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Technical considerations for transabdominal loading of the circular stapler in laparoscopic Roux-en-Y gastric bypass
The American Journal of Surgery 185 (2003) 585–588
How I do it
Technical considerations for transabdominal loading of the circular stapler in laparoscopic Roux-en-Y gastric bypass Michel M. Murr, M.D.a,b,*, Scott F. Gallagher, M.D.a a
Department of Surgery and Interdisciplinary Obesity Treatment Group, University of South Florida College of Medicine, Tampa, FL, USA; b Tampa General Hospital, P.O. Box 1289, Tampa, FL 33601, USA. Manuscript received March 26, 2002; revised manuscript October 28, 2002
Abstract Background: Laparoscopic Roux-en-Y gastric bypass is being undertaken with increasing frequency. We describe a technique for introducing the anvil of the circular stapler using a totally transabdominal approach. Methods: One hundred consecutive patients underwent laparoscopic Roux-en-Y gastric bypass in a university-affiliated teaching hospital. Results: The cardiojejunostomy was constructed in all 100 patients using the circular stapler with no complications. No anastomotic leaks were detected postoperatively. Conclusions: The totally transabdominal approach for introducing the anvil of the circular stapler into the gastric pouch is safe and feasible. © 2003 Excerpta Medica, Inc. All rights reserved. Keywords: Laparoscopic surgery; Obesity; Gastric bypass; Anvil; Bariatric surgery
Roux-en-Y gastric bypass (RYGB) is the most commonly utilized operation for the treatment of clinically significant obesity in North America [1,2]. Technical and product improvements have made a laparoscopic approach to RYGB possible, yet there is no consensus on the method of constructing the gastrojejunostomy. We use the circular stapler in open as well as laparoscopic RYGB, and we have been troubled by reports of complications ensuing from introducing the anvil of the circular stapler perorally [3]; therefore, we have adopted a totally transabdominal approach for introducing the anvil into the gastric pouch. We describe herein the technical steps required for introducing the anvil into the gastric pouch during laparoscopic RYGB.
Technique Five trocars are placed through the abdominal wall in a manner that is similar to that described by Scott and de la Torre [4] (Fig. 1). An 18-mm trocar (Ethicon Endosurgery, Cincinnati, Ohio) is introduced at a midpoint between the * Corresponding author. Tel.: ⫹1-813-844-7394; fax: ⫹1-813-8447396. E-mail address: [email protected]
umbilicus and left subcostal margin. A 16F Baker jejunostomy catheter (Bard, Covington, Georgia) is introduced by the anesthesiologist and then wedged against the gastroesophageal junction after inflating its balloon with 30 cc of air. The equator of the balloon-distended cardia is marked to localize the site to be used for passing the stem of the anvil. The anvil of the no. 21 Stealth endoscopic circular stapler (Ethicon Endosurgery) is introduced into the abdomen through the left upper quadrant 18-mm trocar site after removing the trocar. The anvil is grasped and pulled through the abdominal wall; it is then introduced into the stomach through a gastrotomy and exteriorized through the previously marked site in the anterior wall of the cardia (Fig. 2). The gastrotomy is closed with an application of a linear stapler (EndoGIA; US Surgical Corporation, Hartford, Connecticut). The anvil is secured by placing a purse-string suture around its stem using the Suture-Assistant device (Ethicon Endosurgery) to approximate stomach wall around the anvil (Fig. 3). The stomach is then divided between a window in the lesser curvature and the angle of His using multiple applications of a linear stapler (US Surgical Corporation), thereby creating a small gastric pouch and the excluded stomach (Fig. 4). The Roux limb is prepared by dividing the proximal jejunum at a point of maximal mobility, which is
0002-9610/03/$ – see front matter © 2003 Excerpta Medica, Inc. All rights reserved. doi:10.1016/S0002-9610(03)00063-1
586
M.M. Murr, and S.F. Gallagher / The American Journal of Surgery 185 (2003) 585–588
Fig. 3. A purse-string suture is placed with a suture assistant device around the stem of the anvil to minimize the tissue defect around the anvil and to incorporate full-thickness stomach wall into the staple line.
