CHAPTER 24 Roux-en-y gastric bypass (linear stapler)
♦ When operating on a morbidly obese patient, it is an obvious and important consideration to have an operating table that is safe for the patient’s weight. The table base needs to support the patient’s weight plus the weight of foot plates in steep reverse Trendelenburg position without tipping. We prefer a hydraulically operated operating room table that can drop low to the ground, which makes it possible for all surgeons and staff to stand on the ground instead of step stools.
♦ An optical trocar is used to access the abdomen once insufflation is obtained with a Veress needle. We prefer this to the open Hassan technique so that we can avoid an umbilical incision, which decreases the risk of hernia formation.
♦ The patient is placed supine on a well-padded operating table. The arms are extended on padded arm boards and secured with padded straps. Foot plates as well as safety straps on the waist and legs are used to ensure secure positioning, especially during steep reverse Trendelenburg position.
♦ The abdomen is insufflated using a Veress needle in the left upper quadrant. After adequate carbon dioxide pneumoperitoneum to 15 mmHg, an 11-mm optical trocar is advanced in the same quadrant under laparoscopic visualization using a zero-degree scope. A 45-degree laparoscope is then advanced through the Visiport and used to visualize the peritoneal cavity.
♦ A 10-mm trocar is placed inferolateral to the umbilicus, and the laparoscope is transferred to that position. Two 12-mm and one 5-mm trocars are placed into the right upper quadrant, and a 5-mm trocar is placed lateral to the umbilicus in the left midabdomen (Figure 24-1).
♦ The transverse colon and omentum are retracted superiorly and the ligament of Treitz identified. The proximal jejunum is divided 50 cm from the ligament of Treitz with a linear stapler (2.5 mm). The mesentery between the two limbs of bowel is taken down using the LigaSure device. The proximal jejunum is the pancreaticobiliary limb, containing secretions from remnant stomach as well as liver and pancreas. The distal jejunum will be brought up to the stomach pouch to contain ingested food and is referred to as the Roux limb or alimentary limb.
♦ Adjoining enterotomies are created. A linear stapler (2.5 mm) is fired distally first (Figure 24-3), then rotated counterclockwise and fired proximally (Figure 24-4). The remaining enterotomy is tacked with 2-0 silks for retraction into a linear stapler (2.5 mm). The enterotomy is closed in a transverse direction to minimize potential narrowing. The small bowel mesenteric defect is closed with a running 2-0 silk suture.