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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_794_Библиотеки_им_академика_М_И_Перельмана.pdf
Section II • Esophagus, Stomach, and Duodenum
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Step3
Placement of 25-mm EEA anvil into the proximal gastric pouch
e distal end of the Orvil tube (Covidien; Dublin, Ireland) (. Fig. 35.4a) is passed into the oropharynx, down the esophagus, into the gastric pouch, and out of a small gastrotomy made with
laparoscopic scissors (.
the post of the anvil appears through the gastrotomy. e orogastric tube is removed aer cutting
the suture and tube at the proximal end with shears (
Fig. 35.4b
). e tube is then pulled into the abdomen with a grasper until
. Fig. 35.4c).
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Step4
. Fig.35.4
Creation of Roux-en-Y limb
e patient is brought into the supine position. e transverse colon is lied up by two graspers
inserted through the le-sided cannulas, and the ligament of Treitz is identied. Transection of
the jejunum is performed 50 cm distally with 60-mm Endo GIA (white cartridge 2.5-mm staples
minimize staple line bleeding). Aerwards, the mesentery is transected perpendicular to the bowel
wall with Ultracision shears.
e Roux-en-Y limb is measured (80–150 cm). Fixation of the pancreatobiliary limb is done
with a one stay suture to the Roux-en-Y limb (the anti-obstruction stitch) and a jejunojejunostomy
is created with a 60-mm Endo GIA stapler using a white cartridge (.
insertion is closed with a running 4-0polydioxanone suture. e mesenteric defect should be
closed fully with interrupted stitches of non-reabsorbable suture (. Fig. 35.5b) to prevent internal
herniation here or via Petersen’s defect (potential infracolic space posterior to the Roux mesentery
and anterior to the retroperitoneum) and transverse mesocolon.
e alimentary Roux-en-Y limb is brought antecolic to the proximal gastric pouch, being
careful to avoid a twist in the mesentery; if necessary (bulky omentum), the omentum can be
transected vertically to allow a path for the Roux limb to be brought antecolic.
Fig. 35.5a
). e site of stapler
Chapter • Operations for Morbid Obesity
Step4 (continued)
. Fig.35.5
Step5
Creation of gastrojejunostomy
e end of the Roux limb is opened with Ultracision shears. A 3-cm incision between the two
trocars in the le mid-clavicular line allows intraperitoneal introduction of the cartridge of the 25mm circular EEA stapler. e cartridge head of the EEA stapler is passed into the lumen through
the end of the Roux limb (
Aer ring the stapler, the “donuts” are checked carefully; if incomplete, the anastomosis must
be evaluated; we prefer a methylene blue test (150 mL of dilute methylene blue injected through
the nasogastric tube into the proximal gastric pouch) aer the end of the Roux limb is closed with
an Endo GIA stapler using a white cartridge. Closure of any leak is done by suture.
Even if there is no leak, the gastrojejunal anastomosis should be oversewn with single stitches
along the anterior circumference; these sutures decrease any tension on the stapled anastomosis. A
perianastomotic drain is le routinely by some but not all surgeons and removed postoperatively
aer a radiographic contrast study conrms integrity of the anastomosis.
. Fig. 35.6a) and docked with the post of the anvil (. Fig. 35.6b).
. Fig.35.6
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Section II • Esophagus, Stomach, and Duodenum
Sleeve gastrectomy (SG)
Sleeve gastrectomy works by a restriction of the oral intake and by a decrease in the serum concentration of the pro-appetite hormone ghrelin through resection of the greater curvature and
fundus of the stomach.
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Step1
Step2
Positioning of the patient and access
e patient is placed as described for laparoscopic RYGB. Aerwards, six trocars are placed:
1. One 5 mm in the midline distal to the xiphoid for the liver retractor
2. One 15 mm on the right in the mid-clavicular line 10 cm caudal to the costal arch for the for
the linear cutter, grasper, and Ultracision
3. One 10/12 mm in the midline 15 cm caudal to the xiphoid as the optic port
4. One 10/12 mm on the le in the mid-clavicular line just distal to the costal arch for the linear
cutter, grasper, needle holder, and Ultracision
5. One 10/12 mm on the le in the mid-clavicular line 15 cm caudal to the costal arch for the
linear cutter, grasper, needle holder, and Ultracision
6. One 5 mm on the le in the extended anterior axillary line for the grasper
Dissection of the greater omentum from the greater curvature
Aer the identication of the gastric antrum (4–6 cm proximal to the pylorus on the greater curvature), ultrasonic scissors are used to divide the gastrocolic ligament from the greater curvature
of the stomach up to the esophagogastric junction (
. Fig. 35.7).
