with Dr. Salvadora Delgado, Dr. Antonio M. Lacy
Bariatric surgery is indicated for patients with a body mass index greater than or equal to 40 kg/m2 or with a BMI greater than or equal to 35 kg/m2 if one additional major comorbidity is present. A major comorbidity could include type 2 diabetes, obstructive sleep apnea, or hypertension. Since this statement was released, the profound effect of gastric bypass on metabolic disease, particularly type 2 diabetes, has been thoroughly documented
A 42-year-old female patient with a previous history of HBP, type 2 DM, DLP suffered from morbid obesity with a BMI of 48 Kg/m2 and weighed 116 Kg. She was operated on for a Cholecystectomy and Appendectomy.
We decided to perform a Roux-en-Y gastric bypass.
The surgical procedure was carried out through a laparoscopic approach. The patient was placed in the supine position with open legs. The surgeon stood between the legs with one assistant on each side of the patient.
A total of 6 trocars were used. A 12 mm trocar was placed in a supraumbilical position for a 30° scope, three 12 mm served as working channels for the leading surgeon at the epigastrium and on each flank, and the 5 mm trocar was placed in a more lateral position at the left flank. The last one of 12mm was placed at the umbilicus and is used at the infraumbilical phase of the surgery.
The patient was transferred to a steep reverse Trendelenburg position to facilitate exposure of the upper abdomen. The upper stomach was exposed by retracting the liver anteriorly with flexible liver retractor. Later we located the angle of His and proceeds to its dissection using the hook.
By means of the dissection, a window was created in the “bare area” of the gastrohepatic ligament immediately anterior to the caudate lobe of the liver. We use the second blood vessel of the lesser curvature as reference.
After that, we use the goldfinger to reach the area of the angle of His. The opening in the gastrohepatic ligament provides quick and direct access to the lesser sac behind the stomach.
The Endo-GIA stapler with 60-mm blue loads was then applied two to three times across the gastric cardia toward the angle of His to create a gastric pouch of approximately 30-40 mL. A reticulating staple cartridge is sometimes helpful here, especially when it is difficult to reach the angle of His. The staple lines on both sides of the transected stomach are examined to ensure that they are intact and not bleeding.
Then the nasogastric tube with the head of the circular stapling device and output through the gastric pouch was placed after opening the pouch. A snuff bag is created around the head of the device to secure it.
The omentum is divided by means of hook dissection from the transverse mesocolon to its inferior edge. Dividing the omentum reduces tension in the Roux-limb as it passes in front of the colon up to the gastric pouch.About 35-40 cm of the jejunum were measured from the ligament of Treitz. The jejunum was positioned in a C configuration to facilitate placement of the Endo-GIA stapler for division. The Endo-GIA stapler was placed through the right upper abdominal 12-mm port and applied perpendicular to the jejunum and parallel to the mesenteric vascular arcade to create the biliopancreatic limb and Roux-limb. The white cartridge was used to minimize staple line bleeding.
Then the gastrojejunostomy was performed. We proceeded to open the jejunum and introduce the CEEA device, enlarging the left upper quadrant hole for the 12mm trocar.
Finally we performed a TL mechanical gastrojejunostomy with a 25mm EEA Premium. Then we proceeded to extract the CEEA machine with the protective bag to avoid contamination of the surgical wound. We closed the jejunum with a white cartridge EndoGIA and we proceeded to extract the jejunal stump extraction using an endobag. Then the anastomosis was reinforced by means of two fixing points to release tension.
The next step was to measure the bowel to locate the place to perform the anastomosis. 180 cm of the he Roux-limb were distally measured.
An end-side jejuno-jejunostomy was performed. By means of hook dissection, enterotomies were performed at the biliopancreatic corner and antimesenteric border of the Roux-limb. The Endo-GIA stapler with the 60mm white load was inserted through each enterotomy and applied to create the end-side anastomosis.
The surgery was completed by closing the mesenteric defect with a running suture. An internal hernia resulting in a bowel obstruction may develop if the defect is left unclosed. We recommend a permanent suture to minimize reopening of the defect.
The surgery took 91 minutes. The patient started oral intake 24 hours after the surgery and left the hospital on the 3rd postoperative day. The patient currently has a successful outcome. HBP and type 2 DM were solved and she currently needs no medication today. Now she weighs 79 kgs with a BMI of 34 Kg/m2.
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