Chapter 10 Laparoscopic Roux-en-Y Gastric Bypass with Medial Rotation of the Left Hepatic Lobe

George S. Ferzli, Sean Rim, Michael F. Timoney

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The laparoscopic Roux-en-Y gastric bypass has now become the most commonly performed bariatric procedure. It has well-established benefits in promoting weight loss and in significantly reducing comorbidities like diabetes and hypertension. One of the crucial steps in performing this procedure is gaining access to the angle of His. In the bariatric population, steatosis of the liver is prevalent. This condition can significantly impair clear visualization of this anatomic region, resulting in a technically difficult and unsafe operation. In the authors’ practice, all patients are required to lose 10% of their body weight during the preoperative period and to maintain a low-calorie diet for 14 days preceding surgery. This is done to reduce liver volume. However, as described in a paper by Morris and colleagues, body mass index (BMI) and outer abdominal fat may not be as reliable in predicting morbidity and mortality as is a measure of intra-abdominal fat. They suggest using a computed tomography (CT) scan to quantitate the amount of perinephric fat as a measure of intra-abdominal fat in patients undergoing liver resection. These findings may perhaps be applied to the correlation between intra-abdominal fat measurements and liver volume.

Traditionally, visualization of the angle of His is obtained by retracting the left lobe of the liver cephalad and anteriorly. The triangular ligament is left in place, and retraction is performed with a fan or a Nathanson retractor, or a laparoscopic grasper. In most cases, this technique should provide sufficient exposure of the angle of His to create the gastric pouch. However, in patients having excessive liver bulk, adequate exposure may not be possible with this method. In the past, two-stage procedures have been described to deal with these situations. Either a sleeve gastrectomy or a Roux-en-Y bypass with a larger pouch is performed in the first stage, and the patient returns for revision. In the authors’ experience, we have found that medial rotation of the left lobe of the liver with antehepatic gastrojejunostomy creation is the safest and most effective technique in those whose excessive liver bulk would otherwise preclude a one-stage procedure.

Operative indications

Currently, the standard criteria for undergoing bariatric surgery are a BMI of greater than 40 kg/m² or greater than 35 kg/m² with obesity-related comorbidities (e.g., obesity hypoventilation, obstructive sleep apnea, diabetes, hypertension, cardiomyopathy, or musculoskeletal dysfunction). Patients must also have demonstrated a failure of weight loss under a medically supervised diet. The type of procedure chosen is determined by patients’ weight-loss goals, their comorbidities, and their eating habits. This is a decision shared by the patient and the surgeon. It has been demonstrated by level one evidence that gastric bypass is the gold standard by which other bariatric procedures are measured.

Preoperative assessment and preparation

A multidisciplinary approach is necessary for preoperative evaluation and optimization of the bariatric patient. A dedicated team of internists, cardiologists, pulmonologists, gastroenterologists, nutritionists, and psychologists is used in the preoperative evaluation and preparation of the bariatric patient for surgery (Table 10-1). Any medically reversible causes of obesity such as hypothyroidism are investigated and treated. A careful history of all medications is obtained, including over-the-counter and herbal supplements.

Table 10-1 Preoperative Assessment Team

Psychologist	Mental health assessment
Nutritionist	Low-calorie diet program
Physical therapist	Exercise program
Internist	Complete blood count, metabolic panel, liver function tests, iron studies, prostate-specific antigen level for males >50 years old
Endocrinologist	Thyroid function tests, parathyroid hormone, vitamins A, D, B₁₂ levels
Gastroenterologist	Upper endoscopy, colonoscopy for patients >50 years old
Pulmonologist	Pulmonary function test, sleep apnea study
Cardiologist	Echocardiogram, stress test
Radiologist	Gallbladder sonogram, venous duplex, inferior vena cava filter for high-risk patients, mammogram for women >40 years old
Gynecologist	Papanicolaou test for women >35 years old

Patients also undergo a thorough psychiatric evaluation to ensure that they do not have an underlying eating disorder or a psychotic illness. It is vital that they understand the emotional and mental stress that may occur with the changes in their diet. Support groups in which those being evaluated for bariatric surgery meet with each other, as well as with postoperative patients, to share their experiences and concerns may help to better prepare them for surgery.

Patients with obstructive sleep apnea and obesity hypoventilation routinely undergo pulmonary function tests and respiratory therapy to minimize postoperative respiratory complications.

Preoperative evaluation of the upper gastrointestinal tract is also performed endoscopically to ensure that there are no abnormalities like ulcer disease, masses, Helicobacter pylori infection, or hiatal hernia. A sonogram is also obtained to rule out cholelithiasis. Positive findings like H. pylori may need to be addressed preoperatively or, like cholecystectomy, at the time of surgery. Finally, there should be a low threshold for cardiac evaluation and optimization, given this high-risk patient population.

All patients older than 50 years are required to undergo colonoscopy, and men older than 50 years must have a prostate-specific antigen test. Women older than 35 years must be evaluated by a gynecologist and undergo a Papanicolaou test. Women older than 40 years are required to be up to date with their screening mammography. Women of child-bearing age are advised not to get pregnant for 18 months following surgery. Preoperatively, they are urged to stop oral contraceptives for 6 weeks, owing to the risk for increasing coagulability. A venous duplex is obtained in all patients, and an inferior vena cava filter is placed in those considered at high risk for venous thromboembolism.

Under the guidance of the internist, patients are mandated to lose 10% of their body weight preoperatively. This is done in conjunction with the nutritionist and physical therapist. Monthly documentation of vital signs, weight, and behavioral intervention to reinforce healthy eating and exercise habits is required for a minimum of 6 consecutive months preoperatively. All possible information about bariatric surgery, including preoperative preparation, risks, complications, and postoperative care, is given to patients. The morning of surgery, patients are started on proton pump inhibitors and subcutaneous heparin injections, and they are given a dose of intravenous antibiotics before incision.

Patient positioning

The patients are placed supine on the operating room table with both arms extended (Fig. 10-1). The Lloyd-Davies position can also be employed, with the surgeon standing between the legs. However, we feel the supine position with the surgeon at the patient’s right side reduces stress on the patient’s legs. A Foley catheter is not routinely placed, and patients are asked to void just before entering the operating room. Before induction of anesthesia, they are given a dose of broad-spectrum antibiotics, and intermittent pneumatic compression devices are placed on both legs. A foot board is placed, but with the authors’ technique, we have never required the use of a steep reverse Trendelenburg position. The bariatric anesthesiologists routinely employ a fiberoptic laryngoscope that greatly facilitates endotracheal intubation.