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. Fig.35.7
Aer placing a 32/34 Fr bougie into the stomach transorally, the rst two 45–4.5 mm ap-
plications of the linear stapler are placed at the point of the initial dissection on the greater curvature, creating a vertical cut on the gastric wall (.
linear stapling device with 60–3.5 mm linear staplers are applied along but not tight against the
bougie up to the gastroesophageal junction (
the esophagogastric junction, remain about 1 cm lateral to the esophagogastric junction to avoid
having the staple line include the much less secure intraabdominal esophagus. e staple line
is oversewn; some surgeons use a bioabsorbable “peri-strip” when applying the linear stapler to
“reinforce” the staple line.
. Fig. 35.8b). When placing the last staple line near
Fig. 35.8a
). en sequential rings of the
Chapter • Operations for Morbid Obesity
Step2 (continued)
Laparoscopic Adjustable Gastric Banding (LAGB)
Adjustable gastric banding works by restriction of the oral intake. High patient compliance is
required for ecacy, because strict dietary implementations are needed for an adequate weight
loss. Band- and port-related complications and inadequate weight loss are common, which makes
patient selection dicult.
. Fig.35.8
Step1
Step2
Positioning of patient and access
e patient and trocars are placed as described for laparoscopic RYGB; the right lower 5-mm
trocar is not necessary for LAGB.
Determination and creation of pouch size
A specially designed orogastric balloon calibration tube is inserted; the balloon is lled with 25 mL
saline and pulled back to wedge itself at the esophagogastric junction (. Fig. 35.9).
e dissection begins at the lesser curvature at the largest circumference of the balloon. e
“pars accida technique” has been shown to have less band slippage.
e lesser omentum is entered in the avascular window, and the right crus of the diaphragm
identied.
. Fig.35.9
Section II • Esophagus, Stomach, and Duodenum
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Step3
Retrogastric preparation and band placement
e retrogastric passage from right to le crus is created by blunt dissection using an articulating
“nger” dissector which exits at the angle of His. However, the lesser sac should not be entered
during this maneuver. If the lesser sac is entered, retrogastric passage is too far distal along the
lesser curvature of the stomach and will predispose to band slippage.
e Silastic band is then pulled through the retrogastric tunnel from the le to right side of
the stomach, encircling the most proximal stomach, anterior vagus nerve, and upper part of the
lesser omentum (
e Silastic band is locked around the inating calibrating catheter, which is inated with
15 mL saline and positioned proximal to the band, thereby determining the size of the proximal
pouch. e calibration catheter is deated but le in place.
35.10).
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Step4
. Fig.35.10
Band fixation
e band is xed in position along the anterior stomach by placing 3–5 interrupted, seromuscular
sutures of nonabsorbable material, approximating the gastric wall proximal and distal to the band.
e le gastric wall distal to the band is xed to the le crus of the diaphragm (. Fig. 35.11).
e procedure is nished by implantation of the reservoir subcutaneously just below the
xiphoid, allowing easy access to the port.
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. Fig.35.11
Chapter • Operations for Morbid Obesity
Biliopancreatic diversion with duodenal switch (BPD/DS)
Biliopancreatic diversion with duodenal switch works similar to the gastric bypass but with a much
more pronounced malabsorptive component. It is technically more demanding than other the
procedures and has a higher complication rate than RYGB and SG. e division of the duodenum
can lead to the feared duodenal stump leak. e procedure can be done as a two-step procedure
with a sleeve gastrectomy initially for weight loss, with completion of the duodenal switch aer
one to two years.
Step1
Step2
Step3
Positioning of the patient and access
e patient and trocars are placed as described for laparoscopic sleeve gastrectomy.
Creation of the sleeve gastrectomy
e sleeve gastrectomy is performed as described before.
Division of the duodenum
e duodenum is divided 3 cm distal to the pylorus (. Fig. 35.12) by carefully dissecting the duodenal mesentery just distal to the duodenal bulb using the Ultrasonic shears and then mobilizing
bluntly behind the duodenum. e duodenum is then divided using a 60-mm Endo GIA stapler
using a white cartridge.
. Fig.35.12
Section II • Esophagus, Stomach, and Duodenum
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Step4
Creation of the jejunoileostomy
e small bowel is divided 250 cm proximal the ileocecal valve (junction of distal jejunum and
proximal ileum) with a 60-mm Endo GIA stapler using a white cartridge. e biliopancreatic
limb is formed by anastomosing the distal jejunum just proximal to the transection to a point
50–150 cm proximal to the ileocecal valve. e jejunoileostomy is created with a 60-mm Endo GIA
stapler using a white cartridge (. Fig. 35.13). e site of stapler insertion is closed with a running
4-0polydioxanone suture. e ileum distal to the transaction is brought up as an alimentary limb
to the upper abdomen for the duodenoileostomy.
