Step 2: Preoperative Considerations
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The patient’s height and weight should be measured accurately in the office by the surgeon to determine the patient’s body mass index (BMI). The patient’s BMI should fall within the National Institutes of Health guidelines for weight loss surgery. The BMI should be greater than 40 kg/m 2 , or >35 kg/m 2 with an obesity-associated comorbidity.
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All patients should be asked to stop smoking prior to any weight loss procedure. Smoking will impede healing and increase the risk of perioperative pulmonary complications. Furthermore, smoking is currently the number one cause of preventable death. There is no indication to correct the second cause, obesity, if the first one will already result in early mortality.
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Patients should undergo psychologic evaluation to rule out a binge eating disorder. The psychologist or psychiatrist can also help assess the patient’s readiness for surgery and determine if the patient has realistic expectations from the surgery. The patient should have a nutritional evaluation and a thorough medical evaluation prior to surgery.
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Review the potential complications with the patient in detail, including the risk of anastomotic leak and death. Every patient’s perioperative risk will vary depending on his or her comorbidities.
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The patient should be well educated about the dietary and lifestyle changes that will be required for successful, sustained weight loss. The patient should know and prepare for the modified diet he or she will follow after the surgery.
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It is helpful to advise the patient to lose weight prior to surgery to facilitate the operative procedure. One option is to require patients to lose 10 lbs between their first clinic visit and the surgery date. Placing patients on a liquid diet for 2 weeks prior to the surgery is also advisable. This helps to shrink the visceral fat and particularly the fatty deposits within the liver.
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Have an operating room team that is familiar with bariatric surgery. The nurses should be familiar with the steps of the procedure. The anesthesiologist should be aware of the aggressive fluid resuscitation the patient will require intraoperatively and be skilled at difficult intubations.
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Patients receive a bowel prep the day prior to the procedure.
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On the day of the procedure patients receive prophylactic antibiotics. Patients receive deep venous thrombosis prophylaxis with sequential compression devices and subcutaneous or fractionated heparin.
Step 3: Operative Steps
1.
Room Setup ( Figure 20-1 )
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The patient is positioned supine on the bed. The feet are secured to a footboard and both arms are left out. Care should be taken to be sure the arms are well padded to avoid a brachial plexus injury. The feet should be positioned flat on the footboard and secured so that they cannot supinate or pronate. A Foley catheter should be placed prior to positioning. The surgeon stands to the right side of the patient. The assistant stands to the left of the patient and will also operate the camera.
2.
Port Placement ( Figure 20-1 )
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The patient’s prior surgical history should be assessed prior to port placement. If the patient has no prior history of surgery in the left upper quadrant, then this area is used as the point of initial entry. An optical trocar is used to enter the peritoneal cavity under direct visualization. Due to the thickness of the abdominal wall, a direct Hasson approach may be challenging.
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The camera port is measured 21 cm from the xiphoid process and positioned just to the left of midline. An imaginary line is drawn from this point to the junction of the left costal margin and midclavicular line. The initial port, a 12-mm bladeless optical trocar that allows direct visualization as one enters the peritoneal cavity, is placed at the midpoint of this line in the left upper quadrant. This port will serve as the surgeon’s right hand. The abdomen is insufflated to 15 mm Hg, and a 30-degree scope is inserted through this port.
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Three additional trocars are placed. A 10-mm trocar is placed at the previously determined site near the midline (for the camera). A 12-mm trocar is placed four fingerbreadths from the xiphoid process off of the right costal margin and is directed to the patient’s left, so that it enters the peritoneal cavity off the tip of the left lobe of the liver and falciform ligament junction (for the surgeon’s left hand). A 5-mm trocar is placed in the left anterior axillary line just below the left costal margin (for the assistant).
3.
Dissection into Lesser Sac ( Figure 20-2 )
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The lesser sac is entered along the body of the greater curvature of the stomach using a harmonic scalpel to avoid bleeding from the short gastrics. The opening is made about 2 to 3 cm in diameter.
4.
Creation of Jejunojejunostomy
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The omentum is lifted up and over the transverse colon and placed in the upper abdomen, exposing the ligament of Treitz. The small bowel is rotated from this point in a clockwise fashion for a distance of 30 cm, and this site is chosen to divide the jejunum. Using blunt dissection, a DeBakey-tipped grasper is used to dissect through the mesentery in the avascular plane next to the bowel. A blue cartridge stapler is then passed through the dissected area and around the bowel, and the bowel is divided. ( Figure 20-3 ) The harmonic scalpel is then used to divide the mesentery toward its base. ( Figure 20-4 ) A small Penrose drain is sutured to the distal cut end of bowel with a 2-0 silk suture to mark it for later in the procedure. ( Figure 20-5 )
Figure 20-3
Figure 20-4
Figure 20-5
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The distal bowel (future Roux limb) is then rotated in a counterclockwise fashion for a distance of 150 cm, and this site is chosen for the jejunojejunostomy. The biliopancreatic limb and this distal end of the Roux limb are sutured together using a 2-0 silk suture placed at the distal end of the future anastomosis.
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The assistant holds this suture, and the surgeon creates an enterotomy in each limb of bowel using the harmonic scalpel. Care is taken to make these enterotomies only large enough to accommodate the stapler. ( Figure 20-6 ) A white cartridge stapler is then passed through the right upper quadrant port and roticulated anteriorly. ( Figure 20-7 ) A side-to-side, functional end-to-end anastomosis is created.
