Chapter 19 Laparoscopic Gastric Bypass
INTRODUCTION
During the 5 years from 1998 to 2003, the field of bariatric surgery in the United States underwent a veritable revolution. The number of Roux-en-Y gastric bypass (RYGB) procedures performed annually in the country increased from approximately 20,000 to 140,000.1 The major reason for this may be debatable, but this author’s hypothesis is that the explosion in popularity of the operation was driven largely by the availability of the performance of the operation using a laparoscopic approach. The temporal relationship of the advent of the laparoscopic approach and the rise in popularity of the operation are strongly correlated. Laparoscopic surgery was popular among young surgeons, and the popularity spread to bariatric surgery. The public and referring physicians had already demonstrated the inclination to view a laparoscopic approach to surgery as much more acceptable as a treatment option for operations such as cholecystectomy and antireflux surgery. This pattern continued with bariatric surgery. Multimedia and the Internet made the spread of information about laparoscopic gastric bypass much more rapid and prevalent. Laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery became one of the most commonly performed abdominal operations in this country by the year 2003. During that year, approximately 130,000 gastric bypass operations were performed in the United States; in 1998, the number was approximately 20,000. The rapid proliferation of the operation resulted in the need for training opportunities for surgeons interested in beginning their experience with the operation. The complications that could occur with an inexperienced surgeon performing the operation became problematic in some situations. The large number of procedures performed led to a variety of complications being reported in the surgical literature. Although these were often not well quantitated in terms of frequency, the author’s own significant institutional experience along with the literature will serve as the primary basis for judging such frequencies, in instances in which the literature is lacking.
The relative brief duration of performance of LRYGB in large volume may preclude a true estimation of the incidence of certain long-term complications, yet the operation itself, done as an open procedure, has a track record of over 40 years of careful scrutiny by the bariatric and surgical community.2 Unless directly related to the method of access, such long-term complications are as likely to occur after open as after laparoscopic RYGB. Therefore, an underestimation of their frequency is less likely. The literature already supports the fact that two considerable advantages to the laparoscopic over the open approach for RYGB are the significantly lower incidence of wound complications and the remarkably lower incidence of incisional hernias.3
INDICATIONS
• LRYGB is performed to achieve surgically induced weight loss for patients who are morbidly obese, as defined next:
• Individuals who have a body mass index (BMI = weight in kg/height in m2) of 40 or greater with no comorbid medical conditions associated with or caused by obesity or those with a BMI of 35 or greater with at least one such comorbidity.4
OPERATIVE PROCEDURE
Creation of a Pneumoperitoneum
Viscus Injury
• Consequence
If the injury was created with a Veress needle, it is often of a relatively minor nature. Tangential laceration may cause hemorrhage or perforation, leading to leakage, infection, and peritonitis. If the injury to the hollow viscus was created by a cutdown to insert a Hassan trocar, the degree of injury may often be more severe and the perforation or injury of greater size. Creation of the pneumoperitoneum with a directly inserted trocar using visualization through the trocar without pneumoperitoneum is advocated by some. This approach, should visceral injury occur, would almost certainly lead to a more severe degree of injury than that with the Veress needle, similar to the severity rarely seen with the Hassan approach. Failure to detect and repair any significant size injury often results in severe peritonitis and sepsis, frequently presenting after discharge. Delay in having the patient return for treatment often results in the patient representing in extremis, and mortality is not uncommon.
• Repair
Suture repair is indicated if hemorrhage or any appreciable perforation of a hollow viscus is evident. Solid organ injury with hemorrhage can usually be controlled with hemostatic energy sources. Extensive injury is reason for conversion to an open procedure to ensure adequate repair. Extensive injury may even require segmental intestinal resection.
