Totally Stapled Jejuno-jejunostomy

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

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

This Month’s Technique: Totally Stapled Jejuno-jejunostomy

This Month’s Featured Experts: Emanuele Lo Menzo, MD, PhD, FACS, FASMBS,
Staff Surgeon, The Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic Florida, Weston, Florida; Associate Professor of Surgery, Florida International University, Miami, Florida, and Abraham Betancourt, MD, MIS/Bariatric Clinical Research Fellow, Bariatric and Metabolic Institute and Section of Minimally Invasive Surgery Dept. of General and Vascular Surgery, Cleveland Clinic Florida, Weston, Florida

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

Disclosures: The authors report no conflicts of interest relevant to the content of this article.

Bariatric Times. 2013;10(4):10–11.

Introduction
Although the jejunojejunostomy is a less technically demanding anastomosis compared to the gastrojejunostomy, its complications can lead to disastrous consequences. In fact, obstruction at this level can cause disruption of a recent gastrojejunostomy and gastric remnant perforation.[1]

The jejunojejunostomy is the third most common site of postoperative leaks (5% of the cases) following the gastrojejunostomy and the gastric pouch.[2]

Several techniques of construction of the jejunojejunostomy have been described, including the triple-stapled technique, the bi-directional stapling technique, the mix stapled and handsewn, and the completely handsewn. Each technique has potential disadvantages, and the technique performed is typically the personal preference of the surgeon.

Here, we describe the technique we use at the Bariatric and Metabolic Institute of the Cleveland Clinic Florida, Weston, Florida.

Surgical Technique
Step 1: Preparation of the jejunum. This step commences earlier in the procedure when the jejunum is first divided. After making the mesenteric window with the energy device, the jejunum is divided using a 45mm linear stapler with a 2.5mm staple height (vascular). It is important to make sure that the staple line is oriented in the same direction of the mesentery and not perpendicular to it (Figure 1 and Figure 2). The mesentery is not divided.

Step 2: Creation of enterotomies. With the assistant retracting the loop of jejunum upward and toward the left upper quadrant, the surgeon stretches the jejunum by pulling down and toward the right lower quadrant. Using the open jaw of the energy device, the surgeon applies steady pressure on the anti-mesenteric border while activating the high-speed button (Figure 3). Care must be taken not to apply too much pressure to avoid invagination of the anterior wall of the jejunum, as this can cause a burn or enterotomy of the back wall. The enterotomy on the biliopancreatic limb side should be as close to the staple line as possible (Figure 4). Once the initial enterotomy is done, the jejunal wall is opened for a distance of approximately one-third of the length of the energy device tip.

Step 3. Side-to-side stapling. Maintaining a similar traction and counter traction, as described previously, the cartridge side of the 45mm linear stapler (with the 2.5mm vascular load) is inserted in the Roux limb side of the jejunum. The traction is then applied to the biliopancreatic limb and the anvil side of the stapler is inserted. It is important to advance the stapler along the axis of the jejunum to avoid perforations with the tip of the stapler. Care must be taken to assure that the stapler is on the anti-mesenteric border of the bowel (Figure 5). The stapler is fired, partially opened, in order to avoid stretching of the enterotomies, and removed. A second firing of the 45mm stapler is done in a similar fashion. Care must be taken to assure that the jaws of the second stapler are on either sides of the jejunum. The staple line is inspected for bleeding.

Step 4: Closure of the common enterotomy. A 2-0 suture is placed at the anti-mesenteric proximal corner of the staple line and tied in order to assure inclusion of this corner in the staple line (Figure 6). Using this suture for retraction, two additional firings of the 45mm linear stapler with the 2.5mm vascular load are used to close the common enterotomy (Figure 7). Care must be taken to make sure that serosa is present on both sides of the stapler (Figure 8). It is paramount to avoid narrowing of the Roux limb corner of the anastomosis. If bleeding from the staple line is present, additional sutures or clips can be utilized (Figure 9). Clips are also helpful for radiographic identification of the anastomosis.

References
1.    Lee S, Carmody B, Wolfe L, et al. Effect of location and speed of diagnosis on anastomotic leak outcomes in 3828 gastric bypass cases. J Gastrointest Surg. 2007;11(6):708–713.
2.    Gonzalez R, Nelson LG, Gallagher SF, Murr MM. Anastomotic leaks after laparoscopic gastric bypass. Obes Surg. 2004;14(10):1299–1307.

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