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Laparoscopic approach to open gastric bypass
The American Journal of Surgery 184 (2002) 61– 62
How I do it
Laparoscopic approach to open gastric bypass Kristi L. Harold, M.D., B. Todd Heniford, M.D., Brent D. Matthews, M.D., Ronald F. Sing, D.O.* Department of Surgery MEB 601, Carolinas Medical Center, 1000 Blythe Blvd., Charlotte, NC 28203, USA Manuscript received December 21, 2001; revised manuscript March 29, 2002
Abstract Background: Gastric bypass is a successful tool in the treatment of morbid obesity. In recent years, laparoscopic Roux-en-Y gastric bypass has gained popularity. However, open bypass is sometimes more suitable for patients who are “superobese.” Laparoscopic instrumentation can be used during an open gastric bypass to facilitate dissection, formation of the gastric pouch, and creation of the gastrojejunostomy. Methods: We describe the use of laparoscopic ultrasonic coagulating shears for dissection during open gastric bypass. Additionally, laparoscopic gastrointestinal anastomosis and end-to-end anastomosis staplers are used for creating bowel anastomoses. Conclusions: Laparoscopic instrumentation can be useful in the setting of open procedures. Their long handles and jaw design make them ideal for working in the depths of a superobese abdomen. © 2002 Excerpta Medica, Inc. All rights reserved. Keywords: Gastric bypass; Obesity; Laparoscopy
The surgical treatment of morbid obesity has become widely accepted for its ability to provide long-term weight loss and improve comorbid conditions [1]. Multiple surgical procedures have been used to treat obesity including jejeunoileal bypass, gastric banding, gastroplasty, gastric stapling, biliopancreatic bypass, and Roux-en-Y gastric bypass. More recently the laparoscopic isolated gastric bypass has gained acceptance in the armamentarium to treat morbid obesity [2– 6]. However, “superobese” (body mass index ⬎60) patients can be technically challenging and are often better suited for an open operation. Advancements in laparoscopic surgery have supplied new surgical instruments which have traditionally been used only in minimally invasive procedures. However, these tools have many attributes which lend them to use in open surgery as well. In the superobese patient the gastroesophageal junction is often difficult to visualize, and once identified, the area for gastric pouch formation can be difficult to expose. We describe the use of laparoscopic instrumentation and techniques to facilitate dissection, formation of the gastric pouch, and creation of a gastrojejunostomy.
* Corresponding author. Tel.: ⫹1-704-355-3168; fax: ⫹1-704-3555619. E-mail address: [email protected]
Technique Under general anesthesia the patient is surgically prepared in a supine position. An upper midline incision is made, and a Bookwalter retractor is placed for retraction. The gastroesophageal junction is identified, and an appropriate line of transection is determined to allow for creation of a 30-mL gastric pouch. A small area along the lesser curvature of the stomach is cleared using the ultrasonic coagulating shears. The 36-cm shaft of the laparoscopic version of the coagulating shears facilitates dissection deep in the upper abdomen. This instrument eliminates the need to clamp and tie the small vessels in this area, which tend to be quite short and difficult to separate and troublesome if they bleed. Care is taken to avoid vagal branches. A roticulating laparoendoscopic gastrointestinal anastomotic (GIA) linear stapler is then used to divide the stomach to create the isolated pouch. This technique avoids problems with recanalization due to staple line breakdown, which can be a complication when a standard transanastomotic (TA) stapler is used [3]. The standard GIA or TA stapler can be technically difficult to position across the stomach in patients with a large, immobile left hepatic lobe. The long shaft of the laparoscopic GIA stapler allows the working handpiece of the instrument to remain outside of the abdomen, which improves the surgeon’s ability to construct the gastric pouch
0002-9610/02/$ – see front matter © 2002 Excerpta Medica, Inc. All rights reserved. PII: S 0 0 0 2 - 9 6 1 0 ( 0 2 ) 0 0 8 8 7 - 5
62
K. L. Harold et al. / The American Journal of Surgery 184 (2002) 61– 62
ostomy. A stapled side-to-side gastrojejunostomy is performed, and the EEA is removed. The open end of the Roux limb is closed using a replacement load for the GIA stapler [7]. The Roux limb is anastomosed to the biliary limb using either a hand-sewn or stapled technique.
