-
by exposing the posterior
Lift staple line to
expose posterior aspect
of gastrojejunostomy
aspect of the staple line (10).
A reinforcing, running 2-0 suture
is placed distally on the posterior staple
line and run continuously to meet the previously
placed stay suture, to which it is then tied (11).
Reinforcing the
posterior
staple line
10
Roux
limb
Gastric
pouch
11
The anesthesia team carefully pass-
Laparoscopic Roux-en-Y Gastric Bypass 111
12
es a 32 French round-end bougie
from the mouth through the gastro-
jejunal anastomosis and into the
Roux limb. The bougie can be seen
through the opening that was formed
after the stapler was removed (12).
Pouch
Roux limb
Bougie
inserted
Enterotomy closed
13
With the anastomosis in its normal,
resting position, a stay suture is placed at
the halfway point of the opening
between the two end stay sutures. This
midpoint stay suture and the stay
suture on the patient’s left (angle of
His side) are again used, just as in
the jejunojejunostomy, to elevate the
tissue so that the linear stapler
loaded with a blue staple cartridge
can be used to partially close the
opening (13).
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