Laparoscopic Roux-en-YLaparoscopic Roux-en-YGastric Bypass:Gastric Bypass:

One Surgeon’s TechniqueOne Surgeon’s Technique

George S. Ferzli MD, FACSGeorge S. Ferzli MD, FACS

New York, NYNew York, NY

Dr. John Linner

1954

Jejuno-ileal bypass

THE BEGINNING

COMPLICATIONS OF COMPLICATIONS OF JEJUNOILEAL BYPASSJEJUNOILEAL BYPASS

Electrolyte disturbancesElectrolyte disturbances Osteoporosis/osteomalaciaOsteoporosis/osteomalacia Protein malnutritionProtein malnutrition CholelithiasisCholelithiasis DiarrheaDiarrhea Hair lossHair loss

ArthritisArthritis Liver failureLiver failure SteatosisSteatosis Renal calculiRenal calculi NeuropathyNeuropathy AnemiaAnemia

Dr. Edward Mason

University of Iowa

1967 Gastric Bypass with

loop gastroenterostomy

GASTRIC BYPASS WITHROUX-en-Y LIMB

Roux-en-Y Gastric Bypass

50 mL POUCH WITH A ROUXLIMB TO MINIMIZE BILEREFLUX

COMBINED RESTRICTIVEAND MALABSORPTIVE

GASTRIC BYPASS WITHROUX-en-Y LIMB

Roux-en-Y Gastric Bypass

SUBSEQUENTLY MODIFIED

50 mL POUCH WITH A ROUXLIMB TO MINIMIZE BILEREFLUX

ROUX LIMB WAS LENGTHENEDTO INCREASE MALABSORPTIONAND IMPROVE WEIGHT LOSS

COMBINED RESTRICTIVEAND MALABSORPTIVE

ROUX-en-Y GASTRIC ROUX-en-Y GASTRIC BYPASSBYPASS

GOAL: To restrict theGOAL: To restrict the

gastric reservoirgastric reservoir

ADVANTAGESADVANTAGES Controls food intakeControls food intake Dumping reduces intake Dumping reduces intake

of sweetsof sweets Reversible if indicatedReversible if indicated

Roux-en-Y Gastric Bypass

Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Operative OptionsOperative Options

Retro-colic/Retro-gastric gastrojejunostomyRetro-colic/Retro-gastric gastrojejunostomy Ante-colic/Ante-gastric gastrojejunostomyAnte-colic/Ante-gastric gastrojejunostomy Stapled gastrojejunostomyStapled gastrojejunostomy Hand-sewn gastrojejunostomyHand-sewn gastrojejunostomy

Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Our TechniqueOur Technique

Identify LOTIdentify LOT Divide jejunumDivide jejunum Measure Roux limbMeasure Roux limb Complete jejuno-jejunostomy, close Complete jejuno-jejunostomy, close

mesenterymesentery Create gastric pouchCreate gastric pouch Ante-colic/Ante-gastric gastrojejunostomyAnte-colic/Ante-gastric gastrojejunostomy Leak testLeak test

Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Port PositioningPort Positioning

Approximate position Approximate position for ports marked with for ports marked with abdomen insufflatedabdomen insufflated

Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Identify LOTIdentify LOT

Retract Retract omentum and omentum and transverse colon transverse colon cephaladcephalad

LOT exposedLOT exposed

Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Distance to Jejunal divisionDistance to Jejunal division

Approx. 50-60cm Approx. 50-60cm from LOTfrom LOT

Assure that this Assure that this

reaches liver edgereaches liver edge

Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Jejunal DivisionJejunal Division

Mark proximal Mark proximal jejunumjejunum

Minimal division of Minimal division of mesenterymesentery

Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Distance to jejuno-jejunostomyDistance to jejuno-jejunostomy

Approx 100-110cmApprox 100-110cm

Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Stapled jejuno-jejunostomyStapled jejuno-jejunostomy

Creates large common Creates large common channelchannel

Roux-en-Y Gastric Bypass: Roux-en-Y Gastric Bypass: Jejuno-jejunostomy stitchJejuno-jejunostomy stitch

Hand-sewn single-Hand-sewn single-layer anastamosislayer anastamosis

Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Finished jejuno-jejunostomyFinished jejuno-jejunostomy

Final view of jejuno-Final view of jejuno-jejunostomyjejunostomy

Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Closure of mesenteryClosure of mesentery

Interrupted peritoneal Interrupted peritoneal sutures sutures

Prevents internal Prevents internal herniahernia

Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:First Gastric divisionFirst Gastric division

Along lesser curve, at Along lesser curve, at first gastric veinfirst gastric vein

May use ultrasonic May use ultrasonic device/cauterydevice/cautery

Assure entry by Assure entry by visualizing posterior visualizing posterior wallwall

Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Creation of gastric pouchCreation of gastric pouch

Calibration tube in Calibration tube in placeplace

Target is angle of HisTarget is angle of His

Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Final gastric divisionFinal gastric division

Full division to angle Full division to angle of Hisof His

Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:First G-J stitchFirst G-J stitch

Find Roux limbFind Roux limb Proper orientation of Proper orientation of

Roux limbRoux limb Begin with posterior Begin with posterior

layerlayer

Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Posterior sutures completedPosterior sutures completed

Sufficient sutures to Sufficient sutures to allow for proper allow for proper anastamosisanastamosis

Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Creating enterotomiesCreating enterotomies

Approx 1cm Approx 1cm anastamosisanastamosis

Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Anterior G-J sutureAnterior G-J suture

Begin with lateral Begin with lateral cornercorner

Sero-muscular stitchesSero-muscular stitches

Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Last anterior G-J sutureLast anterior G-J suture

Anterior row of Anterior row of stitching completed stitching completed

Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Final view G-JFinal view G-J

Methylene blue has Methylene blue has been injectedbeen injected

Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:Leak TestingLeak Testing

Occlude Roux limb Occlude Roux limb during dye and air during dye and air insufflation under insufflation under fluidfluid

Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:SummarySummary

Jejuno-jejunostomy created Jejuno-jejunostomy created – Correctly identify LOT, proximal and distal Correctly identify LOT, proximal and distal

limbslimbs– Minimal division of mesenteryMinimal division of mesentery

Gastric pouch createdGastric pouch created– Assure appropriate pouch sizeAssure appropriate pouch size– Use calibrating tube if necessaryUse calibrating tube if necessary

Roux-en-Y Gastric Bypass:Roux-en-Y Gastric Bypass:SummarySummary

Ante-Colic/Ante-Gastric gastro-Ante-Colic/Ante-Gastric gastro-jejunostomyjejunostomy– Properly orient Roux limb, with minimal Properly orient Roux limb, with minimal

tensiontension– Split omentum if necessarySplit omentum if necessary

Stapling device used primarily for divisionsStapling device used primarily for divisions– Hand-sewn anastamosis whenever possibleHand-sewn anastamosis whenever possible

Always perform leak testAlways perform leak test– Best opportunity to fix/reinforce anastamosisBest opportunity to fix/reinforce anastamosis