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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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122 Atlas of Gastrointestinal Surgery: Stomach
The gastric sleeve staple line can be oversewn with a
running absorbable suture (5 and 6). Alternatively,
an absorbable staple buttress material may be used to
prevent bleeding.
An orogastric tube is inserted into the stomach
and any blood is removed. The stomach is
clamped below the staple line and an air leak
or liquid dye test is then performed to rule
Esophagus
out a leak. The lateral stomach specimen is
removed through one of the trocar sites,
which may need to be enlarged, and
then have its fascia closed. A drain
is placed in the left upper quad-
rant. The trocars are removed and
local anesthetic is injected fol-
lowed by a subcuticular closure of
the trocar sites (6).
Gastric
Sleeve
5
Pylorus
Vertical Sleeve
Gastrectomy
6
Laparoscopic Duodenal Switch with
Biliopancreatic Diversion
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 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
four trocars (one 15 mm trocar, one 12 mm trocar, and
two 5 mm 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 tro-
car. The right-sided trocars are both placed in
the right upper quadrant, approximately at the
Camera
1
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).
124 Atlas of Gastrointestinal Surgery: Stomach
The small intestinal part of the operation begins with the surgeon standing on the patient’s left side and the assistant
on the right. The left upper quadrant 12 mm port and left lower 5 mm port are the surgeon’s operating ports for the meas-
uring of the small intestine from the terminal ileum to the point of its division. The omentum and transverse colon are retract-
ed cephalad. The cecum and ileocecal valve are then identified and the ileum is measured back 100 cm proximal to the
cecum. A stay suture is placed, and then another 150 cm of ileum are measured proximal from the stay suture. The sur-
geon then moves to the patient’s right side to complete the small intestinal anastomosis and formation of the Roux limb.
The ileum is transected 250 cm proximal to the ileocecal valve using a linear stapler loaded with a white staple cartridge
(2). The mesentery is divided with the ultrasonic shears and a stay suture is placed on the distal transected bowel to mark
the Roux end that will eventually connect to the proximal duodenum. The proximal divided bowel is the biliopancreatic
limb, which is brought down to the previous stay suture marking the ileum at 100 cm from the cecum.
Biliopancreatic limb
Mesentery
Ileum divided 250 cm
proximal to cecum
Roux limb
Cecum
Terminal
ileum
2
Suture marking 100 cm
proximal to cecum
Roux
limb
Laparoscopic Duodenal Switch with Biliopancreatic Diversion 125
Stomach
Biliopancreatic limb
Biliopancreatic limb
100 cm to
ileocecal
valve
Ileoileostomy
Distal ileum,
100 cm from cecum
3
Stapled
ileoileostomy
Roux limb
A stapled side-to-side ileoileostomy is then constructed. Care should be taken to avoid a twist or misalignment of the
bowel at this point. The anastomosis is performed with the linear stapler loaded with a white staple cartridge inserted
through small enterotomies made with the ultrasonic shears below the stay suture (3).
126 Atlas of Gastrointestinal Surgery: Stomach
Enterotomy closed
Biliopancreatic limb
4
Roux limb
The enterotomy is closed using a linear stapler
loaded with a blue staple cartridge. It helps to
place a second stay suture to elevate the enterotomy
site while positioning the stapler (4). An unzippering stitch
is placed in the crotch of the stapled anastomosis and an anti-
obstruction stitch is placed to keep the Roux limb from kinking
at the inlet of the ileoileostomy. The mesenteric
defect is closed with a running suture (5).
Mesenteric defect closed
5
Laparoscopic Duodenal Switch with Biliopancreatic Diversion 127
The patient is then placed in a steep reverse
6
Omentum
Stomach
Angle of His
Trendelenburg position. The legs and feet are checked
to make sure they are still straight and on the foot-
board. The left lateral segment of the liver is retracted
using a fixed retractor placed through a 4 mm subx-
iphoid puncture and held in position with a movable
arm attached to the table.
A window is created in the omentum along the
greater curvature of the stomach. The short gastric
vessels along the greater curvature are divided up to
the angle of His using the ultrasonic shears.
Short gastric vessels
7
Stomach
Omentum
128 Atlas of Gastrointestinal Surgery: Stomach
Window at angle of His
Stomach
Bougie in
“sleeve”
8
The anesthesiologist places a 48 French bougie transorally, through the esophagus, and positions it along the lesser cur-
vature of 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. The larger green staple cartridges are usually used for the first two to three sta-
ple firings because of the increased thickness of the stomach at this point (8). The stomach is divided all the way up to
the angle of His. The lateral stomach, which is now disconnected, will be removed.
Laparoscopic Duodenal Switch with Biliopancreatic Diversion 129
The first portion of the duodenum is mobilized, taking care to not injure any of the structures in the hepatoduodenal ligament.
At the same level, posteriorly, the duodenum is mobilized off the pancreas (9). The duodenum is then divided approximate-
ly 3 to 4 cm distal to the pylorus with a linear stapler loaded with a blue staple cartridge (10). The distal duodenal stump
is reinforced with a continuous absorbable suture. Absorbable stapler buttress material can be used as an alternative.
Pylorus
Gastric sleeve
Duodenum
Pancreas
Colon
9
Duodenum divided
Bile duct
Pylorus
Gastric sleeve
Pancreas
10
Colon
130 Atlas of Gastrointestinal Surgery: Stomach
The omentum is divided up the middle with
the ultrasonic shears. This allows the Roux limb
to easily be delivered, in an antecolic position,
to the proximal duodenal end. Two stay
sutures are placed for the side-to-side
duodenoileal anastomosis. Small
enterotomies are made below the
inferior stay suture with ultrasonic
Duodenoileostomy
Roux
limb
11
Gastric
sleeve
shears. The anastomosis is performed
using a linear stapler loaded with a
blue cartridge placed partway into the
two lumens for approximately 25 to
30 mm and then fired (11).
Discarded
stomach
Pylorus
Roux
limb
Duodenum
Biliopancreatic
limb
100 cm to
ileocecal
valve
Laparoscopic Duodenal Switch with Biliopancreatic Diversion 131
Roux
limb
Stay
sutures
12
Colon
Gastric
sleeve
The 48 French bougie is
removed and a 40 French
bougie is placed through the
anastomosis into the Roux limb.
The enterostomy is closed with a
running suture or a blue staple car-
tridge under two stay sutures (12).
The anastomosis is reinforced circum-
ferentially with a running seromuscular
absorbable 2-0 suture (13).
Bile and
pancreatic ducts
Gastric
sleeve
Duodenal
stump
Duodenum
(first portion)
Transverse colon
Roux limb
13
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