Comments Fig. 1. Creation of the gastric pouch with a laparoendoscopic gastrointestinal anastomosis stapler.
and maintain visualization (Fig. 1). The laparoscopic GIA requires several firings to complete the stomach transection; however, this can be advantageous because it allows the surgeon to “mold” the pouch and adapt to anatomical variants. The small bowel is divided with a linear stapler 100- to 200-cm distal to the ligament of Treitz to form the Roux limb. The ultrasonic shears are used to divide the mesentery. The shears easily and quickly control the small vessels of the jejunal arcades, and the addition of suture ligature is rarely needed. The conventional “clamp, divide, and tie” technique of dividing the small bowel mesentery can be cumbersome in very obese patients owing to the excess fat in the mesentery. Clips can also be used if larger vessels are encountered. The use of a laparoscopic clip applier again gives the advantage of a longer handle length in these very large patients. The ultrasonic shears are then used to make a small opening in the transverse colonic mesentery, and the Roux limb is passed retrocolic. The gastrojejunostomy is constructed using a circular end-to-end anastomotic (EEA) stapler by a method we have described for laparoscopic isolated gastric bypass [7]. The anvil of the 25-mm EEA is attached to a nasogastric tube and passed through the mouth and esophagus to the gastric pouch. A small hole is made in the pouch to allow the tip of the nasogastric tube and, subsequently, the anvil to traverse the gastric wall. The stapled end of the Roux limb is resected, and the EEA handpiece is passed through the enter-
Despite the advances of minimally invasive surgery, there are still limitations to performing laparoscopic gastric bypass in superobese patients. We modified our open gastric bypass operation based on our experience with the laparoscopic isolated gastric bypass. We have used this technique with laparoscopic instruments in our last 26 open cases, including 1 patient with a body mass index of 108. The length of the instruments and the mobility of the operating jaws make endoscopic staplers ideal for working in the deep, obese abdomen. The laparoscopic ultrasonic coagulating shears also offer this extended reach and simplify tissue dissection and division of the small bowel mesentery during gastric bypass.
References [1] Balsiger BM, Murr MM, Poggio JL, Sarr MG. Bariatric surgery. Med Clin North Am 2000;84:477– 89. [2] Nguyen NT, Ho HS, Palmer LS, Wolf BM. A comparison study of laparoscopic versus open gastric bypass for morbid obesity. J Am Coll Surg 2000;191:149 –55. [3] Kirkpatrick JR, Zapas JL. Divided gastric bypass: a fifteen year experience. Am Surg 1998;64:62–5. [4] Schauer PR, Ikramuddin S, Gourash W, Ramanathan R, Luketich J. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg 2000;232:515–29. [5] Schirmer BD. Laparoscopic bariatric surgery. Surg Clin North Am 2000;80:1253– 67. [6] Higa KD, Boone KB, Ho T. Complications of the laparoscopic Rouxen-Y gastric bypass: 1,040 patients—what have we learned? Obes Surg 2000;10:509 –13. [7] Matthews BD, Sing RF, DeLegge MH, Ponsky JL, Heniford BT. Initial results with a stapled gastrojejunostomy for the laparoscopic isolated Roux-en-Y gastric bypass. Am J Surg 2000;179:476 – 81.
How I do it
Laparoscopic approach to open gastric bypass Kristi L. Harold, M.D., B. Todd Heniford, M.D., Brent D. Matthews, M.D., Ronald F. Sing, D.O.* Department of Surgery MEB 601, Carolinas Medical Center, 1000 Blythe Blvd., Charlotte, NC 28203, USA Manuscript received December 21, 2001; revised manuscript March 29, 2002
Abstract Background: Gastric bypass is a successful tool in the treatment of morbid obesity. In recent years, laparoscopic Roux-en-Y gastric bypass has gained popularity. However, open bypass is sometimes more suitable for patients who are “superobese.” Laparoscopic instrumentation can be used during an open gastric bypass to facilitate dissection, formation of the gastric pouch, and creation of the gastrojejunostomy. Methods: We describe the use of laparoscopic ultrasonic coagulating shears for dissection during open gastric bypass. Additionally, laparoscopic gastrointestinal anastomosis and end-to-end anastomosis staplers are used for creating bowel anastomoses. Conclusions: Laparoscopic instrumentation can be useful in the setting of open procedures. Their long handles and jaw design make them ideal for working in the depths of a superobese abdomen. © 2002 Excerpta Medica, Inc. All rights reserved. Keywords: Gastric bypass; Obesity; Laparoscopy
The surgical treatment of morbid obesity has become widely accepted for its ability to provide long-term weight loss and improve comorbid conditions [1]. Multiple surgical procedures have been used to treat obesity including jejeunoileal bypass, gastric banding, gastroplasty, gastric stapling, biliopancreatic bypass, and Roux-en-Y gastric bypass. More recently the laparoscopic isolated gastric bypass has gained acceptance in the armamentarium to treat morbid obesity [2– 6]. However, “superobese” (body mass index ⬎60) patients can be technically challenging and are often better suited for an open operation. Advancements in laparoscopic surgery have supplied new surgical instruments which have traditionally been used only in minimally invasive procedures. However, these tools have many attributes which lend them to use in open surgery as well. In the superobese patient the gastroesophageal junction is often difficult to visualize, and once identified, the area for gastric pouch formation can be difficult to expose. We describe the use of laparoscopic instrumentation and techniques to facilitate dissection, formation of the gastric pouch, and creation of a gastrojejunostomy.
