Laparoscopic Roux En-Y-Gastric Bypass: One Surgeon's Technique
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Transcript of Laparoscopic Roux En-Y-Gastric Bypass: One Surgeon's Technique
Laparoscopic Roux-en-YLaparoscopic Roux-en-YGastric Bypass:Gastric Bypass:
One Surgeon’s TechniqueOne Surgeon’s Technique
George S. Ferzli MD, FACSGeorge S. Ferzli MD, FACS
New York, NYNew York, NY
Dr. John Linner
1954
Jejuno-ileal bypass
THE BEGINNING
COMPLICATIONS OF COMPLICATIONS OF JEJUNOILEAL BYPASSJEJUNOILEAL BYPASS
Electrolyte disturbancesElectrolyte disturbances Osteoporosis/osteomalaciaOsteoporosis/osteomalacia Protein malnutritionProtein malnutrition CholelithiasisCholelithiasis DiarrheaDiarrhea Hair lossHair loss
ArthritisArthritis Liver failureLiver failure SteatosisSteatosis Renal calculiRenal calculi NeuropathyNeuropathy AnemiaAnemia
Dr. Edward Mason
University of Iowa
1967 Gastric Bypass with
loop gastroenterostomy
GASTRIC BYPASS WITHROUX-en-Y LIMB
Roux-en-Y Gastric Bypass
50 mL POUCH WITH A ROUXLIMB TO MINIMIZE BILEREFLUX
COMBINED RESTRICTIVEAND MALABSORPTIVE
GASTRIC BYPASS WITHROUX-en-Y LIMB
Roux-en-Y Gastric Bypass
SUBSEQUENTLY MODIFIED
50 mL POUCH WITH A ROUXLIMB TO MINIMIZE BILEREFLUX
ROUX LIMB WAS LENGTHENEDTO INCREASE MALABSORPTIONAND IMPROVE WEIGHT LOSS
COMBINED RESTRICTIVEAND MALABSORPTIVE
ROUX-en-Y GASTRIC ROUX-en-Y GASTRIC BYPASSBYPASS
GOAL: To restrict theGOAL: To restrict the
gastric reservoirgastric reservoir
ADVANTAGESADVANTAGES Controls food intakeControls food intake Dumping reduces intake Dumping reduces intake
of sweetsof sweets Reversible if indicatedReversible if indicated
Roux-en-Y Gastric Bypass
Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Operative OptionsOperative Options
Retro-colic/Retro-gastric gastrojejunostomyRetro-colic/Retro-gastric gastrojejunostomy Ante-colic/Ante-gastric gastrojejunostomyAnte-colic/Ante-gastric gastrojejunostomy Stapled gastrojejunostomyStapled gastrojejunostomy Hand-sewn gastrojejunostomyHand-sewn gastrojejunostomy
Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Our TechniqueOur Technique
Identify LOTIdentify LOT Divide jejunumDivide jejunum Measure Roux limbMeasure Roux limb Complete jejuno-jejunostomy, close Complete jejuno-jejunostomy, close
mesenterymesentery Create gastric pouchCreate gastric pouch Ante-colic/Ante-gastric gastrojejunostomyAnte-colic/Ante-gastric gastrojejunostomy Leak testLeak test
Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Port PositioningPort Positioning
Approximate position Approximate position for ports marked with for ports marked with abdomen insufflatedabdomen insufflated
Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Identify LOTIdentify LOT
Retract Retract omentum and omentum and transverse colon transverse colon cephaladcephalad
LOT exposedLOT exposed
Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Distance to Jejunal divisionDistance to Jejunal division
Approx. 50-60cm Approx. 50-60cm from LOTfrom LOT
Assure that this Assure that this
reaches liver edgereaches liver edge
Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Jejunal DivisionJejunal Division
Mark proximal Mark proximal jejunumjejunum
Minimal division of Minimal division of mesenterymesentery
Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Distance to jejuno-jejunostomyDistance to jejuno-jejunostomy
Approx 100-110cmApprox 100-110cm
Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Stapled jejuno-jejunostomyStapled jejuno-jejunostomy
Creates large common Creates large common channelchannel
Roux-en-Y Gastric Bypass: Roux-en-Y Gastric Bypass: Jejuno-jejunostomy stitchJejuno-jejunostomy stitch
Hand-sewn single-Hand-sewn single-layer anastamosislayer anastamosis
Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Finished jejuno-jejunostomyFinished jejuno-jejunostomy
Final view of jejuno-Final view of jejuno-jejunostomyjejunostomy
Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Closure of mesenteryClosure of mesentery
Interrupted peritoneal Interrupted peritoneal sutures sutures
Prevents internal Prevents internal herniahernia
Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:First Gastric divisionFirst Gastric division
Along lesser curve, at Along lesser curve, at first gastric veinfirst gastric vein
May use ultrasonic May use ultrasonic device/cauterydevice/cautery
Assure entry by Assure entry by visualizing posterior visualizing posterior wallwall
Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Creation of gastric pouchCreation of gastric pouch
Calibration tube in Calibration tube in placeplace
Target is angle of HisTarget is angle of His
Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Final gastric divisionFinal gastric division
Full division to angle Full division to angle of Hisof His
Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:First G-J stitchFirst G-J stitch
Find Roux limbFind Roux limb Proper orientation of Proper orientation of
Roux limbRoux limb Begin with posterior Begin with posterior
layerlayer
Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Posterior sutures completedPosterior sutures completed
Sufficient sutures to Sufficient sutures to allow for proper allow for proper anastamosisanastamosis
Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Creating enterotomiesCreating enterotomies
Approx 1cm Approx 1cm anastamosisanastamosis
Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Anterior G-J sutureAnterior G-J suture
Begin with lateral Begin with lateral cornercorner
Sero-muscular stitchesSero-muscular stitches
Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Last anterior G-J sutureLast anterior G-J suture
Anterior row of Anterior row of stitching completed stitching completed
Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Final view G-JFinal view G-J
Methylene blue has Methylene blue has been injectedbeen injected
Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Leak TestingLeak Testing
Occlude Roux limb Occlude Roux limb during dye and air during dye and air insufflation under insufflation under fluidfluid
Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:SummarySummary
Jejuno-jejunostomy created Jejuno-jejunostomy created – Correctly identify LOT, proximal and distal Correctly identify LOT, proximal and distal
limbslimbs– Minimal division of mesenteryMinimal division of mesentery
Gastric pouch createdGastric pouch created– Assure appropriate pouch sizeAssure appropriate pouch size– Use calibrating tube if necessaryUse calibrating tube if necessary
Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:SummarySummary
Ante-Colic/Ante-Gastric gastro-Ante-Colic/Ante-Gastric gastro-jejunostomyjejunostomy– Properly orient Roux limb, with minimal Properly orient Roux limb, with minimal
tensiontension– Split omentum if necessarySplit omentum if necessary
Stapling device used primarily for divisionsStapling device used primarily for divisions– Hand-sewn anastamosis whenever possibleHand-sewn anastamosis whenever possible
Always perform leak testAlways perform leak test– Best opportunity to fix/reinforce anastamosisBest opportunity to fix/reinforce anastamosis