• Prevention
Surgeons who routinely perform laparoscopic surgery should be well versed in the potential complications of the creation of a pneumoperitoneum. It is recommended that all surgeons have documented training and accreditation in the performance of basic laparoscopy through the completion of the Fundamentals of Laparoscopic Surgery (FLS) program currently offered by the Society of Gastrointestinal and Endoscopic Surgeons (SAGES).5 FLS instructs all trainees in the appropriate steps to minimize visceral injury during creation of the pneumoperitoneum. These steps include the elevation of the abdominal wall during Veres needle insertion. In the morbidly obese patient, this becomes problematic at the umbilical area. We recommend the use of a tracheostomy hook to elevate the fascia in the left subcostal midclavicular region, where underlying viscera are less common and less prone to injury. Use of this location for creation of the pneumoperitoneum in the morbidly obese patient is documented to be safe and effective.6 The Veress needle is then inserted through the elevated fascia. Use of a Hassan trocar is discouraged in the morbidly obese patient because of the large incision needed to reach the peritoneum with adequate visualization and, hence, the inability of that site to hold the pneumoperitoneum. Previous surgery in the left upper quadrant is an indication to insert the Veress needle in the right subcostal region, with care being taken to avoid liver injury. We do not favor the direct visualization technique because, in this author’s opinion, its best aspect is that it allows excellent visualization of the mucosa of the hollow organ being entered. It is contraindicated to use this approach in any area in which previous surgical scarring is likely.
Gas Embolism
• Consequence
Gas embolism, although rare, is a life-threatening complication of creation of a pneumoperitoneum. CO2 gas is uniformly used to create the pneumoperitoneum during LRYGB. The solubility of the gas at least allows the potential for patient recovery if the complication is immediately recognized and treated. Failure to do so results in anoxic brain injury, pulmonary or visceral ischemia, and potentially, death from cardiovascular collapse.
• Repair
The problem arises from insertion of the Veress needle into an intravascular space. The hemodynamic effects are similar to that seen with a massive pulmonary embolism. Sudden decrease in end-tidal CO2 with accompanying hypoxia and hypotension should alert the anesthesiologist and surgeon to this problem. Immediate action is needed. The Veress needle must be removed, the pneumoperitoneum decompressed, the patient turned to a right-side-up position, and a central venous catheter passed to aspirate as much of the CO2 that still occupies the superior aspect of the right atrium as possible.
• Prevention
Gas embolism occurs essentially exclusively with the Veress needle approach to pneumoperitoneum. Its incidence is very low, but attention to proper technique in terms of needle insertion, confirmation of the “hanging drop” saline test to ensure the needle is in a free space of low resistance, and not persisting with insufflation at elevated intra-abdominal pressures on the insufflation monitor will prevent this complication.7
Cardiac Arrhythmia
• Consequence
During insufflation of the pneumoperitoneum, a not-uncommon problem is sudden development of cardiac arrhythmias, usually of the supraventricular type. Bradycardia is the most frequent arrhythmia seen. These are believed to arise because of the sudden change in venous return coupled with the change in intra-abdominal pressure. If appropriately managed, these are usually of little consequence and resolve quickly. However, persistence can mean conversion to an open operation for the procedure, cancellation of the operation altogether if too persistent and hemodynamically consequential, and further treatment, including pharmacologic therapy, as appropriate for bradyarrhythmias.8
• Repair
The immediate measure that must be taken is cessation of insufflation of CO2 and full decompression of the pneumoperitoneum, which normally resolves the arrhythmia. Occasionally, a pharmacologic agent is additionally needed. If the patient is suspected to be hypovolemic, this should be corrected. Once cardiac rhythm and hemodynamic stability have been achieved, it is appropriate to cautiously and slowly reinsufflate the abdomen to establish the pneumoperitoneum. In most instances, this will not result in a return of the arrhythmia. Should the arrhythmia return, the laparoscopic approach must be abandoned and a decision made by the surgeon as to whether to proceed with conversion to an open operation. The latter is appropriate only if hemodynamic stability occurs with decompression once again of the pneumoperitoneum.
• Prevention
There is no guaranteed method of prevention of this complication. However, appropriate pharmacologic treatment of known existing cardiac arrhythmias preoperatively, adequate hydration and intravascular volume, excellent oxygenation, and inquiring about any previous arrhythmia history are all appropriate measures that will lessen the incidence of this complication.
