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Laparoscopic Roux-en-Y Gastric Bypass: The Linear Technique
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24 Laparoscopic Roux-en-Y Gastric Bypass: The Linear Technique Sayeed Ikramuddin, M.D.
Obesity surgery has become widespread over the past decade. The reasons for this probably are related to the increase in public awareness of the disease of morbid obesity and also to the patient-driven demand for minimally invasive approaches to bariatric surgery. According to Steinbrook approximately 140,000 procedures were performed in 2004.1 Although not suitable for all patients, particularly those with multiple previous abdominal operations, the laparoscopic Roux-en-Y gastric bypass has gained tremendous popularity. The first recorded case was performed by Wittgrove and colleagues in 1994. They reported a circular-stapled gastrojejunostomy with a retrogastric, retrocolic Roux-en-Y gastric bypass.2 There are other approaches to this operation, including a linear-stapled technique for the gastrojejunal anastomosis with the Roux limb passed either retrocolically or antecolically.3 There is also an approach in which the Roux limb can be passed retrocolically and then placed antegastrically over the gastric remnant and then sutured to the gastric pouch. A totally hand-sewn procedure has also been described.4 The wide availability of suturing devices, as well as robot technology, makes the linear technique or handsewn technique palatable. Regardless of the technique, it is important that surgeons master one approach to the operation and be at least as familiar with other techniques, should technical complications during surgery warrant them. A fundamental knowledge of intracorporeal suturing is necessary in order to perform safe, reliable bariatric surgery.
◗ TECHNIQUE We perform a laparoscopic Roux-en-Y bypass with an antecolic, antegastric Roux limb with a linear-stapled gastrojejunostomy, the enterotomy of which is oversewn in two layers over a 30F stent, typically a 30F endoscope. We use a stapled jejunojejunostomy that is performed at variable distances for the Roux limb and biliopancreatic limb, 204
based on the patient’s body mass index and comorbid conditions. Our procedure is as follows. We use a six-port technique. The surgeon stands on the right. We begin with a Veress needle in the left upper quadrant. After instilling a mixture of 1/2% Marcaine and lidocaine, we place a 150-mm Veress needle (AutoSuture, Norwalk, Conn.) into the left upper quadrant. (We avoid this approach in a patient who has had left upper quadrant surgery or large ventral hernia repair with mesh or a history of a bowel obstruction.) We insufflate the abdomen to a maximum pressure of approximately 5 mmHg. We insert a 5-mm nonbladed trocar (Ethicon Endo-Surgery, Cincinnati, Ohio) into this area 15 to 20 cm below the xiphoid. We then place an 11-mm nonbladed trocar to reduce the rate of herniation. The patient is then placed into a steep reverse Trendelenburg position. Another left lateral 5-mm port is placed just inferiorly and just subcostal on the left side, more lateral to the first trocar site. Two ports are then placed for the surgeon, one below the right subcostal margin, and another just paramedian, roughly at the same level as that placed for the camera port. The two working ports are 5 mm and 12 mm, respectively. One 5-mm lateral port is placed for the liver retractor. We use an angulating triangular liver retractor (Genzyme, Cambridge, Mass.) held in place with a side clamp to the table. Figure 24-1 shows the port sites. After retracting the left lateral segment of the liver, we begin the procedure by incising the hepatogastric ligament with the Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, Ohio). Adhesions at the angle of His are taken down sharply with scissors. We use a 45-degree endoscope to perform the procedure because it allows great ease in navigating around complex angles. The lesser sac is entered using the Harmonic Scalpel. In most cases, the lesser sac is free of adhesions, but in a patient who has a history of pancreatitis or gall bladder disease, there tend to be some significant adhesions. Sometimes, sharp and blunt dissection is necessary. Care is taken to avoid injury to the splenic artery and to the pancreas.
