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Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity Dr. Alex Gandsas, Head of the Division of Bariatric and Minimally Invasive Surgery at Sinai Hospital in Baltimore, is presenting the technique for the laparoscopic roux-en-Y gastric bypass for morbid obesity. All candidates for bariatric surgery must meet the requirements suggested by the 1991 National Institues of Health consensus statement for morbid obesity which include a BMI of >40 kg/m2, or a BMI of at least 35 kg/m2 with at least one comorbid condition. In addition, patients should be younger than 60 years old, and should not have any significant psychiatric illness. Depression is a common comorbidity of obesity and does not necessarily disqualify patients if they are devoid of psychotic symptoms and are under the care of a psychologist and or psychiatrist. The technique currently showen is based on antecolic, antegastric approach described by Dr. Shauer. Laparoscopic Roux-en-Y Gastric Bypass - The Movie - Body Mass Index Calculator WARNING: The following material is protected by copyright laws. Unauthorized use of this content should result in prosecution and/or severe fines. The patient is placed in the supine position. Pneumoperitoneum is achieved via a Veress needle placed in the left lateral subcostal margin and the abdomen is insufflated to a pressure of 15mmHg. This picture demonstrates the trocar set-up. Once all ports have been placed, the liver is retracted and the jejunum is divided 40 centimiters from the ligament of Treitz by using a 2.5 mm endostapler. The mesentery is also divided using a 2.5 mm endostapler. It is important to keep the instrument talways aiming the root of the mesentery to avoid inturruption of blood suply to the small bowel. A communication or anastomosis is created between the proximal end of small bowel (biliary limb) and 75 cm (or 150 cm for patients with a BMI > 50) distal to the division. The anastomosis is accomplished using a 2.5mm linear stapling device The enterotomy is then closed by firing a endostapler. A hand-sewn technique with a running 3-0 Vicryl suture can be used to close the defect. The mesenteric rent created by the division of the jejunum is then repaired with a hand-sewn 2-0 silk running suture.. The greater omentum is then brought back into the operative field and divided down the midline using an ultrasonic scalpel. This creates a "valley" for the roux limb to lie in its antecolic approach to the soon-to-be-created gastric pouch. Once access has being gained to the lesser sac, the stomach is divided using a 3.5 mm (blue) endostapler. The objecive is to create a 30 cc pouch. During the division of the stomach, care should be taken to avoid lacerations to the spleen. The roux limb is brought up to the new stomach pouch and an end-to-side gastrojejunostomy is performed. This anastomosis begins with a single row of hand sewn 2-0 silk suture which will become the posterior wall of the anastomosis. A side-by-side gastrotomy and enterotomy are then made using a ultrasonic scalpel. A communication (gastrojejunostomy) between the new stomach (gastric pouch) and the Roux limb (small bowel) is created by placing 3.5 mm endostapling device into those openings and firing the stapler to form a 2.5-3cm anastomosis The gap (gastro-enterotomy) is then closed hand-sewn using a 2/0 running silk. Finally, once the closure has been completed, a clamp is applied to the roux limb a few centimeters distal to the gastrojejunostomy. The newly formed anastomosis is immersed in normal saline and tested for leaks by infusing air into the pouch lumen via the endoscope and looking for escaping bubbles.