Simplified laparoscopic gastric bypass
Case A 30-year-old woman, obese since childhood, with a BMI of 51 Kg/m2 and a previous history of several years’ treatment with the endocrinologist and dietitian, with no success. Medical history: deep-vein thrombosis, knee arthrosis Surgical history: Knee surgery Treatment The patient is placed in a supine position with legs opened wide in a 45-degree Anti-Trendelenburg position. The patient is attached to the table with a belt around the pubis and both legs. The surgeon stands between the patient’s legs, the first assistant stands on the right and the second assistant on the left. The nurse stands between the surgeon and the second assistant. The pneumoperitoneum is performed with a 10 mm optic trocar placed at the mesogastrium around 10-12 cm below the xiphoid appendix, 5-6 centimeters to the left of the midline. This will be used for the camera. Then a 5 mm trocar is placed at the upper right quadrant which will be used for the liver retractor. Then we place two 10 mm trocars, one between the optic port and the 5 mm trocar and the other one on the left mid-clavicular line. The fifth port is then placed in the left lateral position below the ribcage. The procedure starts with the gastric pouch construction. We dissect the esophagogastric angle to expose the left crus of diaphragm. Then we look for the second vein of the lesser curvature to create the retrogastric tunnel. We then introduce a 34 bougie down to the esophagogastric junction, to avoid getting too close to the angle of His. We perform the gastric section with a linear cutting stapler loaded with a 44mm length gold reinforced cartridge (3.8 mm), oriented towards the left crus of diaphragm. The goal is to create a 30-50 ml gastric pouch. Then we look for the Treitz angle, and the first jejunal loop is mobilized toward the gastric pouch to perform a latero-lateral mechanical anastomosis. A small opening is made in the jejunum and the gastric pouch, and the linear stapler, loaded with a blue charge (3.5 mm), is introduced. The remaining opening is closed with a continuous absorbable suture. From the gastro-jejunal anastomosis, we measure approximately 150 centimeters on the distal jejunum to perform the jejuno-jejunal anastomosis using a 60mm length white linear stapler, close to the gastro-jejunal anastomosis. We then close the defect with a continuous absorbable suture. Next, we dissect the mesenterium between both anastomoses, the gastrojejunal anastomosis and the biliary loop, to introduce the linear a blue cartridge, and cut the intestine, close to the gastric pouch. This way, the Roux-en-Y reconstruction is completed. Finally we test the gastro-jejunal anastomosis with methylene blue through the bougie tube.
