laparoscopic gastric bypass surgery: current technique

INTRODUCTION

THE TECHNIQUE OF LAPAROSCOPIC Roux-en-Y gastric by-pass has evolved significantly since Wittgrove and

Clark developed their technique in the early 1990s1 Mul-tiple variations of each key aspect of the procedure haveevolved2ndash8 The major steps of the procedure include pa-tient positioning setup and port placement pouch cre-ation Roux-limb construction jejuno-jejunostomy andgastrojejunostomy Table 1 lists the multiple variationsof each major step along with their advantages and dis-advantages The most complex step of the procedure isthe gastrojejunostomy which correspondingly variesmost from surgeon to surgeon

Our approach to the laparoscopic Roux-en-Y gastricbypass at the University of Pittsburgh has also evolvedsince we began our laparoscopic bariatric program in Julyof 1997 Our goal has been simplification of the proce-dure to reduce technical complications facilitate teach-ing it to our fellows residents and visiting surgeons andcomplete each case consistently within 15 to 25 hoursOur current experience as of January 2003 is approxi-mately 2000 cases and we have taught the procedure tomore than 500 surgeons including residents and fellowsIn our first technique (cases 1ndash150) adapted from themethod of Wittgrove and Clark we created a retrocolicretrogastric Roux-limb and used a circular stapler for thegastrojejunal anastomosis The anvil was placed withinthe gastric pouch by passing it through the mouth with apull wire technique This method worked quite well butwe found that by using a linear stapler (cases 151ndash850)for the gastrojejunal anastomosis as described by Cham-pion et al3 we could simplify the procedure significantlyWith the linear stapler we observed a reduction (from3 to less than 1) in the rate of wound infections re-lated to withdrawal of the contaminated circular staplerthrough the port site We also achieved a 15- to 30-minutereduction in operating time with the linear stapler In our

most recent modification (cases 851ndash2000) we switchedfrom a retrocolic retrogastric Roux-limb to an antecolicantegastric Roux-limb as described by Gagner et al4

This modification has resulted in a significant reductionin the number of internal hernias caused by protrusion ofthe bowel through the mesocolon defect required in theretrocolic technique Furthermore we have not seen anincrease in the number of complications resulting fromthe increased tension at the gastrojejunal anastomosis thatis required with an antecolic Roux-limb Thus our cur-rent technique which we describe and illustrate in thisarticle involves the following a 15-mL gastric pouch atwo-layer gastrojejunal anastomosis (sutured outer layerand stapled inner layer) an antecolic antegastric Roux-limb and an end-side (stapled) jejuno-jejunostomy

MINIMALLY INVASIVE OPERATING ROOM

Laparoscopic Roux-en-Y gastric bypass is a complexoperation that is performed on complex severely obesepatients Specialized operating rooms such as the oneshown in Figure 1 along with advanced surgical instru-ments and equipment can significantly aid the surgeonin completing these procedures laparoscopically Themain features of the advanced operating room includehigh-quality optics with three-chip cameras (Stryker En-doscopy) high-quality monitors (Sony) voice activationof all controls (HERMES Computer Motion and StrykerEndoscopy) equipment booms to allow easy access toinstruments and controls (Bercholdt) and an operatingtable suitable for patients weighing up to 800 lb(Skytron) The multiple high-quality monitors providethe surgeon with access to a variety of image inputs fromthe laparoscope overhead camera flexible endoscopesultrasonographic probes digital x-rays Internet imagesand the patientrsquos electronic medical record Built-in com-

JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 13 Number 4 2003copy Mary Ann Liebert Inc

Laparoscopic Gastric Bypass Surgery Current Technique

PHILIP R SCHAUER MD1 SAYEED IKRAMUDDIN MD2 GISELLE HAMAD MD1

GEORGE M EID MD1 SAMER MATTAR MD1 DAN COTTAM MD1

RAMESH RAMANATHAN MD1 and WILLIAM GOURASH CRNP1

This paper was modified in part from Schauer P Laparoscopic Roux-en-Y Gastric Bypass at the University of PittsburghEvolution of Techique Operative Techniques in General Surgery 20035114ndash124

1Department of Surgery University of Pittsburgh Pennsylania 2Department of Surgery University of Minnesota