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Figure 24-1. Division of lesser curvature, with bovine pericardial
Figure 24-3. Loop of intestine 100 cm distal to ligament of Treitz
reinforcement.
being brought up to gastric pouch; the loop will be divided after the back wall of the gastrojejunostomy is sewn. The proximal portion will be the biliopancreatic limb.
We begin formation of the gastric pouch immediately below the left gastric artery unless we find it to be aberrant, in which case we start about 3 cm down from the esophagogastric junction on the right side (Fig. 24-2). We use an Endocutter (Ethicon Endo-Surgery) with a wide load with three rows of staples reinforced by a seam guard (W.L. Gore, Flagstaff, Ariz.) to divide the lesser curvature’s blood supply. The division and dissection continue just up to the lesser curvature of the stomach. Dissection is carried up to the angle of His with the aim of constructing a very small, narrow, gastric pouch. The final pouch is approximately 5 to 20 ml in size. The Harmonic Scalpel is used to dissect free the posterior gastric adhesions. Care is taken not to injure the left gastric artery, which may be found quite medially.
With the patient supine, we divide the transverse omentum just to the right of midline with the Harmonic Scalpel. We then identify the ligament of Treitz, elevating the mesentery just above it to confirm clear identification. A Maryland dissector is then passed just below the mesentery of the small bowel. The biliopancreatic limb is to the left, and what is to become the Roux limb will be to the right of this loop. A Penrose drain is then dragged below the bowel, encircling the small bowel and allowing us to place traction on the loop to bring it up to the gastric pouch and begin the suturing of the back row (Fig. 24-3). The back wall suture is run between the gastric pouch and the loop of small bowel with the Penrose drain still in place to prevent traction. The Endostitch (Autosuture) is used to perform this maneuver. The Penrose drain is then removed from the field, and a reticulating, 60-mm, wideload Autostapler (Autosuture) is used to divide the small bowel, essentially maintaining what is to the left as the biliopancreatic limb and what is to the right as the Roux limb. The Harmonic Scalpel is used to dissect down along the mesentery, enlarging the mesenteric defect by about 1 cm, with care taken carefully to coagulate the small vessels and care taken not to migrate to the right or to the left into the mesentery. The bowel that is attached to the gastric remnant is run downstream. In patients with body mass indexes greater than 50 kg per m2 and in patients with type 2 diabetes, we use a longer Roux limb of 150 cm. The biliopancreatic limb is reconnected to the Roux limb about 150 cm downstream with an Endostitch. Enterotomies are made using the Harmonic Scalpel, and an endogastrointestinal, wide-load, 60-mm, three-row stapler is inserted into the lumen of each bowel segment and fired. The resultant enterotomy is approximated with the Endostitch, and the entire enterotomy is rotated between 100 and 180 degrees to the left upper quadrant. A wide-load 60-mm stapler is used to close the common enterotomy (Fig. 24-4). An antiobstruction stitch of
Figure 24-2. Beginning division of stomach to create gastric pouch 1 cm distal to left gastric anastomosis.
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Section V • OPERATIVE PROCEDURES
Figure 24-4. Stapled completion of jejunojejunostomy prior to the place-
Figure 24-6. Mesenteric closure of jejunojejunostomy.
ment of the antiobstruction stitch.
2-0 Prolene is made, and then a running closure of the jejunojejunostomy mesenteric defect is performed to completely close the jejunojejunostomy mesenteric defect (Figs. 24-5 and 24-6). At this point, the patient is brought into the steep reverse Trendelenburg position. Enterotomies are made with the Harmonic Scalpel in the gastric pouch as well as in the Roux limb, and an Endocutter (Ethicon EndoSurgery) blue load is inserted to 1.5 cm and fired (Fig. 24-7). In the process, the upper stitch from the back-wall anastomosis is held and pulled directly to the left upper quadrant toward the left shoulder. This facilitates the proper angle of closure. The Endostitch is used to begin the anastomosis from the patient’s right and the patient’s left, beginning at the right corner of the anastomosis and the left corner of the anastomosis. The ends are brought together without tying.
