Tips and Tricks for OAGB/MGB procedure
OAGB is routinely performed with a five- or six-port laparoscopic technique. Patient is placed in the reverse Trendelenburg position. At the beginning of the operation, the surgeon stands between the patient’s legs in order to prepare the phrenogastric ligament then, in some cases, moves to the right side of the patient. The fashioning of a long gastric pouch is mandatory to avoid the problem of bile esophagitis that occurs with the original Mason’s loop gastric bypass. The pouch should be constructed by applying one horizontal 45-mm roticulator linear stapler at the angle of the lesser curvature, just above the left branch of the crow’s foot. The pouch should be calibrated along a 32- to 36-Fr and it must never be shorter than 12–14 cm. No reinforcement is routinely applied on the staple line. The ligament of Treitz is then identified and the jejunum is measured with a graded grasper up to 180–250 cm. Rutledge first proposed to tailor the limb length on the patient: in the super obese, it would be about 250 cm, in the elderly or vegetarians 180–200 cm and in type II diabetics without major obesity about 150 cm. The gastrojejunostomy is performed using a posterior 45-mm Roticulator linear stapler and an anterior running suture with an adsorbable suture. The original Rutledge technique implied an end-to-side anastomosis, but Carbajo and Caballero variation of the OAGB provided a latero-lateral anastomosis in order to prevent gastroesophageal bile reflux. The anastomosis is created with a size of 1.5–3 cm, which is wider than for the RYGB because the restriction is provided by the narrow stomach rather than the gastrojejunostomy. There is still no consensus regarding the use of nasogastric tubes and drains in the postoperative period. Supplements of iron, vitamin B12, and vitamin D are routinely prescribed to OAGB patients.