Fig. 1. Placement of trocars for laparoscopic Roux-en-Y gastric bypass utilizing the Visiport trocar to enter the abdominal cavity under direct visualization. Four additional trocars are then placed as depicted. We introduce an 18 mm trocar midway between the umbilicus and the left subcostal margin to facilitate removing the gallbladder through the thick abdominal wall and to dilate an adequate tract that will accommodate the anvil and circular stapler at a later stage of the operation. The most lateral, right, subcostal trocar (5 mm) is used for a liver retractor. The remaining two trocars (12 mm) are positioned as depicted.
Fig. 2. The anvil is introduced into the stomach through a gastrotomy and exteriorized through the anterior wall of the cardia at an area previously marked by the equator of the balloon of a Baker jejunostomy catheter.
usually 40 to 70 cm from the ligament of Treitz. Using a linear stapler, a side-to-side jejunojejunostomy is constructed 100 to 150 cm distal to the point of transection. Subsequently, the Roux limb is then positioned in the upper
Fig. 4. The stomach has been divided using a linear stapler placed through a window between the neurovascular bundle and the lesser curvature of the stomach. Multiple applications are needed to divide the stomach to the angle of His. The no. 21 Stealth endoscopic circular stapler is introduced into the abdomen and into the open end of the Roux limb in a “closed” position. The dial is turned to the “open” position and the spear emerges through the antimesenteric border of the Roux limb. A modified Allis grasper stabilizes the stem of the anvil as the stapler is connected to the anvil. The stapler is closed, applied, opened, and removed in the standard fashion.
M.M. Murr, and S.F. Gallagher / The American Journal of Surgery 185 (2003) 585–588
587
circular staple line. The staple line was reinforced with sutures in that area as previously described. There was no evidence of contrast extravasation in any of the patients on routine contrast examination of the cardiojejunostomy done within 36 hours postoperatively. Clear liquid diet was initiated once the contrast examination was confirmed to show no evidence of leak. None of the patients developed leaks from the cardiojejunostomy after discharge. One patient underwent a celiotomy within 8 hours of the initial procedure for hemoperitoneum secondary to bleeding from the 18-mm trocar site. On review of the taped procedure, it was evident that there was excessive manipulation of the left rectus muscle upon introducing the circular stapler through the 18-mm trocar site, and the bleeding was not a result of trauma while introducing the anvil. In 2 patients a wound infection developed at the 18-mm trocar site and responded to oral antibitoics.
Comments
Fig. 5. Schema of the completed laparoscopic Roux-en-Y gastric bypass. The cardiojejunostomy is completed and its anterior aspect reinforced with sutures. The jejunojejunostomy has been completed at an earlier step. All mesenteric defects have been closed.
abdomen in a retrocolic/antegastric position. The no. 21 Stealth circular stapler (Ethicon Endosurgery) is introduced through the 18-mm trocar site after removing the trocar (Fig. 4) and into the open end of the Roux limb. A side-toside cardiojejunostomy is constructed and the stapler is removed in the usual manner. The enterotomy used to introduce the stapler into the Roux is closed using a linear stapler. The anterior aspect of the circular staple line is reinforced with interrupted sutures (Fig. 5) using the SutureAssistant. The pouch and Roux limb are then inflated with air under water seal to detect any defects in the anastomotic lines.