The endoscope is then passed into the Roux limb os. It is 30F in size, and the suture is snugged down. A second layer, using the Endostitch, is used to oversew the anastomosis to complete a two-layer anastomosis. The anastomosis is tested under saline to inspect for any evidence of bubbling or leakage. Small holes can be oversewn. Figure 24-8 demonstrates the anastomosis being tested under saline, with no evidence of bubbling. The limitations of the procedure arise when a very thickened small bowel or very short mesentery is found; in these cases it is preferable to use the retrocolic, retrogastric position. An additional advantage of this approach is that when there are multiple adhesions in the lower abdomen, with potential hernias and fat stuck in the hernia defect, it is prudent not to remove those contents unless definitive repair of the hernia can be contemplated at that time.
Figure 24-5. Placement of antiobstruction stitch at jejunojejunostomy.
Figure 24-7. The gastrojejunostomy.
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◗ CONCLUSION It is important that surgeons be familiar with multiple techniques in performing the laparoscopic Roux-en-Y gastric bypass. The linear technique is one of the most common techniques being used today.
◗ REFERENCES
Figure 24-8. Complete gastrojejunostomy anastomosis oversewn in two layers.
1. Steinbrook R: Surgery for severe obesity. N Engl J Med 2004;350: 1075-1079. 2. Wittgrove AC, Clark GW, Tremblay LJ: Laparoscopic gastric bypass, Roux-en-Y: preliminary report of five cases. Obes Surg 1994;4:353-357. 3. Schauer PR, Ikramuddin S, Gourash WF: Laparoscopic Roux-en-Y gastric bypass: a case report at one-year follow-up. J Laparoendoscop Adv Surg Tech A 1999;9:101-106. 4. Higa KD, Boone KB, Ho T: Complications of the laparoscopic Roux-en-Y gastric bypass: 1,040 patients: what have we learned? Obes Surg 2000;10:509-513.
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24 Laparoscopic Roux-en-Y Gastric Bypass: The Linear Technique Sayeed Ikramuddin, M.D.
Obesity surgery has become widespread over the past decade. The reasons for this probably are related to the increase in public awareness of the disease of morbid obesity and also to the patient-driven demand for minimally invasive approaches to bariatric surgery. According to Steinbrook approximately 140,000 procedures were performed in 2004.1 Although not suitable for all patients, particularly those with multiple previous abdominal operations, the laparoscopic Roux-en-Y gastric bypass has gained tremendous popularity. The first recorded case was performed by Wittgrove and colleagues in 1994. They reported a circular-stapled gastrojejunostomy with a retrogastric, retrocolic Roux-en-Y gastric bypass.2 There are other approaches to this operation, including a linear-stapled technique for the gastrojejunal anastomosis with the Roux limb passed either retrocolically or antecolically.3 There is also an approach in which the Roux limb can be passed retrocolically and then placed antegastrically over the gastric remnant and then sutured to the gastric pouch. A totally hand-sewn procedure has also been described.4 The wide availability of suturing devices, as well as robot technology, makes the linear technique or handsewn technique palatable. Regardless of the technique, it is important that surgeons master one approach to the operation and be at least as familiar with other techniques, should technical complications during surgery warrant them. A fundamental knowledge of intracorporeal suturing is necessary in order to perform safe, reliable bariatric surgery.
