Patient Positioning and Placement of Trocars

The patient is placed in Lloyd-Davies (French) position. Central venous and arterial lines are placed at the discretion of the anesthesiologist but are rarely necessary. We directly access the peritoneal cavity with a bladeless 5-mm-port trocar just below the left costal margin at the anterior axillary line, insufflate the abdomen to 20 mm Hg until five standard ports are safely placed (Fig. 9-1), and then reduce the pneumoperitoneum to 15 mm Hg CO₂. In patients with previous abdominal surgery, once the pneumoperitoneum has been established, the initial 5-mm port can be exchanged with a 10- to 12-mm port, and further ports are placed under vision with a 30-degree laparoscope to enable adhesiolysis; standard ports are subsequently placed as shown in Figure 9-1.

FIGURE 9-1 Schematic illustration of port sites.

We prefer to first perform the intestinal part of the operation and the jejunojejunal anastomosis (JJA). For that, the surgeon and assistant stand at the head of the table with the surgeon on the patient’s right and the assistant on the patient’s left. The scrub nurse stands on the patient’s right, the monitor is placed over the patient’s left knee, and the operating table is kept in a horizontal position. Once the Roux loop has been fashioned and the JJA is completed, the surgeon moves to stand between the legs, the assistant stands against the patient’s left leg, the scrub nurse remains in the same position to the patient’s right, and the monitor is moved over the patient’s head and the table tilted into a steep reverse Trendelenburg position. It is very helpful to have an operating table that can be dropped to a fairly low position to reduce surgeon and assistant’s shoulder strain.

Construction of the Jejunojejunal Anastomosis

The transverse colon is identified, and the greater omentum is split from its attachment to the colon in a straight line toward the pelvis using an ultrasonically activated scalpel; this line of division runs parallel and often to the right of a constant mid-omental vessel. The intestine is thus exposed, and tension on the antecolic Roux loop is reduced. Upward retraction on the appendices epiploicae of the transverse colon at the point of omental division facilitates exposure of the duodenojejunal flexure. The small intestine is then measured using a marker placed 5 cm from the tips of a pair of atraumatic Yohan graspers.

The length of the biliopancreatic and alimentary limbs will depend on the patient’s BMI and comorbidities, although there is no consensus. In patients with BMI of less than 50 kg/m², a randomized trial of these conventional lengths (50-cm bilioenteric limb and 100-cm alimentary limb) versus longer limbs (100 and 150 cm, respectively) found no difference in the excess weight loss 12 months after surgery. In patients with a BMI of 50 kg/m² or higher, a randomized trial of shorter (50 and 100 cm, respectively) versus longer (100 and 250 cm, respectively) limbs found no significant differences between the two lengths in terms of the excess weight loss at 48 months of follow-up, but significantly greater rates of resolution of type 2 diabetes and lipid disorders were observed when longer limbs were fashioned.

At the chosen distance, the jejunum is divided with an endostapler (we prefer 60-mm, 2.5-mm thick, white cartridge load), and the mesentery is split with the Harmonic scalpel down to its root to allow for a tension-free gastrojejunal anastomosis. The distal jejunal loop is marked with a Vicryl suture to avoid confusing it with the proximal end when the jejunojejunostomy is to be constructed and to facilitate its delivery to the gastric pouch for construction of the gastrojejunostomy (Fig. 9-2). The alimentary limb is measured, and a side-to-side jejunojejunal anastomosis is constructed. We prefer to hand-suture this anastomosis because we had encountered postoperative bleeding from the stapled jejunojejunostomy that necessitated laparoscopic reexploration to evacuate an obstructing hematoma, blood transfusion, and prolongation of hospital stay, as well as intussusception at the stapled jejunojejunostomy that appears to be related to the presence of a staple line acting as a lead point; the authors’ experience with both techniques indicates that the sutured anastomosis is safer. A seromuscular layer is fashioned using a 15-cm 3-0 Vicryl suture, the jejunal loops are then opened for approximately 2-cm distance using the Harmonic scalpel (Fig. 9-3), and a second posterior layer is then fashioned using a continuous 26-cm 3-0 Vicryl suture that takes full-thickness bites posteriorly (forming a second posterior layer) and seromuscular bites of a single layer anteriorly (Fig. 9-4). It is difficult to check for leak at the jejunojejunostomy, and we rely on meticulous technique. In the literature, the leak rate of the jejunojejunostomy is extremely low, and we have encountered none.

FIGURE 9-2 The distal (Roux) jejunal loop is marked with a suture stitch.

FIGURE 9-3 Parallel jejunal openings with the ultrasonically activated scalpel for the side-to-side jejunojejunal anastomosis.

FIGURE 9-4 Suturing of the jejunojejunal anastomosis.

An alternative option is to double-staple the jejunojejunal anastomosis; this involves firing the stapler (45-mm long, 2.5-mm thick white cartilage) in one direction to fashion a side-to-side jejunojejunostomy, and then firing a second cartilage in the opposite direction before suture-closing or stapling the common enterotomy (the Frantzides-Madan triple-stapling technique is described in Chapter 6 of the Atlas of Minimally Invasive Surgery, 2009; see Suggested Readings at the end of this chapter). Double-stapling the jejunojejunostomy avoids stenosis at its proximal end where the alimentary limb joins, but care should be taken to ensure that the second stapler firing crosses the first staple line if a gap within the posterior layer of the jejunojejunal anastomosis is to be avoided with subsequent leak; the posterior staple line should always be inspected for such gap if a stapled technique is employed. It is also imperative to check the stapled anastomosis for bleeding before the common enterotomy is closed.

The mesenteric defect is then suture-closed using a 15-cm continuous 3-0 Vicryl suture (Fig. 9-5). Although some surgeons recommend closure of the defect with a nonabsorbable suture, we have not encountered any herniation at this mesenteric defect—having used absorbable sutures to close it—in more than 1500 cases, and have always found the defect closed at repeat laparoscopy in the occasional patient for investigation of abdominal pain with the intent to look for or exclude internal small bowel herniation.

FIGURE 9-5 Suture closure of the small bowel mesenteric defect.