. Fig.35.13
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Step5
Creation of the duodenoileostomy
Similar to the gastrojejunostomy for a RYGB, the anvil of a 25-mm EEA stapler can be used to
create the duodenoileostomy using the Orvil tube. Aer a small duodenotomy is made in the
proximal duodenum, the distal end of the Orvil® tube is passed into the oropharynx, down the
esophagus, and into the gastric remnant. e tube is then pulled into the peritoneum with a
grasper until the post of the anvil appears through the duodenotomy.
e end of the ileal alimentary limb is opened with Ultracision shears. A 3-cm incision in
the right mid-clavicular line allows intraperitoneal introduction of the cartridge of the 25-mm
circular EEA stapler. e cartridge head of the EEA stapler is passed into the lumen through the
end of the alimentary limb and docked with the post of the anvil (
is oversewn with three single transmural stitches to reduce tension.
. Fig.35.14
. Fig. 35.14). e anastomosis
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Biliopancreatic diversion Scopinaro
e original biliopancreatic diversion developed by Scopinaro is performed by a hemigastrectomy
gastrectomy to create a 250-mL proximal gastric pouch, which is then anastomosed to a 200-cm
Chapter • Operations for Morbid Obesity
alimentary limb of mid to distal ileum, joining a 50-cm common channel of the terminal ileum.
Because of the high rate of malnutrition and side eects like diarrhea, most surgeons prefer a
longer common channel.
Step1
Step2
Positioning of the patient and access
e patient and trocars are placed as described for laparoscopic Sleeve Gastrectomy.
Hemigastrectomy
e omentum is freed from the distal stomach using harmonic scalpel in the direction to the
duodenum, beginning approximately 15 cm distal to the angle of His along the greater curvature.
e dissection ends at the pylorus. e duodenum just distal to the pylorus is divided by a 45-mm
linear stapling device. Aer this step, the gastric lesser curvature is mobilized up to the level of
the le gastric artery.
Gastric division is performed with a 60-mm linear stapling device starting from the lesser
curvature (.
e resected stomach is removed through the right subcostal incision.
Some surgeons prefer a nonresectional biliopancreatic diversion in which the distal stomach
is neither mobilized nor removed.
Fig. 35.15
). e gastric remnant should have a capacity of approximately 200–400 mL.
Step3
. Fig.35.15
Jejunoileostomy
e next step is the measurement for the common channel (marked at 50–100 cm proximal to
the ileocecal valve; we prefer 100 cm) and division of the small bowel (250 cm proximal to the
ileocecal valve creating the alimentary limb of ileum). e alimentary limb is temporarily sutured
to the stomach for better orientation.
e biliopancreatic limb is then brought to the marked point, and an jejunoileostomy is created
with a 60-mm Endo GIA stapler using a white cartridge (. Fig. 35.16).
. Fig.35.16
Section II • Esophagus, Stomach, and Duodenum
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Step4
Gastroenterostomy
e gastroileostomy anastomosis is created to the posterior wall of the stomach. Parallel openings
are made in the small intestinal limb and the gastric pouch (.
device is positioned toward the greater curvature. e defect is closed with a hand-sewn, running
seromuscular suture.
. Fig.35.17
Fig. 35.17
). A 45 mm linear stapling
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Step1
Vertical banded gastroplasty (VBG)
e vertical banded gastroplasty is a procedure with one of the highest long-term complication
rates. It is important for its historic background (performed between 1980 and 2000) and because
it is encountered frequently in revisional bariatric surgery. erefore, some of the key steps should
be mentioned here, although its use as a primary bariatric procedure today is low.
Placement of anvil of circular stapler
e gastrohepatic ligament is opened in the avascular window with Ultracision shears to expose
the posterior aspect of the stomach. e optimal position of the anvil is 6–7 cm distal to the esophagogastric junction close to the lesser curvature. It should allow a 32-Fr tube to pass alongside
the lesser curvature; once the optimal site is determined, a straight needle is passed from anterior
to posterior through the stomach and a suture tied to the tip of the anvil (.
suture will guide the spike of the anvil through the posterior and then the anterior gastric walls.
A tight hold of the anvil by a strong grasper is essential (.
electrocautery where the tip of the anvil will pass helps it to perforate the gastric wall. e circular
stapler cartridge is passed through the abdominal wall, docked with the anvil, and red, creating
the transgastric circular “donut hole” defect in the gastric wall (
Fig. 35.18b
. Fig. 35.18c).
Fig. 35.18a
). A short incision with
). is
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Chapter • Operations for Morbid Obesity
Step1 (continued)
. Fig.35.18