Results We have deployed the anvil using this technique in 100 consecutive patients undergoing laparoscopic RYGB. Tissue doughnuts were intact in all patients. In 2 patients, a small defect in the circular staple line was detected intraoperatively by the air leak test. The defects were at the most anterior (ventral) aspect of the staple line and were repaired satisfactorily with sutures. Another patient leaked air under water seal (bubbles) from the left lateral aspect of the
Refinement of operative techniques is inevitable as bariatric surgeons undertake laparoscopic gastric bypass with greater frequency [1,2]. Timely exchanges of early experiences and operative techniques will expedite refinement of the operation; this is especially important in laparoscopic RYGB, which has both a difficult and a slow learning curve. Surgeons interested in offering laparoscopic RYGB to their patients should have a solid foundation in bariatric surgery as well as advanced laparoscopy [1]. Initial reports of introducing the anvil perorally reflected inexperience in bariatric surgery as this method has been tried and abandoned during open RYGB owing to esophageal perforation and inability to pass the anvil into the pouch. In addition, introducing the anvil perorally as advocated by others requires a skilled endoscopist/surgeon to introduce the anvil into the esophagus as well as to perform an endoscopic examination of the esophagus and pouch upon completion of the cardiojejunostomy in the operating room. These additional steps may increase operating time significantly. And while there has been a recent, rapid escalation in the number of surgeons using endoscopy and laparoscopy, it is very difficult to perform endoscopy and advanced laparoscopy simultaneously in the same operating room from a logistical point of view. As most surgeons who do open RYGB introduce the anvil into the pouch transabdominally and not perorally, we saw no reason to change this time-tested method [5] (especially since the alternative requires additional set-up and endoscopy that may not be available to all surgeons). The skills required to introduce the anvil into the cardia of the stomach in the manner described herein are commensurate with the skills developed for other maneuvers during laparoscopic RYGB. We recommend approximating the cardia wall around the stem of the anvil with a purse-string suture. Because the
588
M.M. Murr, and S.F. Gallagher / The American Journal of Surgery 185 (2003) 585–588
wall of the cardia is usually quite thin, as the stem of the anvil emerges from the cardia it creates a defect larger than its diameter in most instances. Therefore, the purse-string minimizes the likelihood that a portion of the defect will be included in the staple line, especially since the distance between the stem of the anvil and the staples is very small in the no. 21 circular staplers. By using techniques that we have employed and repeatedly tested in our larger experience of open RYGB, we have shortened our learning curve for that portion of the laparoscopic operation. Moreover, there were no complications in this cohort directly attributable to introducing the anvil transabdominally. Anecdotal reports that attribute the high incidence of anastomotic strictures at the cardiojejunostomy to the use of no. 21 circular staplers have prompted some surgeons to abandon their use and to construct the cardiojejunostomy using a linear stapler, or a hand-sewn technique. Our estimated incidence of anastomotic strictures in both open and laparoscopic gastric bypass is 2%. We have no reason to believe that the rate of anastomotic strictures will be higher in laparoscopic RYGB, as we employ the same technique in the open RYGB, which has a low reported incidence (1%) of anastomotic strictures [6]. The positive advantages of utilizing the circular stapler include efficiency, automation, and standardization. These advantages are in contrast to a hand-sewn anastomosis, which requires the use of a Bougie as well as some method to calibrate the anastomosis without the benefit of direct tactile senses. In addition, the enterotomies used to introduce the linear stapler will also have to be closed by sutures
We attribute the low incidence of anastomotic strictures and the absence of leaks from the cardiojejunostomy to the technique that we utilize preparing the gastric pouch and placing the anvil into the anterior wall of the pouch and subsequently through the linear staple line. The neurovascular bundle, which includes the left gastric artery, is preserved thereby ensuring adequate blood supply to the pouch. Moreover, placement of the Roux limb in the retrocolic/antegastric position minimizes the mechanical tension on the anastomosis. The technique we describe herein has evolved from lessons learned during open RYGB. It is simple and pragmatic and does not encumber the surgeon with learning additional skills or utilizing additional equipment in the operating room. References [1] Al Saif O, Banasiak M, Gallagher S, et al. Who should be doing laparoscopic bariatric surgery? Obesity Surg. 2003;13:82– 87. [2] Lopez J, Sung J, Anderson W, et al. Is bariatric surgery safe and cost-effective in academic centers? Am Surg. 2002;68:820 – 823. [3] Nguyen NT, Wolfe BM. Hypopharyngeal perforation during laparoscopic Roux-en-Y gastric bypass. Obesity Surg 2000;10:64 –7. [4] de la Torre RA, Scott JS. Laparoscopic Roux-en-Y gastric bypass: a totally intra-abdominal approach—technique and preliminary report. Obesity Surg 1999;9:492– 8. [5] Sarr MG. Vertical disconnected Roux-en-Y gastric bypass. Obesity Surg 1996;13:45–9. [6] Balsiger BM, Kennedy FP, Abu-Lebdeh HS, et al. Prospective evaluation of Roux-en-Y gastric bypass as primary operation for medically complicated obesity. Mayo Clin Proc 2000;75:673– 80.
