Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

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◆ The jejunum is followed for approximately 100 cm for a standard length gastric bypass. Here a small

enterotomy is made on the antimesenteric border. Another small enterotomy is made at the antimes-

enteric corner of the proximal blind end of the jejunum. The enterotomies are only the length of the

jaws of the ultrasonic shears (Figure 34-8).

◆ With a jaw of the 2.5-mm stapler height linear cutter inserted though each of the enterotomies, the

stapler is ﬁ red to create the anastomosis. Either one 60-mm stapler or two successive ﬁ rings of the

45-mm stapler is used here (Figure 34-9).

Ligament

of Treitz

30 cm

Roux limb is 100 cm

from initial jejunal

transection to

anastomosis

FIGURE 34–8

Stapling to create

anastomosis

FIGURE 34–9

CHAPTER 34 • Roux-en-Y Gastric Bypass (Open and Laparoscopic)

359

360 Section IV • The Abdomen

◆ The resulting enterotomy is closed with one 60-mm or two ﬁ rings of the 45-mm linear

stapler using the 2.5-mm stapler loads (Figure 34-10).

◆ A seromuscular stitch of 2-0 silk is placed at the left side of the anastomosis, and the mes-

enteric defect is closed on the right side of the anastomosis with a running 2-0 silk suture,

starting at the base of the defect and ending with a seromuscular bite of each portion of

jejunum. This seromuscular bite is reported to decrease the risk of anastomotic obstruction

(Figure 34-11).

◆ The jejunojejunostomy is inspected for adequacy of the lumen and hemostasis of the suture

and staple lines. The Roux limb is held in place as the omentum and colon are swept back

downward. The patient is turned to the reverse Trendelenburg position. The telescope is ex-

changed for a 45-degree long scope. A table-mounted retractor is clamped to the bed.

◆ The 5- or 10-mm Fisher or Nathanson liver retractor is positioned to elevate the liver by di-

rect insertion through the abdominal wall to the left of the midline in the epigastrium. This

insertion site should be just at the caudal extent of the left lateral lobe. No attempt should

be made to incise the lateral liver attachments. The retractor is secured to the table mount

(Figure 34-12).

Stapling enterotomies

FIGURE 34–10

CHAPTER 34 • Roux-en-Y Gastric Bypass (Open and Laparoscopic)

361

FIGURE 34–12

Arrow going through

mesentery defect

Mesentery

to be closed

∗

FIGURE 34–11

Closure of

mesentery defect

Anastomosis

complete

∗

362 Section IV • The Abdomen

◆ The peritoneum overlying the left crus of the diaphragm at the angle of His is disrupted

bluntly and spread open to expose the diaphragmatic muscle. An articulating right-angled

instrument is used to create a space by blunt dissection posterior to the stomach and along

the crus. A thin veil of peritoneum is left between the stomach and spleen (Figure 34-13).

◆ A balloon-tipped orogastric tube is placed in the stomach to guide the pouch creation. The

balloon is inﬂ ated to 20 mL and pulled back snuggly to the esophagogastric junction. Once

the line of transection is identiﬁ ed, the balloon is deﬂ ated and the tube is pulled back into

the esophagus. One must always be certain of the position of any esophageal tube, because

stapling across the tubes can result in a difﬁ cult and lengthy revision (Figure 34-14).

Phrenogastric ligament

entered with dissector

FIGURE 34–13

Inflated balloon at

esophagogastric junction

Line of

transection

FIGURE 34–14

CHAPTER 34 • Roux-en-Y Gastric Bypass (Open and Laparoscopic)

363

◆ The assistant grasps the stomach in two places along the lesser curvature above and below

the site of transection. The ultrasonic shears are used to carefully incise the peritoneum and

underlying fat of the gastrohepatic ligament to enter the lesser sac without injuring the wall

of the stomach, the vagus branches, or the vasculature of the pouch. There are a number of

small veins that, when not entirely sealed with the shears, can cause troublesome bleeding.

Therefore this dissection should be performed slowly and meticulously with a delicate com-

bination of sweeping and sharp dissection with the ultrasonic device (Figure 34-15).

◆ An articulating 45-mm linear cutting stapler loaded with 3.5-mm staples is angled,

placed, and ﬁ red transversely across the lesser curvature approximately 3 to 4 cm distal to

the esophagogastric junction at the site identiﬁ ed by the balloon to begin creation of the

pouch (see Figure 34-15).

