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

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◆ 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 cautery or 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

(Figures 34-42 and 34-43).

Anvil

Gastrotomy

Band passer

FIGURE 34–42

Angled dissector

Bovie used to

create gastrotomy

FIGURE 34–43

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

379

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

containing 3.5-mm staples (Figure 34-44).

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

the lesser curve. Downward traction on the suture on the anvil facilitates proper placement.

Before ﬁ ring the stapler, the orogastric tube is advanced until it can be certain that it is visible

within the pouch and not within the main body of the stomach or caught by the stapler. This

is repeated until the surgeon is certain the pouch has been completely separated from the

main body of the stomach (Figure 34-45).

◆ The spike is removed and discarded (Figure 34-46).

◆ The jejunal Roux limb is opened longitudinally on its end (Figure 34-47).

◆ The circular stapler is placed into the lumen of the Roux limb (Figure 34-48).

Closing gastrotomy

with stapler

FIGURE 34–44

Begin completion

of pouch with stapler

FIGURE 34–45

Section IV • The Abdomen380

Applying a one-quarter turn,

trocar is removed from anvil

Stomach pouch

FIGURE 34–46

Inserting circular stapler

into Roux limb lumen

FIGURE 34–48

Open staple line

FIGURE 34–47

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

381

382 Section IV • The Abdomen

◆ Once past the demarcated segment, the stapler is opened to pierce the antimesenteric

border (Figure 34-49).

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

is partially opened and removed (Figure 34-50).

Piercing through

antimesenteric border

of jejunum

FIGURE 34–49

Mating together

circular stapler

and anvil

Circular stapler

Anvil

FIGURE 34–50

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

383

◆ The redundant open segment of jejunum is trimmed and sealed by ﬁ rst incising the mesen-

tery and then applying the linear stapler with 2.5-mm staples. Before ﬁ ring the stapler, the

orogastric tube should be passed through the gastrojejunostomy for the subsequent leak

check (Figure 34-51).

◆ A seromuscular stitch of 2-0 Vicryl is placed at the right side of the gastrojejunostomy

(Figure 34-52).

◆ The leak check and placement of the closed suction drain complete the operation.

Cutting away

jejunal excess

Stomach pouch

FIGURE 34–51

Pouch

One seromuscular

suture

FIGURE 34–52

384 Section IV • The Abdomen

3. CLOSURE

◆ Interrupted #2 Vicryl sutures are used to close the abdominal fascia, and the skin is closed

with staples after thorough irrigation.

STEP 4: POSTOPERATIVE CONSIDERATIONS

◆ Telemetry and pulse oximetry monitoring should be strongly considered for several hours

postoperatively in these high-risk patients.

◆ Ambulation within the ﬁ rst 2 hours of emergence from anesthesia should help prevent

venous thrombosis. Patients appropriately educated preoperatively will be anxious to get up

out of bed.

STEP 5: PEARLS AND PITFALLS

◆ A thorough preoperative educational program is the best way to achieve the lowest risk of

perioperative complications and highest patient compliance.

◆ Venous thrombosis and gastrointestinal leaks are among the most lethal perioperative com-

plications, and surveillance for them is important.

◆ Despite prophylaxis with ambulation, sequential compression devices, and low-molecular-

weight heparin, the risks of deep venous thrombosis and pulmonary embolism are still

signiﬁ cant.

◆ Intraoperatively, a simple and quick way to test the integrity of the gastrojejunostomy is

to occlude the Roux limb with an atraumatic instrument, ﬂ ood the upper abdomen with

saline, and inject boluses of air through the orogastric tube. Bubbles of air when present

should be traced to their source to reinforce the staple line with Vicryl sutures. This proce-

dure can also be performed with methylene blue injection through the orogastric tube.

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

385

◆ Another way to detect leaks in the early postoperative period is to place a closed suction

drain at the gastrojejunostomy under the left lateral segment of the liver. This also helps

protect against the progression of gastrojejunal leaks to peritonitis and abscess.

◆ Finally, consideration should be given to a contrast swallow with ﬂ uoroscopy before allow-

ing any oral intake to screen for early postoperative leaks.

SELECTED REFERENCE

1. Brolin RE: The antiobstruction stitch in stapled Roux-en-Y enteroenterostomy. Am J Surg 1995;169:

355-357.

386

STEP 1: SURGICAL ANATOMY

◆ Experience with the anatomy and a surgical procedure of the esophagogastric junction is a

prerequisite to a successful gastric banding operation (see Figure 34-1).