Subcutaneous Emphysema
• Consequence
Subcutaneous emphysema, including preperitoneal emphysema, and organ emphysema such as insertion of gas into the tissue planes of the omentum, are all considered under this heading. The occurrence of subcutaneous emphysema may not manifest itself until later during a long laparoscopic operation. Insufflation of the preperitoneal space or of the omentum will be immediately apparent on initial laparoscopic exploration. These latter two problems become issues only if they prevent the ability of the surgical team to safely visualize the organs in the operative field. In this case, the operation may need to be converted to an open incision, delayed while the CO2 gas is absorbed, or cancelled. Rarely do further complications occur. In the case of subcutaneous emphysema, the increased CO2 load to the patient’s system can result in systemic acidosis. This may not be apparent simply from the measurement of end-tidal CO2 on the ventilator, which will be elevated as a result of the emphysema but may remain static although elevated. In patients with preexisting cardiopulmonary disease, inability to process the excess CO2 that is absorbed may lead to a systemic acidosis with resultant hemodynamic and metabolic complications.9
• Repair
Insufflation of CO2 into the preperitoneal space or the omentum will resolve with time. Placement of the trocar with the CO2 gas input securely within the peritoneal cavity will expedite the resolution of preperitoneal emphysema by exerting the pneumoperitoneum pressure on the peritoneal surface, which hastens gas absorption and decompression. Placement of an arterial line should be done if one is not in place and the procedure may be lengthy or if the patient has a history of preexisting cardiopulmonary disease. Serial arterial blood gases during the remainder of the operation are indicated to monitor systemic pH. Subcutaneous emphysema may occur because the port is only partially into the peritoneal cavity, causing direct insufflation of CO2 into the abdominal wall. Correction of the port position is indicated. If systemic pH drops, the operation may need to be completed using an open approach.
• Prevention
Organ and preperitoneal insufflation can best be prevented by attention to technique with Veress needle insertion and stopping insufflation if the pressure rises to high levels after an amount of insufflated gas is less than expected. Reinserting the needle from the first step is indicated in this situation. Subcutaneous emphysema is best prevented by visually confirming that the port in which CO2 is being insufflated has its end securely within the peritoneal cavity. Avoiding repositioning, removing, and reinserting trocars during the operation will lessen the incidence of this problem. The thin elderly patient, with loose subcutaneous tissue, is at particular risk for the development of subcutaneous emphysema. Correct port placement technique is particularly important in these patients, and they should be carefully monitored for signs of this problem. Arterial blood gas measurement is indicated if the condition develops and persists. Lengthy laparoscopic procedures on such patients should be undertaken only when absolutely necessary and with the understanding that subcutaneous emphysema may result in conversion to an open incision to complete the operation.
Organ Injury
• Consequence
Injury to an organ from trocar insertion after or before the creation of a pneumoperitoneum carries a significantly higher likelihood of severe injury to the organ than does penetration with a Veress needle. Repair is almost always indicated, and the need for conversion to an open procedure is more likely. Unrecognized injury to a hollow viscus with a trocar carries an almost certain likelihood of delayed leak and peritonitis.
• Prevention
Placement of trocars using a controlled twisting pressure, with care to avoid sudden rapid advancement of the trocar through the abdominal wall, is the best means of preventing this complication. Making an adequate skin incision such that the skin is not a source of resistance to the trocar insertion is important. Using a blunt-tip noncutting trocar will decrease but not prevent such injuries. Placing trocars only once an adequate pneumoperitoneum exists to serve as a counterresistance to the insertion pressure is also an important preventive and safety step. The initial trocar placement must by necessity be a blind maneuver, and this trocar has the overwhelming likelihood of creating such an injury. Inspection of the organs in the area of initial trocar insertion is always mandatory to confirm that its insertion caused no injury. Subsequent trocars must always be placed under direct laparoscopic vision.
Vascular Injury
• Consequence
The mechanism of vascular injuries is the same as that for hollow viscus injury: from the uncontrolled initial trocar insertion into the peritoneal cavity. Whenever such a situation occurs, the patient is in a life-threatening situation. This is further compounded if the surgeon fails to realize the presence of the vascular injury, allowing untreated hemorrhage to occur. This complication is fortunately rare.10 However, many of the deaths from simple diagnostic and therapeutic laparoscopic procedures have been a direct result of vascular injuries from trocar insertion with resultant hemorrhage, hypovolemic shock, and death.
