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

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

369

Mating together

circular stapler

and anvil

Circular stapler

Anvil

FIGURE 34–26

Jejunal Roux

end excess

Cutting away

jejunal excess

Stomach pouch

FIGURE 34–27

Pouch

One seromuscular

suture

FIGURE 34–28

370 Section IV • The Abdomen

3. CLOSURE

◆ The port site that had been dilated to 26 mm can be closed with two successive sutures of 0

Vicryl placed using the laparoscopic suture passer or fascial sutures through the open wound.

There is no need to close the 5- and 12-mm port sites when using bladeless trocars.

◆ The instruments and ports are removed under direct visualization as the pneumoperito-

neum escapes.

◆ The circular stapler site should be copiously irrigated before closure, because this site has

been contaminated by the circular stapler and removal of the trimmed tissue from the stom-

ach and small bowel.

◆ The skin incisions are closed with subcuticular sutures and either tissue adhesive or sterile

tapes.

OPEN

1. INCISION

◆ A midline laparotomy from the xiphoid to near the umbilicus is preferred (Figures 34-29

and 34-30).

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

371

Esophagogastric junction

esophageal hiatus

Midline incision

FIGURE 34–29

Stomach

Hepatogastric ligament

Left gastric artery

FIGURE 34–30

372 Section IV • The Abdomen

2. DISSECTION

◆ A table-mounted body wall retractor such as the Bookwalter model facilitates exposure.

◆ The omentum is divided in the midline all the way to and for a short distance along the

transverse colon using the ultrasonic shears. This will allow placement of the Roux limb

anterior to the colon and stomach with less tension. Adhesions to the abdominal wall may

need to be divided ﬁ rst (Figure 34-31).

◆ The ligament of Treitz is identiﬁ ed, and the jejunum is divided approximately 40 cm distal to it. An

opening is made in the transverse mesocolon if a retrocolic approach is favored (Figure 34-32).

◆ The mesentery of the distal aspect of the divided jejunum is incised next to the bowel wall

to provide additional mobility of the Roux limb. Any ischemia area created by this maneu-

ver will be trimmed during one of the ﬁ nal steps.

◆ 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 antimesenteric corner of the proximal blind end of the jejunum. The enterotomies are

only large enough to accommodate the end of the stapler (Figure 34-33).

Creating

omental window

FIGURE 34–31

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

373

Opening created in

mesocolon

Biliopancreatic limb

Roux limb

Ligament of Treitz

FIGURE 34–32

Ligament of Treitz

Creating

enterotomies

30 cm

Roux limb 100 cm

from initial jejunal

transection

FIGURE 34–33

374 Section IV • The Abdomen

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

mies, the stapler is ﬁ red to create the anastomosis. Either one ﬁ ring of the 60-mm stapler or

two successive ﬁ rings of the 45-mm stapler is used here (Figure 34-34).

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

45-mm linear stapler using the 2.5-mm stapler loads (Figure 34-35).

◆ A seromuscular stitch of 2-0 silk is placed at the left side of the anastomosis. The mesen-

teric defect is closed from the right side 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 sero-

muscular bite is reported to decrease the risk of anastomotic obstruction (Figure 34-36).

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

and staple lines. The patient is turned to the reverse Trendelenburg position.

Creating a

jejunojejunal

anastomosis

FIGURE 34–34

Enterotomy

stapled closed

FIGURE 34–35

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

375

Arrow going through

mesentery defect

Mesentery

to be closed

∗

Closure of

mesentery defect

Anastomosis

complete

∗

FIGURE 34–36

376 Section IV • The Abdomen

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

and spread open to expose the diaphragmatic muscle. Blunt dissection with a ﬁ nger is used

to enlarge this space posterior to the stomach and along the crus. A thin veil of peritoneum

is left between the stomach and spleen (Figure 34-37).

◆ A balloon-tipped orogastric tube is placed in the stomach to size the pouch. 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 pulled back into the esophagus. One

must be continuously aware of the position of all tubes in the esophagus, because stapling

across the tubes requires a difﬁ cult and lengthy revision (Figure 34-38).

◆ The cautery or ultrasonic shears is 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, can cause troublesome bleeding. Therefore this dissec-

tion should be performed slowly and meticulously, with a delicate combination of sweeping

and judicious use of energy sources (Figure 34-39).

Entering

phrenogastric ligament

at angle of His

FIGURE 34–37

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

377

Inflated balloon at

esophagogastric

junction

Line of

transection

FIGURE 34–38

Opening in

phrenogastric ligament

at angle of His

Entering

lesser sac

FIGURE 34–39

378 Section IV • The Abdomen

◆ 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 4 cm distal to the esophagogastric

junction at the site identiﬁ ed by the balloon to begin creation of the pouch (Figure 34-40).

◆ A gastrotomy is made near the greater curvature of the stomach. The anvil of a 25-mm

end-to-end stapler is loaded with the spike that has a 2-0 polyester suture knotted through

its eye. The anvil is placed through the gastrotomy. The suture is threaded downward

through the eye of the 5-mm articulating dissector (Figure 34-41).

Stapling transversely

across lesser curvature

FIGURE 34–40

Trocar (spike) with

2-0 polyester suture

Circular staple anvil

Laparascopic

band passer

Gastrotomy

FIGURE 34–41