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ The standard indications for a bariatric operation include either a body mass index of at

least 40 kg/m

or a body mass index of at least 35 kg/m

with signiﬁ cant associated medical

illness. Potential patients must also have tried multiple dietary, activity, and lifestyle modiﬁ -

cation programs. They should be free of substance abuse and be psychologically stable so

that they can make an intelligent decision regarding the risks of the operation and the need

to dramatically alter their lifestyles. The indications for banding are the same as the indica-

tions for gastric bypass.

◆ Bariatric operations should not be offered unless a dedicated team is in place for the

thorough preoperative evaluation and close long-term follow-up that are required for every

patient.

◆ Banding is considered the safest of all the bariatric operations.

◆ Twenty percent to 40% of patients getting an adjustable gastric band will need to have a hi-

atal hernia repair. Small but signiﬁ cant hiatal hernias can be missed on preoperative studies.

These are often not diagnosed until the intraoperative test, so the surgeon must be prepared

for this inevitable situation.

◆ Patients should receive prophylaxis against wound infection with an intravenous cephalo-

sporin and against venous thrombosis with sequential compression devices and low-

molecular-weight heparin before induction of anesthesia.

CHAPTER

Laparoscopic Placement

of Adjustable Gastric Band

(Pars Flaccida Approach)

Michael D. Trahan

C HAPTER 35 • Laparoscopic Placement of Adjustable Gastric Band 387

◆ Each incision site is preemptively anesthetized with local anesthetic injection.

◆ General anesthesia is required for this operation. An anesthesia team specially trained and

equipped for the morbidly obese patient is necessary.

◆ There are currently two devices with approval from the U.S. Food and Drug Administration

(FDA) for use in the United States. There are several others being used internationally. The

techniques for insertion may differ slightly, but the principles are the same.

◆ Use of the devices requires a formal education and ofﬁ cial proctoring process before the

bands are made available to the surgeon. This description is not meant to substitute for that

qualiﬁ cation process.

STEP 3: OPERATIVE STEPS

1. INCISIONS

◆ Five small incisions are made as diagrammed. Initial entry is made using a 5-mm optically

guided bladeless trocar at the left costal margin in the midclavicular line—this will be the

main telescope port. The peritoneal cavity is insufﬂ ated and the remaining ports are placed

under direct internal visualization. The liver retractor is inserted near the xiphoid process.

A 5-mm trocar is placed on either side of the midline to be used as the surgeon’s working

ports. A 15-mm trocar is placed below the left costal margin near the anterior axillary line.

The assistant will use this port to expose the esophagogastric area (Figure 35-1).

Surgeon

Assistant

FIGURE 35 –1

2. DISSECTION

◆ The orogastric calibration tube is inserted and watched as it enters the stomach. The bal-

loon is inﬂ ated with 15 mL of air or water. The tube is pulled back to identify and test the

integrity of the esophagogastric junction. If the balloon slips up into the mediastinum, a

hiatal repair should be performed, usually by mobilization of the anterior aspect of the dis-

tal esophagus and suturing the anterior aspect of the hiatus. A larger hiatal hernia may re-

quire a posterior repair. Once the balloon conﬁ rms adequate hiatal repair, it is deﬂ ated, and

the tube is removed.

◆ The pars ﬂ accida is the clear membrane covering the caudate lobe and running between the

lesser curvature of the stomach and the liver. This membrane is bluntly opened (Figure 35-2).

◆ The assistant grasps the fat along the lesser curvature and retracts it to the patient’s left.

This maneuver exposes the right crus of the diaphragm, which should be carefully distin-

guished from the inferior vena cava. The peritoneum covering the fat just anterior to the

lower aspect of the right crus is bluntly opened just enough to allow passage of the 5-mm

articulating dissector. The dissector is placed through this opening and should pass without

the slightest resistance behind the stomach aiming toward the angle of His (Figure 35-3).

◆ The band is selected and prepared according to the manufacturer’s speciﬁ cations. The band

and tubing are inserted through the 15-mm trocar by grasping the tip of the band buckle

and pushing the device through the trocar with the band ﬁ rst. The grasper then releases the

band, and the tubing is gently grasped and fed through the trocar, as well. The tip of the

tubing is grasped before inserting the tubing all the way through the trocar. The tip of the

tube is grasped by the retrogastric grasper or, if using a band passer, fed through the eye at

the tip of the instrument (Figure 35-4).

Opening pars flaccida

15 mL fluid

insufflated in

intragastric balloon

FIGURE 35 –2

Section IV • The Abdomen388