How I do it
Technical considerations for transabdominal loading of the circular stapler in laparoscopic Roux-en-Y gastric bypass Michel M. Murr, M.D.a,b,*, Scott F. Gallagher, M.D.a a
Department of Surgery and Interdisciplinary Obesity Treatment Group, University of South Florida College of Medicine, Tampa, FL, USA; b Tampa General Hospital, P.O. Box 1289, Tampa, FL 33601, USA. Manuscript received March 26, 2002; revised manuscript October 28, 2002
Abstract Background: Laparoscopic Roux-en-Y gastric bypass is being undertaken with increasing frequency. We describe a technique for introducing the anvil of the circular stapler using a totally transabdominal approach. Methods: One hundred consecutive patients underwent laparoscopic Roux-en-Y gastric bypass in a university-affiliated teaching hospital. Results: The cardiojejunostomy was constructed in all 100 patients using the circular stapler with no complications. No anastomotic leaks were detected postoperatively. Conclusions: The totally transabdominal approach for introducing the anvil of the circular stapler into the gastric pouch is safe and feasible. © 2003 Excerpta Medica, Inc. All rights reserved. Keywords: Laparoscopic surgery; Obesity; Gastric bypass; Anvil; Bariatric surgery
Roux-en-Y gastric bypass (RYGB) is the most commonly utilized operation for the treatment of clinically significant obesity in North America [1,2]. Technical and product improvements have made a laparoscopic approach to RYGB possible, yet there is no consensus on the method of constructing the gastrojejunostomy. We use the circular stapler in open as well as laparoscopic RYGB, and we have been troubled by reports of complications ensuing from introducing the anvil of the circular stapler perorally [3]; therefore, we have adopted a totally transabdominal approach for introducing the anvil into the gastric pouch. We describe herein the technical steps required for introducing the anvil into the gastric pouch during laparoscopic RYGB.
Technique Five trocars are placed through the abdominal wall in a manner that is similar to that described by Scott and de la Torre [4] (Fig. 1). An 18-mm trocar (Ethicon Endosurgery, Cincinnati, Ohio) is introduced at a midpoint between the * Corresponding author. Tel.: ⫹1-813-844-7394; fax: ⫹1-813-8447396. E-mail address: [email protected]
umbilicus and left subcostal margin. A 16F Baker jejunostomy catheter (Bard, Covington, Georgia) is introduced by the anesthesiologist and then wedged against the gastroesophageal junction after inflating its balloon with 30 cc of air. The equator of the balloon-distended cardia is marked to localize the site to be used for passing the stem of the anvil. The anvil of the no. 21 Stealth endoscopic circular stapler (Ethicon Endosurgery) is introduced into the abdomen through the left upper quadrant 18-mm trocar site after removing the trocar. The anvil is grasped and pulled through the abdominal wall; it is then introduced into the stomach through a gastrotomy and exteriorized through the previously marked site in the anterior wall of the cardia (Fig. 2). The gastrotomy is closed with an application of a linear stapler (EndoGIA; US Surgical Corporation, Hartford, Connecticut). The anvil is secured by placing a purse-string suture around its stem using the Suture-Assistant device (Ethicon Endosurgery) to approximate stomach wall around the anvil (Fig. 3). The stomach is then divided between a window in the lesser curvature and the angle of His using multiple applications of a linear stapler (US Surgical Corporation), thereby creating a small gastric pouch and the excluded stomach (Fig. 4). The Roux limb is prepared by dividing the proximal jejunum at a point of maximal mobility, which is
0002-9610/03/$ – see front matter © 2003 Excerpta Medica, Inc. All rights reserved. doi:10.1016/S0002-9610(03)00063-1
586
M.M. Murr, and S.F. Gallagher / The American Journal of Surgery 185 (2003) 585–588
Fig. 3. A purse-string suture is placed with a suture assistant device around the stem of the anvil to minimize the tissue defect around the anvil and to incorporate full-thickness stomach wall into the staple line.
