Surgical Pearls: Techniques in Bariatric Surgery
Surgical Pearls: Techniques in Bariatric Surgery
Column Editors: Raul J. Rosenthal, MD, FACS, FASMBS, and Daniel Jones, MD, MS, FACS
This column recruits expert surgeons to share step-by-step technical pearls on bariatric procedures
This month’s technique: How to Perform a Hand-sewn Gastrojejunostomy
by Kelvin Higa, MD, FACS, Clinical Professor of Surgery, University of California, San Francisco, Fresno, California, and Director, Minimally Invasive and Bariatric Surgery, Fresno Heart and Surgical Hospital, Fresno, California
Bariatric Times. 2011;8(6):8–9How to Perform a Hand-sewn Gastrojejunostomy
The gastrojejunal anastomosis was a subject of considerable debate during the development of the laparoscopic gastric bypass. The complications of failure (leakage), stenosis, bleeding, and ulceration are seen in all techniques, whether stapled (circular or linear) or hand sewn. Comparative studies are few and the superior technique remains surgeon’s choice.
The development of the laparoscopic technique used by my colleagues and I emulated our open operation that utilized a two-layer hand-sewn gastrojejunal anastomosis. As we observed a zero-leak rate and respectable five-percent stenosis in our open series, it seemed justified to expect the same results from the laparoscopic procedure. Suture-assist devices were just beginning to be commercially available and they lacked precision afforded by gastrointestinal (GI)-specific needles and thread.
Manual suturing is technically challenging and requires triangulation of the objective with the optical perspective bifurcating the operative trocars. The trocar placement for hiatal hernia, anti-reflux procedures seemed a logical model for our procedure in deference to other popular techniques specific to the gastric bypass proposed at the time. The principles of the technique are as follows:
1. Triangulation
2. Suturing distal to proximal
3. Two-layer closure with 3-0 absorbable suture
4. Calibrated anastomosis
The first layer incorporates the suture line and is performed with the bowel closed. This facilitates better visualization and, therefore, precision. The second suture approximates the posterior mucosa and serosa once the enterotomy is performed; thus the two posterior suture lines are completed before the anterior closure. The anterior closure is performed similarly, working distally to proximally as this avoids confusion and simplifies the operative field. The first anterior suture is tied to the inner posterior suture line, therefore, each layer, although discontinuous, is preserved. The last suture line is tied to the first, completing the anastomosis.
For revision procedures, or where the tissue is edematous or fragile, I prefer a single-layer, full-thickness, interrupted anastomosis. There is no science behind this, it just appears that there is less tissue trauma with an interrupted anastomosis.
The anastomosis is performed over a calibrated bougie (my colleagues and I use a 34 Fr.) and can be tested, as the surgeon preference, by instillation of air or dye.
The advantages of this technique are primarily cost and efficiency. Secondary advantages include assimilating additional skills necessary to take care of complications, such as mechanical stapler failures or leaks, suture ligating a vessel, or performing other complex laparoscopic procedures.
Manual suturing skill is mandatory of all open general surgeons; why should it be any different for the laparoscopic surgeon performing advanced procedures?
Category: Past Articles, Surgical Pearls: Techniques in Bariatric Surgery
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