• Repair
Vascular injury is treated with emergent control of the vascular injury. Direct pressure, followed by obtaining both proximal and distal control of the injured vessel, is indicated. This most often requires an emergent conversion to an open incision if a major vascular injury has occurred. Direct suture repair of the vascular injury is imperative as soon as such control is established. Ligation is an option if a smaller vessel is injured and ligation does not lead to untoward consequence. Visceral ischemia secondary to any vascular injury may necessitate partial or complete organ removal, as indicated. Major vascular injury is such a severe complication that accomplishing its repair is usually all the surgery that should be done at that setting, and of necessity, the original operation proposed should be postponed.
Abdominal Wall Vascular Injury/Hematoma
• Consequence
Insertion of a trocar through the epigastric vessels of the abdominal wall will result in potential uncontrolled arterial bleeding, at worst, or subsequent abdominal wall hematoma, at best. This complication may result in some morbidity to the patient if it is unrecognized or delayed, usually in the form of a painful and large hematoma. Intraoperative arterial bleeding is generally recognized and treated with the usual minor consequence. Failure to immediately recognize it does put the patient at risk for significant hemorrhage and hypovolemic shock.
• Repair
When the epigastric vessels have been lacerated and arterial bleeding is evident from around a trocar, control of the hemorrhage can usually be easily accomplished by passing two ligatures, at right angles to each other and through the trocar site, using a suture passer. Each ligature should pass through surrounding tissue of the trocar opening, encompassing a bite of subcutaneous tissue, muscle, and fascia. The suture passer is used to retrieve the end of the suture to form a U-shaped suture. Two such sutures of permanent material, passed at right angles to each other and tied over external bolsters, will normally control hemorrhage from the vascular injury of the abdominal wall. The more transverse of the two sutures must be placed to occlude the arterial inflow side of the injured vessel. Ligatures should be pulled up taught before tying to confirm that they will arrest the hemorrhage. The ligatures can be removed in 1 to 2 days, as can the bolsters.
Inappropriate Port Placement
• Consequence
This complication is mentioned only to confirm its minimal consequences. Placement of a trocar that subsequently proves to be in a poor location, or in a direction that is almost useless for performing the operation, should NOT be viewed as a major problem. A different, appropriately placed trocar should be inserted as a substitute. Far more danger arises from trying to persist in the performance of an operation in which the trocars limit surgical maneuvering, suturing, or visualization than does the minimal danger or morbidity of placing an additional trocar. The inexperienced surgeon is much more prone to persist in using a suboptimally placed trocar, to the potential detriment of the operation.
• Prevention
Experience with the performance of an operation and the insertion of trocars will prevent location misplacement and inappropriate direction misplacement of a trocar, respectively. Trocar placement by experienced surgeons, or having the senior surgeon present to indicate trocar location, is the best prevention. Understanding that an inappropriately placed trocar is NOT a major problem and that it should NOT necessitate struggling throughout the remainder of the operation just to complete it must be a principle taught to all fledgling laparoscopic surgeons.
Laparoscopic Survey and Assessment of the Abdominal Organs
Missed Abdominal Lesion
• Consequence
The initial survey of the abdominal organs done during LRYGB should constitute a careful assessment of the liver, intestine, and pelvic organs as appropriate. The most likely unexpected pathology will be ovarian tumors in women. These can present as large cysts, dermoid tumors, or even unexpected ovarian carcinoma. Uterine pathology, intestinal diverticula, gastrointestinal stromal tumors (GIST), and other lesions are also possible unexpected findings. The consequence of missing these lesions is the delay in appropriate treatment, including excision, which may be indicated, with the potential for allowing the existence of life-threatening pathology in the worst-case scenario.
• Prevention
The discipline to routinely look at the abdominal viscera, using a laparoscopic-guided approach, is the best prevention for missing such lesions. The liver is generally very obvious, and fatty infiltration or injury as severe as cirrhosis is usually unmistakable. However, the surgeon must take the time to look in the pelvis and, especially with women, confirm that there are no tumors of significant size that pose a potential threat to the patient’s life more severe than the obesity being addressed at surgery.
