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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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112 Atlas of Gastrointestinal Surgery: Stomach
Gastric pouch
The stapler is brought down on top of the bougie
while retracting the tissue to be stapled. This firing
closes most of the opening and the small remaining
defect is easily closed with a 2-0 running suture
Roux limb
Remaining
enterotomy closed
14
The gastrojejunal anastomosis is then completed by running a 2-0
(14). This technique decreases the chance of anas-
tomotic stricture, a potential risk of stapling the
entire opening. Alternatively, the entire opening can
be closed with a running 2-0 suture.
absorbable suture to reinforce the entire anterior staple line (15). The
resultant stapled anastomosis is approximately 12 mm in diameter
and has been completely reinforced with a continuous 2-0 suture.
An air leak test can be performed to check the gastrojejunal anas-
tomosis. The Roux limb distal to the anastomosis is
clamped and air is insufflated either with an
endoscope, an orogastric tube, or a laparo-
scopic gallbladder decompression needle
while the gastric pouch and anastomosis are
submerged in a saline solution.
15
Reinforcing the
anterior staple line
Laparoscopic Roux-en-Y Gastric Bypass 113
The mesenteric defect is then closed between the Roux limb mesentery and the transverse mesocolon, up to the trans-
verse colon. The remaining jejunojejunostomy mesenteric defect is closed with a purse string or running suture. A drain is
placed near the gastrojejunal anastomosis and the trocars are removed. Long-acting local anesthetic is placed in the trocar
sites and they are closed with absorbable subcuticular sutures (16).
Gastric pouch
Roux limb
Ileum
Stomach
Colon
Biliopancreatic
limb
16
Laparoscopic Adjustable Gastric Band
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.
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 cre-
ated with a high flow insufflator with an air warmer. The
45° angled viewing laparoscope is then inserted
and the additional three trocars (one 12 mm
trocar and two 5 mm trocars) are placed
under direct vision. The right-side tro-
cars are both placed in the right
upper quadrant, approximately at
the midclavicular line, with one of
the 5 mm trocars just below the
ribs and the other 5 mm trocar
just above the horizontal plane
of the umbilicus. The 12 mm
supraumbilical trocar is placed
and used as the camera port (1).
Camera
1
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 foot-
Laparoscopic Adjustable Gastric Band 115
Angle of His
dissection
Gastroesophageal
fat pad
board. The left lateral segment of the
liver is retracted using a fixed retrac-
tor that is placed subxiphoid and
held in position with a movable
arm attached to the table. A
small window is opened in the
angle of His attachments (2).
Window at
angle of His
Stomach
2
The bare area of the gastrohepatic ligament
is divided with a hook electrocautery. A ret-
R. crus
Esophagus
Stomach
3
rogastric tunnel, the width of the adjustable
gastric band, is created anterior to the crura.
Dissection with a blunt tip grasper is per-
formed from the right crus to the left crus so
that the retrogastric tunnel is in line with the
previously created window that was opened
at the angle of His (3).
116 Atlas of Gastrointestinal Surgery: Stomach
An articulating dissector is then placed through this tun-
nel, posterior to the gastroesophageal junction, from the
right crus side to the angle of His. The retractor is flexed
into a right angle and locked.
The 12 mm left upper quadrant trocar is removed
and replaced with a 15 mm trocar. The adjustable
gastric band is placed into the abdomen through this
15 mm trocar. Alternatively, instead of using a
15 mm trocar, the 12 mm trocar is removed, the
gastric band is placed directly through the trocar
site, and then the 12 mm trocar is replaced.
The end of the adjustable gastric band tubing
is placed through the opening in the articulating
dissector and pulled behind the gastroesophageal
Adjustable gastric
band tubing
Gastroesophageal
fat pad
4
Stomach
junction (4). The tubing is removed from the
dissector (5) and passed through the buckle of
the gastric band (6). The buckle is locked.
Buckle of adjustable gastric band
Band
Pump
Articulating
dissector
Adjustable
band
(open)
Tubing
Tubing
5 6
Proximal
stomach
Laparoscopic Adjustable Gastric Band 117
Fundus
Band
Anterior wrap
7
Next, two sutures are placed to prevent herniation of
the stomach through the gastric band that could lead
to strangulation. These interrupted 2-0 non-
absorbable sutures are placed from the
fundus of the stomach to the more
proximal stomach, superior to the
gastric band. It is best to start on the
angle of His side of the stomach and
then sew to the patient’s right side (7).
The buckle of the band should not be cov-
Buckle
ered because of the risk of erosion. The band
should lie inside the wrap without tension (8).
8
118 Atlas of Gastrointestinal Surgery: Stomach
Adjustable gastric band
Tubing
Port
Abdominal wall
Tubing is angled
through rectus m.
9
Port
The tubing of the gastric band is is grasped and pulled out through the left upper quadrant trocar site. A subcutaneous
pocket is formed on the anterior surface of the fascia, and four interrupted nonabsorbable fascial sutures are placed. A
small amount of band tubing is cut to size and then connected to the port tubing. The four previously placed sutures are
passed through the holes in the port and tied, securing the port to the fascia (9). It is extremely important to check the
tubing and make sure it has no kinks as it enters the fascia. The port is injected using a side port needle with
4 mL of normal saline to test resistance to flow, and then the saline is removed. The site is irrigated and all the trocar sites
are closed with subcuticular sutures.
Laparoscopic Vertical Sleeve Gastrectomy
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 oro-gastric tube before starting the operation.
Initial access to the peritoneal cavity is gained by making a skin incision in the left upper quadrant and then 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
an additional three trocars (one 15 mm trocar, one 12 mm trocar, and one 5 mm trocar) are placed under direct vision.
The right-side trocars are both placed in the right upper quad-
rant, approximately at the midclavicular line, with the
5 mm trocar just below the ribs and the 15 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 patient is then placed in a steep
reverse Trendelenburg position. The legs and
feet are checked to make sure they are still
Camera
1
straight and on the footboard. The left lateral
segment of the liver is retracted using a fixed
retractor, placed through a 4 mm subxiphoid
puncture, which is held in position with a mov-
able arm attached to the table.
120 Atlas of Gastrointestinal Surgery: Stomach
A window is created in the omentum along the greater cur-
vature of the stomach and extended toward the angle of
His. The short gastric vessels along the greater curvature are
divided using the ultrasonic shears. This mobilization is
Angle of His
Stomach
2
continued until the left crus is identified. The window is
then extended along the greater curvature toward the
pylorus, stopping six cm from the gastroduodenal junction
(2 and 3).
Angle of His
3
Omentum
6 cm
Short gastric vessels
Stomach
Pancreas
Omentum
Esophagus
Laparoscopic Vertical Sleeve Gastrectomy 121
Spleen
Stomach
in “sleeve”
Pylorus
Lesser
omentum
Bougie
Omentum
4
The anesthesiologist places a 40 French bougie through the esophagus, and into the stomach. Either blue or green stapler
cartridges are used to divide the stomach, starting at a point 6 to 7 cm from the pylorus on the greater curvature (4).
The larger green staple cartridges loaded in the linear stapler are usually used for the first two to three staple firings because
of the increased thickness of the stomach at this point. The stomach is divided all the way up to the angle of His, creat-
ing the gastric sleeve. The lateral stomach specimen is removed through the 15 mm trocar site, which may need to be
enlarged and then have its fascia closed.
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