Fig. 1. Placement of trocars for laparoscopic Roux-en-Y gastric bypass utilizing the Visiport trocar to enter the abdominal cavity under direct visualization. Four additional trocars are then placed as depicted. We introduce an 18 mm trocar midway between the umbilicus and the left subcostal margin to facilitate removing the gallbladder through the thick abdominal wall and to dilate an adequate tract that will accommodate the anvil and circular stapler at a later stage of the operation. The most lateral, right, subcostal trocar (5 mm) is used for a liver retractor. The remaining two trocars (12 mm) are positioned as depicted.
Fig. 2. The anvil is introduced into the stomach through a gastrotomy and exteriorized through the anterior wall of the cardia at an area previously marked by the equator of the balloon of a Baker jejunostomy catheter.
usually 40 to 70 cm from the ligament of Treitz. Using a linear stapler, a side-to-side jejunojejunostomy is constructed 100 to 150 cm distal to the point of transection. Subsequently, the Roux limb is then positioned in the upper
Fig. 4. The stomach has been divided using a linear stapler placed through a window between the neurovascular bundle and the lesser curvature of the stomach. Multiple applications are needed to divide the stomach to the angle of His. The no. 21 Stealth endoscopic circular stapler is introduced into the abdomen and into the open end of the Roux limb in a “closed” position. The dial is turned to the “open” position and the spear emerges through the antimesenteric border of the Roux limb. A modified Allis grasper stabilizes the stem of the anvil as the stapler is connected to the anvil. The stapler is closed, applied, opened, and removed in the standard fashion.
M.M. Murr, and S.F. Gallagher / The American Journal of Surgery 185 (2003) 585–588
587
circular staple line. The staple line was reinforced with sutures in that area as previously described. There was no evidence of contrast extravasation in any of the patients on routine contrast examination of the cardiojejunostomy done within 36 hours postoperatively. Clear liquid diet was initiated once the contrast examination was confirmed to show no evidence of leak. None of the patients developed leaks from the cardiojejunostomy after discharge. One patient underwent a celiotomy within 8 hours of the initial procedure for hemoperitoneum secondary to bleeding from the 18-mm trocar site. On review of the taped procedure, it was evident that there was excessive manipulation of the left rectus muscle upon introducing the circular stapler through the 18-mm trocar site, and the bleeding was not a result of trauma while introducing the anvil. In 2 patients a wound infection developed at the 18-mm trocar site and responded to oral antibitoics.
Comments
Fig. 5. Schema of the completed laparoscopic Roux-en-Y gastric bypass. The cardiojejunostomy is completed and its anterior aspect reinforced with sutures. The jejunojejunostomy has been completed at an earlier step. All mesenteric defects have been closed.
abdomen in a retrocolic/antegastric position. The no. 21 Stealth circular stapler (Ethicon Endosurgery) is introduced through the 18-mm trocar site after removing the trocar (Fig. 4) and into the open end of the Roux limb. A side-toside cardiojejunostomy is constructed and the stapler is removed in the usual manner. The enterotomy used to introduce the stapler into the Roux is closed using a linear stapler. The anterior aspect of the circular staple line is reinforced with interrupted sutures (Fig. 5) using the SutureAssistant. The pouch and Roux limb are then inflated with air under water seal to detect any defects in the anastomotic lines.