Stapling transversely

across lesser curve

FIGURE 34–15

◆ A gastrotomy is made near the greater curvature of the stomach. The 12-mm port is removed

from the left upper quadrant, and this incision is dilated sequentially up to 26 mm with

Hegar dilators. The anvil of a 25-mm end-to-end stapler is loaded with the spike possessing

a 2-0 polyester suture knotted through its eye. Using the 12-mm port facilitates insertion of

the anvil into the peritoneal cavity (Figure 34-16).

◆ The anvil is placed through the gastrotomy using an anvil grasper. The suture is threaded

downward through the eye of a 5-mm articulating dissector (Figure 34-17).

◆ The articulating dissector is placed through the gastrotomy and ﬂ exed so that its tip tents

up the stomach at the staple line near the lesser curve. The ultrasonic dissector is activated

while touching the tip of the articulating dissector to create a gastrotomy only big enough

to pass the articulating dissector through it. The suture is then grasped, and once it is

pulled through the tiny gastrotomy, the articulating dissector is straightened and removed

(see Figure 34-17).

Anvil of circular stapler

Clamp keeping

tension on suture

Anvil

Trocar used to insert

anvil into abdomen

FIGURE 34–16

Anvil

Band passer

Gastrotomy

FIGURE 34–17

Section IV • The Abdomen364

◆ The surgeon pulls the suture across the ﬁ eld to the patient’s right while holding the stom-

ach at the crotch of the staple line until the anvil trocar passes through the gastrotomy.

Once the anvil is in position, the original gastrotomy is closed with the linear stapler

containing 3.5-mm staples. Either one ﬁ ring of the 60-mm or two ﬁ rings of the 45-mm

stapler is usually required (Figure 34-18).

Grasper to

pull suture of anvil

through gastrotomy

Angled dissector

and anvil

Harmonic scalpel

creating gastrotomy

FIGURE 34–18

CHAPTER 34 • Roux-en-Y Gastric Bypass (Open and Laparoscopic)

365

366 Section IV • The Abdomen

◆ The 60-mm linear stapler with 3.5-mm staple height is applied to the stomach paralleling

the lesser curve through the 12-mm port on the left side. Downward pulling of the suture

von the anvil facilitates proper placement. Before ﬁ ring, the surgeon advances the orogastric

tube until he or she can be certain that the tube is visible within the pouch and not within

the main body of the stomach or caught by the stapler (Figure 34-19).

◆ The 10-mm articulating dissector is placed through port two. Its tip is passed behind the

stomach and ﬂ exed into the space created at the angle of His. Gentle side-to-side manipula-

tion enlarges this opening. The assistant holds this instrument while the articulating 45-mm

linear stapler loaded with 3.5-mm staples completes the division of the stomach, again

conﬁ rming placement of the stapler by manipulation of the orogastric tube (Figures 34-20

and 34-21).

◆ The anvil trocar can now be removed. It is helpful to note that a 90-degree rotation of the

blue spike with a right-angled dissector while the anvil is held steady with an anvil grasper

or other grasping instrument simpliﬁ es the detachment. The anvil grasper is applied to the

anvil above the springs (Figure 34-22).

Closing gastrotomy

with stapler

FIGURE 34–19

Applying a one-quarter turn,

trocar is removed from anvil

Stomach pouch

FIGURE 34–22

Completion

of pouch with stapler

FIGURE 34–20

Stapler

completing

pouch

FIGURE 34–21

CHAPTER 34 • Roux-en-Y Gastric Bypass (Open and Laparoscopic)

367

368 Section IV • The Abdomen

◆ The jejunal Roux limb is opened longitudinally on its end (Figure 34-23). The 12-mm port

is removed again, and the circular stapler is placed through the dilated port site and into

the lumen of the Roux limb. Once past the demarcated segment, the stapler is opened to

pierce the antimesenteric border. Traction must be maintained on the bowel proximal and

distal to the end of the stapler to keep the bowel from slipping off of the stapler trocar

(Figures 34-24 and 34-25).

◆ The stapler and anvil are mated together, and the instrument is closed and ﬁ red. The stapler

is partially opened and removed. The redundant open segment of jejunum is trimmed and

sealed by ﬁ rst incising the mesentery and then applying the linear stapler with 2.5-mm

staples. Before ﬁ ring the stapler, the orogastric tube should be passed through the gastroje-

junostomy for the subsequent leak check. A seromuscular stitch of 2-0 Vicryl is placed at

the right side of the gastrojejunostomy (Figures 34-26, 34-27, and 34-28).

◆ A test for leaks and placement of a closed suction drain completes the procedure.

Open staple

line

FIGURE 34–23

Inserting circular

stapler into Roux

limb lumen

FIGURE 34–24

Piercing through

antimesenteric border

of jejunum

FIGURE 34–25