and John E. Skandalakis1
(1)
Centers for Surgical Anatomy and Technique, Emory University School of Medicine Piedmont Hospital, Atlanta, GA, USA
Abstract
The roux-en-Y gastric bypass has taken on many forms over the last five decades. While it is still performed as an open procedure across much of the country, the laparoscopic variant has enjoyed increasing popularity among bariatric surgeons and patients since Clark and Wittgrove first described their technique in 1994. The advancement of the roux limb may be performed in an antecolic/antegastric, retrocolic/antegastric, or retrocolic/retrogastric fashion. While each of these techniques has its own merits, it is advantageous for the practitioner to understand and be facile with each one; variations in patient anatomy as the situation presents may require the surgeon to diverge from his or her preferred approach.
General Description of Gastric Bypass
The roux-en-Y gastric bypass has taken on many forms over the last five decades. While it is still performed as an open procedure across much of the country, the laparoscopic variant has enjoyed increasing popularity among bariatric surgeons and patients since Clark and Wittgrove first described their technique in 1994. The advancement of the roux limb may be performed in an antecolic/antegastric, retrocolic/antegastric, or retrocolic/retrogastric fashion. While each of these techniques has its own merits, it is advantageous for the practitioner to understand and be facile with each one; variations in patient anatomy as the situation presents may require the surgeon to diverge from his or her preferred approach.
What is described below is our technique for a laparoscopic retrocolic roux-en-Y gastric bypass. We recognize that there are many ways to “skin a cat,” with each resulting in an excellent outcome. While not described in this manuscript, we will often employ an antecolic approach based on the patient’s body habitus. We recognize, as well, that the use of a circular stapler placed transabdominally in order to create a stapled gastrojejunostomy is perfectly acceptable. However, this technique is not used in our practice. Furthermore, we now employ the DaVinci surgical robot for this procedure with the added advantage of enhanced visualization and intracorporeal dexterity. The technique of the procedure as described below, however, is the same regardless of the surgical approach.
Technique
Retrocolic Roux-en-Y Gastric Bypass
DIET PRIOR TO SURGERY: We employ a two-week modified protein liquid diet in order to reduce the size of the liver, which aids in the visualization of the gastroesophageal junction.
TESTS PRIOR TO SURGERY: H. pylori testing is mandatory. Postoperative gastric ulcers in the remnant stomach are not only quite morbid but also can be a diagnostic and treatment dilemma. We have not found bowel prep to be beneficial preoperatively.
ENDOSCOPY: Routine preoperative upper endoscopy to rule out gastroduodenal lesions which will not be approachable endoscopically once the remnant stomach has been bypassed. Preoperative endoscopy also will help to define posterior herniation of the fundus that may not be evident at the time of the operation and which can lead to suboptimal pouch construction.
Step 1. The surgeon stands on the patient’s right side with an assistant on the left.
Step 2. Prep and drape patient widely in anticipation of conversion to an open procedure if necessary.
Step 3. Establish pneumoperitoneum in the normal manner. We prefer introduction of a Veress needle just below the left subcostal margin.
Step 4. Enter the abdomen using a 5- or 10-mm optical viewing trocar 15–18 cm below the xiphoid and just to the left of the midline.
Step 5. Place two ports on the patient’s right side: one just below the tip of the right lobe of the liver and the other in a line midway between the first port and the umbilicus. The second port should be a 12-mm port in order to accommodate a linear stapler.
Step 6. Place one or two more assistant ports in the left upper quadrant.
Step 7. Retract the left lobe of the liver anteriorly, using a Nathanson liver retractor placed through a small incision just below the xiphoid process.
Step 8. Inspect the entire abdomen. Any adhesions should be carefully taken down.
Step 9. Creation of roux loop prior to the creation of the gastric pouch.
Step 10. Identify the ligament of Treitz by retracting the greater omentum and transverse colon cephalad.
Step 11. Using a linear stapling device, divide the small bowel 40 cm distal to the ligament of Treitz. A vascular load is preferred when stapling the small bowel in order to reduce the incidence of staple line bleeding.
Step 12. To avoid ischemia of the two stapled ends, divide the mesentery for 4–5 cm in a direction perpendicular to the bowel (Fig. 22.1).
Step 13. Create the roux limb from the distal stapled bowel. We prefer a 120-cm roux limb for patients with a BMI less than 50 and a 150 cm roux limb for patients with a BMI greater than 50 kg/m2 (Fig. 22.2).
Step 14. An energy device is used to create an enterotomy on the antimesenteric border of the base of the roux limb and near the stapled end of the proximal biliopancreatic limb.
Step 15. Create a side-by-side isoperistaltic anastomosis by placing a linear stapler into these enterotomies. After deploying the stapler, it is wise to slightly close it while it is being removed from the bowel lumen to avoid unnecessarily widening the common defect (Fig. 22.3).
Step 16. Close the common defect by aligning the edges of the bowel and deploying another staple load externally, or by oversewing the defect with a single layer of running 2–0 absorbable suture.
Step 17. The mesenteric defect must then be closed in order to prevent internal bowel herniation, which can be catastrophic. Close with a single running layer of nonabsorbable suture from the base of the mesenteric defect to the bowel. Care should be taken to avoid ligation of the small arterioles which may cause ischemia of the anastomosis (Fig. 22.4).
Step 18. For a retrocolic roux limb, the transverse mesocolon is held upright. A dimple can usually be seen just to the left of the middle colic vessels anterior to the ligament of Treitz. An energy device is used to open the mesocolon for about 2.5 cm and to create a window into the lesser sac.
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