Fatty Liver with Cirrhosis
• Consequence
Morbidly obese patients are predisposed to development of fatty liver and, if long-standing, to nonalcoholic steatotic hepatitis (NASH). NASH is present when scarring has occurred as a result of the fatty liver infiltration. NASH may progress, in a small number of patients, to cirrhosis and liver failure. Patients with diabetes are at the highest risk.11 Determination of disease presence and severity can help with the prognosis. Severe fatty liver and hepatomegaly can prevent a laparoscopic approach to the operation and make an open approach exceedingly difficult. Cirrhosis is not in and of itself a contraindication to surgery, although this is controversial. Cirrhosis with accompanying portal hypertension is a contraindication to proceeding with LRYGB.
• Prevention
Prevention of fatty liver that can make the exposure of the stomach for RYGB difficult is done by two measures. First, patients should have a preoperative abdominal ultrasound to determine liver size and consistency and whether gallstones are present. Second, if the liver is fatty, the patient should be placed on a low-carbohydrate diet for at least 6 weeks. Because liver fat is derived from the storage of glycogen and triglyceride from carbohydrate metabolism, a low-carbohydrate diet will shrink the liver and remove much of its fat content. Although level-one evidence to this effect is lacking, numerous personal experiences by bariatric surgeons with individual cases using this strategy for successful performance of LRYGB after an initial aborted attempt have led the bariatric surgical community to generally accept this practice. However, it has been shown that visceral obesity was most strongly correlated with hepatomegaly and steatosis in women undergoing gastric banding.12 Hepatologists recommend that, for the patient diagnosed with NASH, ingestion of any substance that is potentially hepatotoxic should be avoided and weight loss should be undertaken.
Excessive Adhesions
• Consequence
Previous abdominal surgery may result in a large number of intra-abdominal adhesions, which are obvious after the initial trocar placement and peritoneoscopy. The surgeon must decide whether the adhesions preclude a safe and relatively feasible performance of laparoscopic RYGB or whether conversion to an open approach is indicated. This decision is one of individual judgment, based on the surgeon’s comfort with laparoscopic adhesiolysis. Severe adhesions may result in undetected organ injury during the adhesiolysis portion of the operation.
• Repair
Excessive adhesions may be dealt with using either a laparoscopic approach or converting to an open approach. The latter is faster for the adhesiolyis and must be entertained if the process will be excessively long laparoscopically. Otherwise, using progressively placed trocars in locations appropriate for LRYGB, the surgeon performs the necessary adhesiolysis to free up the upper abdominal organs and the omentum.
Hernia of the Abdominal Wall
• Consequence
Most hernias of the abdominal wall are readily apparent preoperatively by physical examination. Occasionally, owing to body wall thickness, unexpected small hernias may be encountered. They may require repair, which will lengthen the operative procedure. Failure to repair them could lead to incarceration of the small intestine in them postoperatively, Richter’s hernia. This causes a mechanical small bowel obstruction that, if untreated, can result in retrograde distention of the lower stomach and rupture of the staple lines with consequent peritonitis, sepsis, and potentially, death.
• Repair
Repair is recommended for all hernias large enough (roughly ≥1.5 cm) to potentially incarcerate bowel. Repair is best done using a piece of biologic mesh or small intestine submucosa for the repair. This material resists infection and functions well to patch the hernia. Principles of laparoscopic abdominal wall hernia repair are followed. For very large hernias, in which incarceration is most unlikely, repair is not indicated at the time of the initial LRYGB.
Enterolysis If Necessary to Free the Omentum and Clear the Left Upper Quadrant
Injury to the Abdominal Organs
• Consequence
Consequences of such an event are proportional to its recognition and correct repair. Should both occur, consequences, other than a prolongation of the operation, are minimal. Should the injury be severe, resection of a portion of the organ may be required. This leads to complications associated with such a procedure. The most severe consequence is an unrecognized injury of a hollow viscus. As discussed earlier in the section “Creation of a Pneumoperitoneum,” this situation usually results in a delay in diagnosis of a severe and life-threatening peritonitis.
Hemorrhage
• Consequence
Injury to a vascular solid organ, or to the mesentery or larger vessels in the abdomen during enterolysis may produce significant hemorrhage. This can be life-threatening.
• Repair
Standard measures to control hemorrhage are employed, including direct pressure, application of energy sources, and suture ligature. Outcomes are optimal if the injury is promptly recognized and appropriately treated using one of these methods. Conversion to an open incision may be necessary if laparoscopic means are not working. The need to always have a set of open abdominal instruments available for all LRYGB cases is emphasized by this potential complication.
