Laparoscopic Gastric Bypass Using Linear Stapling Technique

(1)

Department of Surgery, University of Virginia Health Systems, Charlottesville, VA, USA

Electronic supplementary material:

Supplementary material is available in the online version of this chapter at 10.1007/978-1-4939-1637-5_27. Videos can also be accessed at http://www.springerimages.com/videos/978-1-4939-1636-8.

Keywords

Gastric bypassLaparoscopicLoop techniqueGastrojejunostomyLinear stapling technique

Roux-en-Y gastric bypass (RYGB), originally described by Mason [1] as a loop technique, was later modified by him to a Roux limb, the technique of which was further popularized by Griffin [2]. MacLean [3] and others confirmed that dividing the stomach was superior to simply stapling it, eliminating the potential for staple line breakdown causing loss of restrictive capacity of the operation. Gastric bypass then underwent few major revisions until Wittgrove and Clark [4] first described the operation being performed laparoscopically. That is the approach now used in the vast majority of procedures.

The operation has been the gold standard procedure for bariatric surgery since the 1970s in the United States. It has proven to provide durable weight loss through largely a restrictive mechanism. The small proximal gastric pouch restricts food intake dramatically initially. Adaptation allows the pouch to empty more quickly, and later patients may and do eat more. Long-term success is maintained only with a change in patient diet and exercise habits. These are often easily adapted during the first year after surgery when weight loss is dramatic, appetite is suppressed, food intake is limited, and patients experience a major change in overall well-being, body habitus improvement, improvement of major associated medical problems, and improvement in activities of daily living. Most patients are motivated enough by these improvements to maintain these gains through revised eating and exercise habits. A minority, however, may regain weight as time passes.

While simple restriction certainly explains the major reason for weight loss and thereby improvement of weight-associated medical problems, the anatomy of RYGB also produces profound improvement in some medical problems, especially type II diabetes, that weight loss alone cannot account for the changes (Pories article [5]). RYGB causes loss of the pyloric restriction of slow release of food into the duodenum. Rapid passage of food into the Roux limb will produce dumping syndrome if the food is highly osmotic (sweets especially). It has also been shown that the rapid passage of food into the more distal gut will cause the release of GLP-1 with consequent improvement of insulin sensitivity and thereby type II diabetes (Mason or some other articles about GLP-1 release and action [6, 7]). The complete picture of the metabolic effects of RYGB on carbohydrate metabolism, fat metabolism, and gut adjustments to digestion is still being studied, and certainly will be more complex than just the changes in GLP-1 release. Effects on satiety, gut flora alteration, and changes in the inflammatory response contributing to metabolic syndrome are all areas that will contribute to understanding the effectiveness and changes that occur after performance of RYGB.

While it would be optimal for comparing outcomes to have all RYGB operations performed in a standard fashion, unfortunately that has not been the evolution of the operation. Surgeons all have some variability in how they perform the procedure. Some have placed a restrictive band [8] or an adjustable band [9] around the proximal gastric pouch. Other variables include the length of the Roux limb, anatomic positioning of the Roux limb relative to the stomach and transverse colon, size of the proximal gastric pouch, size of the gastrojejunal anastomosis between that pouch and the Roux limb, and the way in which this anastomosis is created.

Despite these variations in the actual performance of RYGB, the main principles that are important to the successful performance of the operation have emerged as being food restriction and bypassing the proximal gut with rapid pouch emptying. Anatomically, then, the operation should be constructed so as to maximize these principles. The performance of the operation as I perform it at the University of Virginia will now be briefly described, emphasizing the use of the linear stapling technique for performance of the proximal anastomosis (the gastrojejunostomy) of the operation. This technique is now my standard method of performing the operation to date, but I evolved to it over many years, having done a circular anastomotic technique in the past. The linear stapling technique will be described, after which the reasons for favoring it will be given.

While the complete description of performing RYGB is given in other chapters, this chapter will briefly describe the procedure aside from the emphasis on the creation of the gastrojejunostomy so that the reader may reproduce it if desired. Port placement, Roux limb position, and creation of the gastric pouch all are done in a manner so as to be compatible with and optimize the creation of the linear-stapled gastrojejunostomy using this approach.

Port Placement

The advent of articulating linear staplers has caused us to modify our port placement slightly. The surgeon now may more easily use a right-hand-dominant stapling technique, and the left-hand port does not need to be a 12-mm size. The adjustability of the stapler now allows the surgeon to more easily work with both ports located in the right upper quadrant. The assistant still benefits from having one 12-mm port in the left upper quadrant, as we do a double-stapling technique for the distal anastomosis (jejunojejunostomy). A second 5-mm port for the assistant is located lower in the left upper quadrant. The 12 mm camera port is located in the umbilical region, with some variability based on body habitus. For a longer torso individual, for example, a supraumbilical location is needed. A liver retractor is placed in the epigastric region. Port placement is shown in Fig. 1.

Fig. 1

Placement of ports for laparoscopic Roux-en-Y gastric bypass with linear stapling technique

Distal Anastomosis

This is performed first, as the patient is already supine. A variable-length Roux limb is created, based on patient BMI and visceral adiposity. Greater levels of one or both parameters are an indication for a longer Roux limb (150 cm or longer range). The linear stapler (white load) is used to divide the bowel and the harmonic scalpel is used to divide the mesentery down to near its base, mobilizing the Roux limb as much as possible yet avoiding too deep a division of the mesentery to cause hemorrhage from major and larger proximal mesenteric vessels. Once the length of Roux limb is determined, a linear double-stapling technique (two white loads) with suturing of the stapler defect is used for the distal anastomosis. The mesenteric defect is then closed using a running permanent suture.

Passing the Roux Limb

In order to create a retrocolic and retrogastric anastomosis, a defect is created in the transverse colon mesentery as it is displayed on a stretch. The area just to the left and above the ligament of Treitz is often relatively avascular, being to the patient’s left of the middle colic vessels. Variability in the mesenteric arcade exists, and this step is performed with a harmonic scalpel. Once the mesenteric opening has been created, the stomach is grasped and pulled down to the level of the defect, and the retrogastric space is cleared of adhesions if present. Then the Roux limb is passed into the retrogastric space (Fig. 2). It is critical to keep the mesentery of the Roux limb correctly oriented and prevent the limb from twisting, which would result in ischemia and breakdown of the anastomosis. We usually attach a Penrose drain to the most proximal end of the Roux limb to help with this passing of the Roux limb into the retrogastric space as well as later retrieval from that space.

Fig. 2

Passing the Roux limb through the transverse colon mesentery for a retrocolic-retrogastric placement of the Roux limb

Creation of the Proximal Gastric Pouch

This step is performed using the linear stapler, beginning by first stapling at right angles to the lesser curvature above the incisura, with the length of the pouch determined by each patient’s anatomy. Excellent mobilization of the Roux limb and a smaller patient allow the pouch to be created beginning more proximal on the lesser curvature, perhaps 5–6 cm below the gastroesophageal junction (Fig. 3). However, we have found with larger patients or patients with less mobile Roux limbs that creation of a longer proximal gastric pouch, even down to the incisura if necessary, is safer and allows a tension-free anastomosis while still preserving excellent weight loss. Indeed, the proximal gastric pouch in these patients begins to resemble the proximal portion of a sleeve gastrectomy. The surgeon and anesthesiologist must remember that removal of all tubes within the gastric lumen is mandatory before the initiation of gastric stapling and division.