◗ TECHNIQUE We perform a laparoscopic Roux-en-Y bypass with an antecolic, antegastric Roux limb with a linear-stapled gastrojejunostomy, the enterotomy of which is oversewn in two layers over a 30F stent, typically a 30F endoscope. We use a stapled jejunojejunostomy that is performed at variable distances for the Roux limb and biliopancreatic limb, 204
based on the patient’s body mass index and comorbid conditions. Our procedure is as follows. We use a six-port technique. The surgeon stands on the right. We begin with a Veress needle in the left upper quadrant. After instilling a mixture of 1/2% Marcaine and lidocaine, we place a 150-mm Veress needle (AutoSuture, Norwalk, Conn.) into the left upper quadrant. (We avoid this approach in a patient who has had left upper quadrant surgery or large ventral hernia repair with mesh or a history of a bowel obstruction.) We insufflate the abdomen to a maximum pressure of approximately 5 mmHg. We insert a 5-mm nonbladed trocar (Ethicon Endo-Surgery, Cincinnati, Ohio) into this area 15 to 20 cm below the xiphoid. We then place an 11-mm nonbladed trocar to reduce the rate of herniation. The patient is then placed into a steep reverse Trendelenburg position. Another left lateral 5-mm port is placed just inferiorly and just subcostal on the left side, more lateral to the first trocar site. Two ports are then placed for the surgeon, one below the right subcostal margin, and another just paramedian, roughly at the same level as that placed for the camera port. The two working ports are 5 mm and 12 mm, respectively. One 5-mm lateral port is placed for the liver retractor. We use an angulating triangular liver retractor (Genzyme, Cambridge, Mass.) held in place with a side clamp to the table. Figure 24-1 shows the port sites. After retracting the left lateral segment of the liver, we begin the procedure by incising the hepatogastric ligament with the Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, Ohio). Adhesions at the angle of His are taken down sharply with scissors. We use a 45-degree endoscope to perform the procedure because it allows great ease in navigating around complex angles. The lesser sac is entered using the Harmonic Scalpel. In most cases, the lesser sac is free of adhesions, but in a patient who has a history of pancreatitis or gall bladder disease, there tend to be some significant adhesions. Sometimes, sharp and blunt dissection is necessary. Care is taken to avoid injury to the splenic artery and to the pancreas.
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Figure 24-1. Division of lesser curvature, with bovine pericardial
Figure 24-3. Loop of intestine 100 cm distal to ligament of Treitz
reinforcement.
being brought up to gastric pouch; the loop will be divided after the back wall of the gastrojejunostomy is sewn. The proximal portion will be the biliopancreatic limb.
We begin formation of the gastric pouch immediately below the left gastric artery unless we find it to be aberrant, in which case we start about 3 cm down from the esophagogastric junction on the right side (Fig. 24-2). We use an Endocutter (Ethicon Endo-Surgery) with a wide load with three rows of staples reinforced by a seam guard (W.L. Gore, Flagstaff, Ariz.) to divide the lesser curvature’s blood supply. The division and dissection continue just up to the lesser curvature of the stomach. Dissection is carried up to the angle of His with the aim of constructing a very small, narrow, gastric pouch. The final pouch is approximately 5 to 20 ml in size. The Harmonic Scalpel is used to dissect free the posterior gastric adhesions. Care is taken not to injure the left gastric artery, which may be found quite medially.