Division of the Small Bowel and Creation of the Roux-en-Y Limb
Misidentification of the Proximal Jejunum for Division
• Consequence
Failure to recognize the proximal jejunum and to then begin the operation by dividing more distal bowel will result in an unnecessary bowel division subsequently requiring reanastomosis to repair the problem. The danger of an extraintestinal anastomosis that could leak, the increased operative time, and the location of a potential postoperative internal hernia are all consequences of this complication. Should the surgical team continue with the operation after division of the bowel considerably beyond the ligament of Treitz, a significant malabsorptive component to the operation will have been created that was not planned for or wished by the patient. Postoperative deficiency in iron and calcium will almost certainly occur and may be more refractory to correction with oral supplements. Steatorrhea, prolific diarrhea as is seen after duodenal switch operations, fat-soluble vitamin deficiency, and protein calorie malnutrition can all result if the length of the biliopancreatic limb is excessive and the length of small intestine beyond the enteroenterostomy is too short.
• Repair
Recognition of the error is the first and most important step. Then the surgeon must determine whether the excess length of the biliopancreatic limb will likely produce any of the untoward effects noted above. If so, reanastomosis of the divided bowel is needed and then repeat creation of the Roux-en-Y limb—this time at the appropriate distance from the ligament of Treitz.
• Prevention
Absolute confirmation of the ligament of Treitz is imperative to prevent this complication. Factors that predispose to it and must be avoided include a poor camera operator who fails to keep the operative field in constant vision, excessive scarring making identification more difficult, and massive obesity similarly making identification difficult. An inappropriately placed camera port can also predispose to this. Any time the surgeon is not clearly seeing the operation, the situation must be reassessed to correct the reasons. These may include placement of a more optimal trocar for the camera, finding a more expert camera operator, and better coordinating the team’s efforts to visualize the ligament of Treitz.
Tear/Injury in Handling the Small Bowel
• Consequence
The potential to tear the small bowel exists in many stages of the operation, but it is discussed here. If tear or injury is recognized, appropriate repair minimizes this complication to simply a few minutes of additional operating time. If unrecognized, it has the same potential as any visceral perforation to cause peritonitis, sepsis, and death.
• Repair
Repair must be preceded by recognition. Once the tear or injury is recognized, the injury is sutured laparoscopically to effect a good repair. If conversion to an open incision is necessary, it should be done. Rarely is such an injury severe enough to require bowel resection.
Repair of a late, unrecognized injury involves bowel resection, reanastomosis, placement of drains, thorough peritoneal lavage, and consideration of creation of an ostomy proximal to or at the injury site if the tissue quality is not appropriate for secure anastomosis. Such patients are usually extremely ill and require the highest level of intensive care expertise postoperatively.
• Prevention
The most important factor in preventing this injury is the use of good technique by the surgical team when handling the bowel. Bowel must be grasped with a large surface area of the grasper, handled gently, and not pulled excessively. Preoperative bowel preparation to decompress the bowel improves the lightness of the bowel and may help decrease this complication, although no data exist to prove that.
Ischemia of the Tip of the Small Bowel after Division
• Consequence
A mild degree of ischemia can occur after small bowel division. Resection of the ischemic end of the bowel is needed. This complication, prevalent enough to not actually be considered a major adverse event, occurs because often the bowel mesenteric vessels are not easily seen through the overlying adipose tissue. They are divided unevenly, dividing too close to one side of the divided bowel. That side will suffer ischemia of the tip of the bowel. If ischemia is recognized and resected, minimal consequence results. If ischemia is allowed to persist, it could lead to postoperative breakdown of the stapled end of the bowel with leakage of bowel contents, peritonitis, sepsis, and death.
• Repair
The problem is easily repaired by resecting back to viable and well-perfused intestine. This may at times mean several inches of bowel. The resected piece should be placed in a bag and removed immediately, unless it is so large as to require trocar site enlargement. Then, a notation of the presence of the bag must be made so it is not forgotten at the end of the operation. Reresection of the bowel is easily accomplished with the use of the linear stapler for both bowel and mesentery or with an energy source such as the harmonic scalpel for the mesentery division.