Results We have deployed the anvil using this technique in 100 consecutive patients undergoing laparoscopic RYGB. Tissue doughnuts were intact in all patients. In 2 patients, a small defect in the circular staple line was detected intraoperatively by the air leak test. The defects were at the most anterior (ventral) aspect of the staple line and were repaired satisfactorily with sutures. Another patient leaked air under water seal (bubbles) from the left lateral aspect of the
Refinement of operative techniques is inevitable as bariatric surgeons undertake laparoscopic gastric bypass with greater frequency [1,2]. Timely exchanges of early experiences and operative techniques will expedite refinement of the operation; this is especially important in laparoscopic RYGB, which has both a difficult and a slow learning curve. Surgeons interested in offering laparoscopic RYGB to their patients should have a solid foundation in bariatric surgery as well as advanced laparoscopy [1]. Initial reports of introducing the anvil perorally reflected inexperience in bariatric surgery as this method has been tried and abandoned during open RYGB owing to esophageal perforation and inability to pass the anvil into the pouch. In addition, introducing the anvil perorally as advocated by others requires a skilled endoscopist/surgeon to introduce the anvil into the esophagus as well as to perform an endoscopic examination of the esophagus and pouch upon completion of the cardiojejunostomy in the operating room. These additional steps may increase operating time significantly. And while there has been a recent, rapid escalation in the number of surgeons using endoscopy and laparoscopy, it is very difficult to perform endoscopy and advanced laparoscopy simultaneously in the same operating room from a logistical point of view. As most surgeons who do open RYGB introduce the anvil into the pouch transabdominally and not perorally, we saw no reason to change this time-tested method [5] (especially since the alternative requires additional set-up and endoscopy that may not be available to all surgeons). The skills required to introduce the anvil into the cardia of the stomach in the manner described herein are commensurate with the skills developed for other maneuvers during laparoscopic RYGB. We recommend approximating the cardia wall around the stem of the anvil with a purse-string suture. Because the
588
M.M. Murr, and S.F. Gallagher / The American Journal of Surgery 185 (2003) 585–588
wall of the cardia is usually quite thin, as the stem of the anvil emerges from the cardia it creates a defect larger than its diameter in most instances. Therefore, the purse-string minimizes the likelihood that a portion of the defect will be included in the staple line, especially since the distance between the stem of the anvil and the staples is very small in the no. 21 circular staplers. By using techniques that we have employed and repeatedly tested in our larger experience of open RYGB, we have shortened our learning curve for that portion of the laparoscopic operation. Moreover, there were no complications in this cohort directly attributable to introducing the anvil transabdominally. Anecdotal reports that attribute the high incidence of anastomotic strictures at the cardiojejunostomy to the use of no. 21 circular staplers have prompted some surgeons to abandon their use and to construct the cardiojejunostomy using a linear stapler, or a hand-sewn technique. Our estimated incidence of anastomotic strictures in both open and laparoscopic gastric bypass is 2%. We have no reason to believe that the rate of anastomotic strictures will be higher in laparoscopic RYGB, as we employ the same technique in the open RYGB, which has a low reported incidence (1%) of anastomotic strictures [6]. The positive advantages of utilizing the circular stapler include efficiency, automation, and standardization. These advantages are in contrast to a hand-sewn anastomosis, which requires the use of a Bougie as well as some method to calibrate the anastomosis without the benefit of direct tactile senses. In addition, the enterotomies used to introduce the linear stapler will also have to be closed by sutures
We attribute the low incidence of anastomotic strictures and the absence of leaks from the cardiojejunostomy to the technique that we utilize preparing the gastric pouch and placing the anvil into the anterior wall of the pouch and subsequently through the linear staple line. The neurovascular bundle, which includes the left gastric artery, is preserved thereby ensuring adequate blood supply to the pouch. Moreover, placement of the Roux limb in the retrocolic/antegastric position minimizes the mechanical tension on the anastomosis. The technique we describe herein has evolved from lessons learned during open RYGB. It is simple and pragmatic and does not encumber the surgeon with learning additional skills or utilizing additional equipment in the operating room. References [1] Al Saif O, Banasiak M, Gallagher S, et al. Who should be doing laparoscopic bariatric surgery? Obesity Surg. 2003;13:82– 87. [2] Lopez J, Sung J, Anderson W, et al. Is bariatric surgery safe and cost-effective in academic centers? Am Surg. 2002;68:820 – 823. [3] Nguyen NT, Wolfe BM. Hypopharyngeal perforation during laparoscopic Roux-en-Y gastric bypass. Obesity Surg 2000;10:64 –7. [4] de la Torre RA, Scott JS. Laparoscopic Roux-en-Y gastric bypass: a totally intra-abdominal approach—technique and preliminary report. Obesity Surg 1999;9:492– 8. [5] Sarr MG. Vertical disconnected Roux-en-Y gastric bypass. Obesity Surg 1996;13:45–9. [6] Balsiger BM, Kennedy FP, Abu-Lebdeh HS, et al. Prospective evaluation of Roux-en-Y gastric bypass as primary operation for medically complicated obesity. Mayo Clin Proc 2000;75:673– 80.