With the patient supine, we divide the transverse omentum just to the right of midline with the Harmonic Scalpel. We then identify the ligament of Treitz, elevating the mesentery just above it to confirm clear identification. A Maryland dissector is then passed just below the mesentery of the small bowel. The biliopancreatic limb is to the left, and what is to become the Roux limb will be to the right of this loop. A Penrose drain is then dragged below the bowel, encircling the small bowel and allowing us to place traction on the loop to bring it up to the gastric pouch and begin the suturing of the back row (Fig. 24-3). The back wall suture is run between the gastric pouch and the loop of small bowel with the Penrose drain still in place to prevent traction. The Endostitch (Autosuture) is used to perform this maneuver. The Penrose drain is then removed from the field, and a reticulating, 60-mm, wideload Autostapler (Autosuture) is used to divide the small bowel, essentially maintaining what is to the left as the biliopancreatic limb and what is to the right as the Roux limb. The Harmonic Scalpel is used to dissect down along the mesentery, enlarging the mesenteric defect by about 1 cm, with care taken carefully to coagulate the small vessels and care taken not to migrate to the right or to the left into the mesentery. The bowel that is attached to the gastric remnant is run downstream. In patients with body mass indexes greater than 50 kg per m2 and in patients with type 2 diabetes, we use a longer Roux limb of 150 cm. The biliopancreatic limb is reconnected to the Roux limb about 150 cm downstream with an Endostitch. Enterotomies are made using the Harmonic Scalpel, and an endogastrointestinal, wide-load, 60-mm, three-row stapler is inserted into the lumen of each bowel segment and fired. The resultant enterotomy is approximated with the Endostitch, and the entire enterotomy is rotated between 100 and 180 degrees to the left upper quadrant. A wide-load 60-mm stapler is used to close the common enterotomy (Fig. 24-4). An antiobstruction stitch of
Figure 24-2. Beginning division of stomach to create gastric pouch 1 cm distal to left gastric anastomosis.
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Figure 24-4. Stapled completion of jejunojejunostomy prior to the place-
Figure 24-6. Mesenteric closure of jejunojejunostomy.
ment of the antiobstruction stitch.
2-0 Prolene is made, and then a running closure of the jejunojejunostomy mesenteric defect is performed to completely close the jejunojejunostomy mesenteric defect (Figs. 24-5 and 24-6). At this point, the patient is brought into the steep reverse Trendelenburg position. Enterotomies are made with the Harmonic Scalpel in the gastric pouch as well as in the Roux limb, and an Endocutter (Ethicon EndoSurgery) blue load is inserted to 1.5 cm and fired (Fig. 24-7). In the process, the upper stitch from the back-wall anastomosis is held and pulled directly to the left upper quadrant toward the left shoulder. This facilitates the proper angle of closure. The Endostitch is used to begin the anastomosis from the patient’s right and the patient’s left, beginning at the right corner of the anastomosis and the left corner of the anastomosis. The ends are brought together without tying.
The endoscope is then passed into the Roux limb os. It is 30F in size, and the suture is snugged down. A second layer, using the Endostitch, is used to oversew the anastomosis to complete a two-layer anastomosis. The anastomosis is tested under saline to inspect for any evidence of bubbling or leakage. Small holes can be oversewn. Figure 24-8 demonstrates the anastomosis being tested under saline, with no evidence of bubbling. The limitations of the procedure arise when a very thickened small bowel or very short mesentery is found; in these cases it is preferable to use the retrocolic, retrogastric position. An additional advantage of this approach is that when there are multiple adhesions in the lower abdomen, with potential hernias and fat stuck in the hernia defect, it is prudent not to remove those contents unless definitive repair of the hernia can be contemplated at that time.
Figure 24-5. Placement of antiobstruction stitch at jejunojejunostomy.
Figure 24-7. The gastrojejunostomy.
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◗ CONCLUSION It is important that surgeons be familiar with multiple techniques in performing the laparoscopic Roux-en-Y gastric bypass. The linear technique is one of the most common techniques being used today.
◗ REFERENCES
Figure 24-8. Complete gastrojejunostomy anastomosis oversewn in two layers.
1. Steinbrook R: Surgery for severe obesity. N Engl J Med 2004;350: 1075-1079. 2. Wittgrove AC, Clark GW, Tremblay LJ: Laparoscopic gastric bypass, Roux-en-Y: preliminary report of five cases. Obes Surg 1994;4:353-357. 3. Schauer PR, Ikramuddin S, Gourash WF: Laparoscopic Roux-en-Y gastric bypass: a case report at one-year follow-up. J Laparoendoscop Adv Surg Tech A 1999;9:101-106. 4. Higa KD, Boone KB, Ho T: Complications of the laparoscopic Roux-en-Y gastric bypass: 1,040 patients: what have we learned? Obes Surg 2000;10:509-513.