Roux-en-Y Gastric Bypass

Fig. 26.1

Port placement for laparoscopic Roux-en-Y gastric bypass

Keynote

Trocars without blade are used to reduce the rate of herniation. It is important to avoid placing the ports too low, as it makes the operation more challenging. The liver can be retracted with a locking Allis grasper clamp or Endo Clinch placed through the subxiphoid 5 mm port and secured to the right crus just anterior to the gastroesophageal junction (GEJ).

Gastric Pouch Creation

We start by removing the GEJ fat pad with the harmonic scalpel. The angle of His is then exposed and dissected up to the base of the left crus. The gastrohepatic ligament is incised between the second and third branch of the left gastric artery, and the lesser sac is entered. The gastric section is performed horizontally using 40–50 mm of a 60 mm blue load linear stapler (Fig. 26.2). A 36-Fr gastric lavage tube is advanced by the anesthesiologist to this horizontal staple line. The gastric section is then completed with additional firings of 60 mm blue loads in a vertical direction toward the previously dissected angle of His (Fig. 26.3). The length of the pouch should be approximately 6–8 cm. The gastric remnant staple line is inspected and reinforced with an absorbable running suture (e.g., polyglactin 2.0) to prevent bleeding.

../images/473262_1_En_26_Chapter/473262_1_En_26_Fig2_HTML.png — Fig. 26.2

Horizontal gastric section

../images/473262_1_En_26_Chapter/473262_1_En_26_Fig3_HTML.png — Fig. 26.3

Gastric pouch creation

Keynote

During the creation of the gastric tunnel needed for placing the linear stapler, care should be taken to avoid injury of the splenic vessels, the pancreas, or the posterior wall of the stomach. After creation of the gastric pouch, it is critical to verify the complete transection of the stomach to avoid communication between the pouch and the gastric remnant and inspect the staple lines to ensure hemostasis.

Creation of Biliopancreatic and Alimentary Limbs

The greater omentum and the transverse colon are retracted cephalad in order to expose the ligament of Treitz and the inferior mesenteric vein. The jejunum is divided 60 cm (BMI < 50 kg/m²) or 100 cm (BMI > 50 kg/m²) distal to the ligament of Treitz using a white load linear stapler. We mark the biliopancreatic limb with a metallic clip to avoid an error when choosing the limb that needs to be sutured to the pouch. The alimentary limb is then raised with the stapler line orientated toward the left upper quadrant in an antecolic antegastric manner.

Keynote

If the greater omentum is thick and bulky, it should be divided vertically using the harmonic scalpel to facilitate bringing the Roux limb up to the gastric pouch. Obtaining a tension-free alimentary limb is key to prevent complications of the anastomosis. In extreme cases in which the division of the omentum is insufficient to release tension, the Roux limb should be placed in the retrocolic–retrogastric position.

Gastrojejunostomy

A gastrostomy at the distal end of the gastric pouch just under the staple line is done with the harmonic scalpel. An enterotomy is then performed with the harmonic scalpel on the anti-mesenteric border of the alimentary limb 4–5 cm away from the stapled end. A side-to-side gastrojejunostomy is created with a blue load linear stapler. We recommend inserting no more than 3 cm of the stapler to create a small anastomosis (Fig. 26.4). The 36-Fr tube is passed through the anastomosis, and the anterior wall is then closed with two layers of running suture using absorbable material (e.g., polyglactin 2.0) (Fig. 26.5).

../images/473262_1_En_26_Chapter/473262_1_En_26_Fig4_HTML.png — Fig. 26.4

Side-to-side gastrojejunostomy

../images/473262_1_En_26_Chapter/473262_1_En_26_Fig5_HTML.png — Fig. 26.5

Final configuration of gastrojejunostomy

Keynote

The 36-Fr tube enables us to calibrate the anastomosis and avoid suturing the posterior wall inadvertently. A methylene blue test or a pneumohydraulic test is recommended to rule out leaks from the anastomosis.

Jejunojejunostomy

A 120 cm (BMI < 50 kg/m²) or 150 cm (BMI > 50 kg/m²) Roux limb is measured to determine the site of the anastomosis. The site chosen for the anastomosis is brought into apposition to the proximal jejunum with the stapled end of the biliopancreatic limb oriented toward the patient’s right side and cephalad to the distal Roux limb. Enterotomies are performed using the harmonic scalpel at the anti-mesenteric border of both limbs. A white 60 mm linear stapler is inserted to its full length into both enterotomies to create a side-to-side jejunojejunostomy (Fig. 26.6). The enterotomy is then closed in one layer by running an absorbable suture (e.g., polyglactin 3.0).

../images/473262_1_En_26_Chapter/473262_1_En_26_Fig6_HTML.png — Fig. 26.6

Side-to-side jejunojejunostomy

Keynote

The mesentery of both limbs should be properly aligned without twists when performing this anastomosis. If any area of separated serosa is noticed in the anastomosis, it should be approximated with Lembert sutures. An “anti-torsion” stitch between the two limbs of the bowel is useful to prevent future kinking of the anastomosis.

Closure of Mesenteric and Petersen Defect

The mesenteric defect is closed in a running, locking fashion toward the root of the mesentery with nonabsorbable suture material (e.g., polyester 2.0). The Petersen space , limited posteriorly by the transverse colon and anteriorly by the alimentary limb, should be also closed with nonabsorbable suture material.

Keynote

Internal hernias are a frequent cause of reoperation after a laparoscopic RYGB. The closure of the mesenteric and Petersen defects is key to prevent this complication.

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