Laparoscopic Antecolic-antegastric Roux-en-Y Gastro-jejunal Anastomosis using a Combined Linear Stapler and Hand-sewn Technique

Surgical Pearls: Techniques in Bariatric Surgery

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

This Month’s Technique: Laparoscopic Antecolic-antegastric Roux-en-Y Gastro-jejunal Anastomosis using a Combined Linear Stapler and Hand-sewn Technique
This Month’s Featured Experts:

Raul J. Rosenthal, MD, FACS, FASMBS
Professor of Surgery and Chairman, Section of Minimally Invasive Surgery and The Bariatric and Metabolic Institute; Director, General Surgery Residency Program; Director, Fellowship in Minimally Invasiveband Bariatric Surgery, Cleveland Clinic, Weston, Florida

Samuel Szomstein, MD, FACS, FASMBS
Associate Director of the Bariatric Institute and Section of Minimally Invasive Surgery, Cleveland Clinic, Weston, Florida, and Clinical Associate Professor of Surgery, Florida International University

Abraham Fridman, DO
Bariatric Fellow, Cleveland Clinic, Weston, Florida

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

Disclosures: Dr. Rosenthal is a speaker, consultant, and advisory board member for Ethicon Endo-Surgery, Cincinnati, Ohio. Drs. Szomstein and Fridman report no conflicts of interest relevant to the content of this manuscript.

Bariatric Times. 2012;9(1):8–9

Introduction
Laparoscopic gastric bypass for morbid obesity is a complex surgical procedure that entails several steps, including the creation of a gastro-jejunal anastomosis. This is the only anastomosis in surgery that we try to perform as small as possible in order to create restriction and avoid dumping syndrome. Since its conception by Dr. Edward E. Mason, multiple variations of this step have been proposed. In previous publications of this section, Drs. Alan Wittgrove and Kelvin Higa presented the technical pitfalls of a gastro-jejunal anastomosis performed using a circular stapler or complete handsewn technique. In this issue of “Surgical Pearls,” we describe a laparoscopic approach using a combined linear stapler and handsewn technique.

STEP 1. PATIENT POSITION AND TROCAR PLACEMENT
The patient is placed in a supine position, and using a 12mm trocar (Ethicon Endo-Surgery, Cincinnati, Ohio), the abdominal cavity is accessed via an incision above and slightly to the left of the umbilicus. Figure 1 shows a diagram for trocar placement for this procedure. Pneumoperitoneum to 15mmHg is obtained and a 5mm trocar (Trocar 1) is inserted in the subxiphoid position for the liver retractor. We routinely use a fan liver retractor for optimal visualization of the hiatus. Next, a 12mm trocar (Trocar 2) is inserted 2 to 3 finger breadths below the right costal margin in the midclavicular line. Another 12mm (Trocar 3) trocar is inserted half way between Trocar 1 and Trocar 2 just left of midline and a 12mm trocar is inserted one hand width to the left of Trocar 4. After this, a 5mm trocar is placed lateral to Trocar 5, and a 12mm trocar is placed along a line intersecting Trocar 3 and Trocar 1 on the right side.

STEP 2. CREATION OF A GASTRIC POUCH
The first step in creating a gastric pouch is the identification and dissection of the left crus of the diaphragm (Figure 2). This maneuver will help the surgeon identify a hiatal hernia as well as the limit between the gastroesophageal junction and gastric fundus. Next, the lesser sac is accessed along the lesser curvature side of the stomach between the first and second short gastric vessel distal to the gastro-esophageal junction (Figure 3 and Figure 4). It is important to divide the stomach below the entrance of the left gastric artery in order to maintain ideal blood supply to the pouch and the anastomosis. Once the lesser sac has been cleared from adhesions to the pancreas and the retro-gastric structures and with the aid of a 45mm linear stapler, a 30 to 50cc gastric pouch is created over a 32 French diameter Ewald tube (Figure 5).

STEP 3. CREATION OF THE ROUX LIMB
The major omentum and transverse meso-colon are lifted and the ligament of Treitz is identified. Approximately 50cm distal to the ligament of Treitz the small bowel is transected using a white cartridge linear stapler. The distal limb of the small bowel is brought into the upper abdomen in an antecolic-antegastric fashion making sure that there is no tension along the mesenteric border. Only if considered necessary, we choose to perform an omental split followed by mesenteric vessel division in order to decrease mesenteric tension of the Roux limb.

STEP 4. CREATION OF THE POSTERIOR WALL OF THE GASTRO-JEJUNOSTOMY USING A LINEAR STAPLER.
Using an ultrasonic energy instrument, an enterotomy is performed at a middle point between the mesenteric and antimesenteric edges of the jejunum approximately 5cm distal to the free end of the Roux limb (Figure 6). This will allow the surgeon to advance the anvil into the alimentary limb comfortably, avoiding a perforation of the distal end of the bowel and preventing a large blind end. With the aid of the ultrasonic energy instrument, a gastrotomy is created over the Ewald tube along the inferior or superior border of the gastric pouch (Figure 7), anterior or posterior to the staple line as it becomes more convenient. Maintaining the Ewald tube in place to better intubate the pouch, a 45mm blue load gastrointestinal anastomosis (GIA) linear stapler is used to create the posterior wall of the gastrojejunostomy (Figure 8). Attention must be paid not to include the tip of the Ewald tube on the stapler line. In addition, we do not use the full load of the linear cartridge in an attempt to fashion an anastomosis that is not larger than 2.5cm in diameter.

STEP 5. CREATION OF THE ANTERIOR WALL OF THE GASTRO-JEJUNOSTOMY USING A HAND-SEWN TECHNIQUE
The anterior common opening of the gastro-jejunal anastomosis is suture closed using a two-layer continuous 3.0 vicryl suture in a longitudinal fashion. An Ewald tube is advanced to assure adequate size of the anastomosis and to prevent suturing of the posterior wall. The anastomosis is then tested using air and methylene blue (Figure 9 and Figure 10).

DISCUSSION
At the Cleveland Clinic Florida Bariatric Institute, 2,817 primary laparoscopic gastric bypasses have been performed since 1999. We report a 5.2-percent stricture rate, and a 0.4-percent leak rate using the above mentioned technique. Our complication rates are comparable to what is reported in the literature.

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