Laparoscopic Bi-Directional Jejuno-Jejunostomy Anastomosis With a Linear Stapler

This column recruits expert surgeons to share step-by-step technical pearls on bariatric procedures.

June 2012

Column Editors: Raul J. Rosenthal, MD, FACS, FASMBS, and Daniel B. Jones, MD, MS, FACS

This month’s technique: Laparoscopic Bi-Directional Jejuno-Jejunostomy Anastomosis With a Linear Stapler

This Month’s Featured Expert:

Scott A. Shikora, MD, FACS, FASMBS
Director, Center for Metabolic Health and Bariatric Surgery, Brigham and Women’s Hospital, Boston, Massachusetts

Bariatric Times. 2012;9(6):8–9

Introduction
The first laparoscopic Roux-en-Y gastric bypass (RYGB) was performed in the mid 1990s by Drs. Wittgrove and Clark. Thanks to advances in equipment and surgeon experience, the procedure has evolved from extremely technically challenging to “relatively” routine. Several hundred thousand RYGBs have been subsequently performed. Yet, despite the vast experience over the past 15 plus years, the procedure remains highly variable in design. There is currently no consensus for limb length, limb orientation (retrocolic/retrogastric, retrocolic/antegastric, antecolic/retrogastric, or antecolic/antegastric), or gastrojejunostomy technique (circular stapled, linear stapled, handsewn, or a handsewn/linear stapled hybrid). The lack of consensus is likely due to the lack of data supporting one technique over another and surgeon’s preference.

Proper construction of the jejuno-jejunostomy is an important aspect of a successful RYGB. If improperly constructed, it may result in life-threatening leaks or intestinal obstruction. Consistment with other aspects of the gastric bypass, there is variation in the construction of the jejuno-jejunostomy. The technique described in this column has shown itself to be safe with few leaks and obstructions. It was designed to reduce the likelihood of obstruction secondary to narrowing of the lumen by the closure of the common enterotomy. The procedure includes proximal and distal stapling to create a 9 to 10cm long anastomosis with a transverse closure of the remaining enterotomy (similar to the Heineke-Mikulicz pyloroplasty). This technique for constructing the jejuno-jejunostomy can be used with any limb orientation or gastrojejunostomy preference.

STEP 1. PATIENT PLACEMENT
The patient is placed in the supine position. Most of the laparoscopic gastric bypass is performed with the operating room table elevated in a reverse Trendelenberg incline. The 12mm optical trocar is inserted in the midline of the abdomen two hand breaths below the xyphoid process. A pneumoperitoneum to 18 mmHg is obtained and then a 45-degree angled laparoscope is inserted. The additional ports include two 5mm trocars placed just below the costal margin in the midclavicular lines bilaterally. Two 12mm ports are placed bilaterally in the anterior axillary lines midway between the umbilicus and the xyphoid process. On the patient’s left side, a balloon port is used so that the port can be removed, and the fascial defect dilated to accept a circular stapler, which will be used for the gastrojejunostomy. An additional 5mm trocar stab wound is created just below the xyphoid process to be used for the Nathanson liver retractor (Cook Medical Inc., Bloomington, Indiana).

STEP 2. DIVIDING THE JEJUNUM
The omentum and transverse mesocolon are lifted in a cephalad and anterior fashion to expose the ligament of Treitz (Figure 1). The jejunum is then run distally for approximately 20cm. It is then divided with the linear cutting stapler using a white load (Figure 2). For the retrocolic approach, only a small area of the mesentery need be divided. A window is then made bluntly through an avascular plane in the mesocolon and a penrose drain is placed into this space with one end positioned into the lesser sac. The other end is sutured to the stump of the Roux limb (Figure 3). This maneuver has two purposes. First, it prevents confusing the two limbs and creating a Roux-en-O. Second, it assists in placing the proximal Roux limb into the lesser sac.

STEP 3. CREATION OF THE JEJUNO-JEJUNOSTOMY—BIDIRECTIONAL STAPLING
The Roux limb is run distally for the preselected length; in this case, 100cm. At that point, the Roux limb is brought alongside the distal stapled end of the biliopancreatic limb (BP [Figure 4]). Care should be taken to run the bowel carefully and to avoid twisting it. No suture is necessary to hold the limbs together and it may be easier to create the anastomosis by simply holding the limbs with graspers. Without the suture, the limbs can be more easily manipulated onto the stapler. A small enterotomy is then created on the antimesenteric surface of both limbs (Figure 5). On the BP limb, the entertomy is placed approximately 5cm proximal to the stapled stump instead of at the stump. The linear cutting stapler with a 60mm white load is then inserted into the abdomen via the 12mm trocar on the patient’s right side. The two jaws of the stapler are carefully inserted into each limb (Figure 6). It is oriented so to run distally into the roux limb and proximally into to the BP limb. The entire lengths of both stapler jaws are inserted. Then, from the 12mm balloon port on the patient’s left side, the stapler is reinserted. This time it has a 45mm white cartridge. The jaws are inserted into the common enterotomy and carefully positioned so that one jaw of the stapler is passed down each limb of bowel (Figure 7). In this step, the stapler is oriented proximally into the roux limb and distally into the BP limb (towards the stapled stump).

STEP 4. CREATION OF THE JEJUNO-JEJUNOSTOMY—TRANSVERSE CLOSURE OF THE COMMON ENTEROTOMY
After the firing of the 45mm white cartridge, the stapler is carefully withdrawn from the common enterotomy to avoid dilating it. The lateral corners of the common enterotomy are grasped from the patient’s left side with allis graspers (Figure 8). The enterotomy is then carefully lifted up and turned so that the transversely oriented enterotomy is now positioned transversely. The linear cutting stapler with a 60mm white cartridge is then advanced back into the abdomen through the 12mm trocar on the patient’s right side. It is then passed just below the allis graspers (Figure 9). Great attention should be paid to the prior positioning of the stapler for this maneuver.  The goal is to insure that the stapling will remove as little tissue as possible yet still be full thickness. After firing the stapler, the excised tissue is removed from the abdomen and inspected on the back table. Serosa must be seen on all sides of the staple line on the specimen. If an area appears to not contain serosa, the corresponding are on the staple line of the anastomosis is oversewn.

STEP 5. CREATION OF THE JEJUNO-JEJUNOSTOMY—FINAL POINTS
The anastomosis is then carefully inspected (Figure 10). The transverse staple line is scrutinized for completeness. The staples should appear in ordered rows and properly closed. Any bleeding points on the staple line can be carefully cauterized, clipped, or sutured. The anastomosis should not appear narrowed but instead widened at this point. The limbs are then also inspected. There should be no kinking or narrowing over the full extent of the anastomosis. After the anastomosis is deemed intact and correct, the mesenteric defect is closed. We prefer to close it from the base of the mesentery up to the bowel. We use a 2.0 silk running suture. The last bite of the closure is on the two limbs of the bowel and also functions as the antiobstruction stitch.

DISCUSSION
Presently, there are many successful variations to the design of the laparoscopic RYGB. This description of a bi-directional stapling to construct the jejuno-jejunostomy is one of several options for this anastomosis. However, in our experience with over 2,000 surgeries, it is a safe and successful technique designed to reduce obstructions.

Funding: There was no funding for the preparation of this manuscript.

Disclosures: Dr. Shikora reports no conflicts of interest relevant to the content of this article.

Category: Past Articles, Surgical Pearls: Techniques in Bariatric Surgery