Laparoscopy.com

Dr. Philip R. Schauer, Associate Professor of Surgery and Director Advanced Laparoscopic and Bariatric Surgery, Cleveland Clinic Foundation is presenting his technique of Roux-en-Y Gastric Bypass for severe obesity (morbid obesity) using a laparoscopic approach.

Over the last 20 years the Roux-en-Y Gastric bypass has been successfully used as one of many surgical treatments to achieve significant long term weight loss (71% mean excess weigh loss). However, this procedure was not free of post operative complications. Wound infection, wound dehiscence, pulmonary embolism and cardiac problems made the recovery of these patients very long and difficult. By using a mini-invasive approach a big incision is spared, resulting in a faster recovery time with less pain and prompt ambulation. According to Dr.Schauer, his procedure is a modification of the technique described by Wittgrove et .al. in 1994.

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The patient is placed on the table and general anesthetics are administered. Trocars are placed as shown in this picture.

Gastric Bypass enterotomy

The patient is placed on the table and general anesthetics are administered. Trocars are placed as shown in this picture.

gastric bypass division of the mesentery

A retrogastric-retrocolic tunnel is performed in the mesocolon anterior and lateral to the ligament of Treitz. This "window" will facilitate the passage of the Roux-limb.

gastric bypass entero enterotomy

In order to create the Roux-limb, the jejunum is divided 15 cm beyond the ligament of Treitz by using an Endo GIA II stapler (US Surgical), 45 mm long with 3.5 mm staples. In addition the mesentery is also divided with a Endo GIA II stapler, but this time using the vascular load (45 mm length, 2.0 mm staples). This maneuver will facilitate mobilization of the small intestine through the mesocolon. A rubber drain is sutured to the jejunum to help with the pulling.

gastric bypass entero enterostomy closure

The Roux-limb is measured according to the patient BMI (Body Mass Index) and can range from 75 to 200 cm in length. Notice that the laparoscopic grasper is used as a ruler.

gastric bypass rent closure

An end-to-side anastomosis between the proximal jejunum and the roux limb is created by firing two Endo GIA II staplers. The enterotomy is closed using another load of staples. The mesentery is also closed to prevent bowel entrapment (internal hernias).

gastric bypass omentum

Close up view of the entero-enterostomy.

The Roux-limb is now advanced trough the mesocolic window (retrocolic and retrogastric) near the transected stomach.

gastric bypass

Using the rubber drain, the Roux-limb is pulled to a retrogastric position.

Following an enterotomy an anastomosis between the gastric pouch and the Roux-limb is created by firing a Endo GIA II.

The enterotomy is stapled shut with another load of Endo GIA II. The anastomosis is secured by placing an extra row of stitches. The gastrojejunostomy and the enterotomy site are tested for leakage by applying insufflation through an nasogastric tube (or endoscope) and submerging the area in irrigation solution.

LAPAROSCOPY.COM would like to thank Dr. Philip R. Schauer, M.D, Director of Endoscopic Surgery at the University of Pittsburgh Medical Center and the outstanding work of medical artist Jennifer Dallal for their contribution.