* Corresponding author. Tel.: ⫹1-704-355-3168; fax: ⫹1-704-3555619. E-mail address: [email protected]
Technique Under general anesthesia the patient is surgically prepared in a supine position. An upper midline incision is made, and a Bookwalter retractor is placed for retraction. The gastroesophageal junction is identified, and an appropriate line of transection is determined to allow for creation of a 30-mL gastric pouch. A small area along the lesser curvature of the stomach is cleared using the ultrasonic coagulating shears. The 36-cm shaft of the laparoscopic version of the coagulating shears facilitates dissection deep in the upper abdomen. This instrument eliminates the need to clamp and tie the small vessels in this area, which tend to be quite short and difficult to separate and troublesome if they bleed. Care is taken to avoid vagal branches. A roticulating laparoendoscopic gastrointestinal anastomotic (GIA) linear stapler is then used to divide the stomach to create the isolated pouch. This technique avoids problems with recanalization due to staple line breakdown, which can be a complication when a standard transanastomotic (TA) stapler is used [3]. The standard GIA or TA stapler can be technically difficult to position across the stomach in patients with a large, immobile left hepatic lobe. The long shaft of the laparoscopic GIA stapler allows the working handpiece of the instrument to remain outside of the abdomen, which improves the surgeon’s ability to construct the gastric pouch
0002-9610/02/$ – see front matter © 2002 Excerpta Medica, Inc. All rights reserved. PII: S 0 0 0 2 - 9 6 1 0 ( 0 2 ) 0 0 8 8 7 - 5
62
K. L. Harold et al. / The American Journal of Surgery 184 (2002) 61– 62
ostomy. A stapled side-to-side gastrojejunostomy is performed, and the EEA is removed. The open end of the Roux limb is closed using a replacement load for the GIA stapler [7]. The Roux limb is anastomosed to the biliary limb using either a hand-sewn or stapled technique.
Comments Fig. 1. Creation of the gastric pouch with a laparoendoscopic gastrointestinal anastomosis stapler.
and maintain visualization (Fig. 1). The laparoscopic GIA requires several firings to complete the stomach transection; however, this can be advantageous because it allows the surgeon to “mold” the pouch and adapt to anatomical variants. The small bowel is divided with a linear stapler 100- to 200-cm distal to the ligament of Treitz to form the Roux limb. The ultrasonic shears are used to divide the mesentery. The shears easily and quickly control the small vessels of the jejunal arcades, and the addition of suture ligature is rarely needed. The conventional “clamp, divide, and tie” technique of dividing the small bowel mesentery can be cumbersome in very obese patients owing to the excess fat in the mesentery. Clips can also be used if larger vessels are encountered. The use of a laparoscopic clip applier again gives the advantage of a longer handle length in these very large patients. The ultrasonic shears are then used to make a small opening in the transverse colonic mesentery, and the Roux limb is passed retrocolic. The gastrojejunostomy is constructed using a circular end-to-end anastomotic (EEA) stapler by a method we have described for laparoscopic isolated gastric bypass [7]. The anvil of the 25-mm EEA is attached to a nasogastric tube and passed through the mouth and esophagus to the gastric pouch. A small hole is made in the pouch to allow the tip of the nasogastric tube and, subsequently, the anvil to traverse the gastric wall. The stapled end of the Roux limb is resected, and the EEA handpiece is passed through the enter-
Despite the advances of minimally invasive surgery, there are still limitations to performing laparoscopic gastric bypass in superobese patients. We modified our open gastric bypass operation based on our experience with the laparoscopic isolated gastric bypass. We have used this technique with laparoscopic instruments in our last 26 open cases, including 1 patient with a body mass index of 108. The length of the instruments and the mobility of the operating jaws make endoscopic staplers ideal for working in the deep, obese abdomen. The laparoscopic ultrasonic coagulating shears also offer this extended reach and simplify tissue dissection and division of the small bowel mesentery during gastric bypass.
References [1] Balsiger BM, Murr MM, Poggio JL, Sarr MG. Bariatric surgery. Med Clin North Am 2000;84:477– 89. [2] Nguyen NT, Ho HS, Palmer LS, Wolf BM. A comparison study of laparoscopic versus open gastric bypass for morbid obesity. J Am Coll Surg 2000;191:149 –55. [3] Kirkpatrick JR, Zapas JL. Divided gastric bypass: a fifteen year experience. Am Surg 1998;64:62–5. [4] Schauer PR, Ikramuddin S, Gourash W, Ramanathan R, Luketich J. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg 2000;232:515–29. [5] Schirmer BD. Laparoscopic bariatric surgery. Surg Clin North Am 2000;80:1253– 67. [6] Higa KD, Boone KB, Ho T. Complications of the laparoscopic Rouxen-Y gastric bypass: 1,040 patients—what have we learned? Obes Surg 2000;10:509 –13. [7] Matthews BD, Sing RF, DeLegge MH, Ponsky JL, Heniford BT. Initial results with a stapled gastrojejunostomy for the laparoscopic isolated Roux-en-Y gastric bypass. Am J Surg 2000;179:476 – 81.