Hemorrhage of the Small Bowel Mesentery
• Consequence
Figure 19-1 shows division of the small bowel mesentery, maintaining hemostasis. If some bleeding occurred during mesenteric division, a not-uncommon event, the surgeon must remain calm and methodically address the bleeding point or points. Small bleeding areas of the divided mesentery will often be evident after stapled division of the mesentery. Treatment is usually accomplished with no morbidity. If the bleeding arises from vessels at the base of the mesentery, in which case the division of the mesentery was carried down further than needed, then major bleeding may result that can require more severe measures for control, transfusion, and may even rarely be life-threatening if the patient has poor hemodynamic reserves. Conversion to an open incision is usually needed in cases of severe hemorrhage.
• Repair
Small areas of mesenteric bleeding along the divided mesentery are easily treated with limited and local application of the harmonic scalpel for vessel coaptation and achievement of hemostasis. If the harmonic scalpel is used for mesenteric division, small vessels will not usually bleed. If the division of the mesentery is carried down inappropriately deep into the base of the mesentery, some mesenteric vessels in that area will not be adequately controlled with a single application of the harmonic scalpel or a stapler. In these cases, direct grasping of the mesenteric base to limit blood flow followed by application of the harmonic scalpel in several adjoining locations on the vessel or careful placement of clips or sutures will achieve hemostasis. It is rare for hemorrhage along the more superficial mesenteric edges to be severe enough to require conversion to an open incision. Major hemorrhage from deeper vessels will often require this measure.
• Prevention
Once the bowel is divided, we usually use the harmonic scalpel to divide the mesentery. However, the linear stapler with a white load or gray load will also suffice to achieve good hemostasis. Careful division of the mesentery to provide adequate Roux-en-Y limb mobilization but avoid dissection to the very base of the mesentery, where larger and more difficult to control vessels exist, is the key to preventing this complication (see Fig. 19-1).
Inadequate Length of Roux-en-Y Limb Mobilization
• Consequence
The Roux-en-Y limb will not reach the proximal gastric pouch, necessitating efforts to later further mobilize it, which are much more difficult after creation of the enteroenterostomy and closure of the mesenteric defect. This risks injuring the distal anastomosis. The Roux-en-Y limb may just barely reach the pouch, in which case tension on the anastomosis puts it at high risk for postoperative leak, resulting in peritonitis, sepsis, and death.
• Repair
The steps to correct this include further division of the mesentery at the base of the Roux-en-Y limb, with care being taken to maintain hemostasis but avoid ischemia to the Roux-en-Y limb. Alternatively, passage of the Roux-en-Y limb retrocolic (retrogastric if the original plan was for an antecolic passage) lessens the distance needed to reach the gastric pouch. If tension is suspected after anastomosis, suturing the Roux-en-Y limb just distal to the anastomosis to the undersurface of distal stomach can help alleviate some of the tension on the anastomosis, especially with patient positional changes postoperatively.
• Prevention
By experience, the surgeon can usually determine whether mobilization is adequate. We recommend approximately a 5-inch or longer division of the mesentery. Once division is accomplished, but before creating the enteroenterostomy, a quick check of the likelihood of the end of the Roux-en-Y limb to reach above the incisura of the stomach can be performed. If not, further division and mobilization is needed. For larger patients (BMI > 60), division of the jejunum at a point over 50 cm distal to the ligament of Treitz will provide greater mobility of the Roux-en-Y limb and should be strongly considered. It is always wise to prevent this complication rather than to have to deal with it later in the operation.
Misidentification of the Roux-en-Y Limb Versus the Biliopancreatic Limb
• Consequence
This occurs when the gastric pouch is made first, then the jejunum is divided and brought up to do the gastrojejunostomy first, prior to the enteroenterostomy.14 If the biliopancreatic limb is mistakenly identified as the Roux-en-Y limb and anastomosed to the proximal gastric pouch, the surgeon then realizes when going to create the enteroenterostomy, that this has occurred. Great unhappiness results in the operating room when it is realized the infamous Roux-en-O has been created. If the anastomosis is left this way, food would go from the proximal gastric pouch to the distal gastric pouch. The proximal anastomosis must be taken down and redone, and the biliopancreatic limb must have the anastomosis point resected. Not only is excessive time spent doing this, but the proximal anastomosis, being revised, is now much more prone to leak.
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