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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. |
Dr.
Alex Gandsas,
Associate Professor of Surgery at The Johns
Hopkins University School of Medicine, 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.