229

230 SCHAUER

munications technology allows two-way live audiovisualcommunication to specialty services such as radiologyand pathology For teaching purposes images can bebroadcast locally regionally and internationally

INSTRUMENTS FOR LAPAROSCOPICROUX-EN-Y GASTRIC BYPASS

Many specialized instruments make laparoscopic gas-tric bypass feasible (Fig 2) A high-quality three-chip

camera (Stryker Endoscopy) and a 10-mm 45-degreelaparoscope are critical to obtaining a clear bright im-age Extra-long (55 cm) scopes trocars and instrumentsare available for these super-obese patients Trocars thatprovide a tight seal and allow the use of instruments withmultiple diameters are essential A variety of grasping in-struments enable delicate and firm handling of tissue En-doscopic stapling devices such as the Endo-GIA (US Sur-gical Corporation Norwalk Connecticut) are absolutelyessential for laparoscopic gastric bypass A variety of car-tridges with multiple staple heights (20 25 35 and 48

TABLE 1 LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS VARIATIONS IN TECHNIQUE

Operative technique Description Potential advatages Potential disadvantages

EEA end-to-end anastomosis GERD gastroesophageal reflux disease GIA gastrointestinal anastomosis G-J gastrojejunos-tomy J-J jejuno-jejunostomy

Patient positionSupine legs apart

Supine legs together

Operation sequenceForegut-midgut-foregut

Midgut-foregutPouch creation15 mL

15ndash30 mL verticalGastrojejunostomyStapled

Circular transesophageal

Circular transabdominal

Linear end-side

Hand-sewn

Banded outlet

Roux-limb constructionLength

OrientationRetrocolic retrogastric

Antecolic antegastric

Jejuno-jejunostomyStapled

Stapled plus hand-sewn

Surgeon between legs

Surgeon on right side

Pouch Roux J-J G-J

Roux J-J pouch G-J

Isolated small pouch

Slightly longer larger pouch

Anvil passed downesophagus

Anvil passed throughabdominal wall

Endo-GIA for anastomosissuture for enterotomyclosure (or stapler)

Constructed with suture only

Silastic or Marlex bandreinforced outlet

75 cm standard150ndash250 cm long-limb

Passes through mesocolondefect below colon andstomach

Passes anterior to colon andstomach no mesocolondefect

Endo-GIA stapler foranastomosis andenterotomy closure

Endo-GIA for anastomosisbut enterotomy closed withsuture

Surgeon preference

Easy setup

Allows earlier assessment ofpouch and earlierconversion

Fewer table position changesquicker

Better weight loss decreasedGERD

Easier G-J less tension onG-J

Small pouch small andconstant stoma

Avoids esophageal passage

Avoids EEA stapler andlarge opening in skin andreduces infection

Reduced cost

May enhance long-termweight loss

Enhanced weight loss withlonger Roux

Less tension on G-J

No mesocolon defectreduced risk for internalhernia

Stapled closure faster

Hand-sewn enterotomyclosure lower risk forstenosis

Longer setup time possiblepressure injury

None

More position changes

May delay conversion ifrequired

More difficult G-J increasedtension on G-J

Less weight loss increasedGERD

Potential esophageal injuryduring anvil passage

EEA stapler requires largeopening in abdominal walland risks infection

Stoma size less likelyuniform requires somesuturing

Suturing skill requiredlonger operative time

Band may erode into lumenand require removal

Smaller jejunal lumen withlonger Roux may increaserisk for J-J stenosis

Higher risk for internalhernia must closemesocolon defect

Increased risk for tension onG-J

Higher risk of stenosis

Increased operating time

LAPAROSCOPIC GASTRIC BYPASS SURGERY CURRENT TECHNIQUE 231

mm) and cartridge lengths (30 45 and 60 mm) are avail-able Reticulating cartridges are sometimes helpful whenacute angles are required

OVERVIEW OF TECHNIQUE

An overview of the University of Pittsburgh techniqueof laparoscopic Roux-en-Y gastric bypass with a list ofthe seven major steps is shown in Figure 3 The proce-dure involves the creation of a 15-mL stapled gastricpouch a two-layer end-side gastrojejunostomy (insidestaples and outside sutures) a 75- to 150-cm antecolicantegastric Roux-limb and a stapled end-side jejuno-je-junostomy The sequence of steps in a laparoscopic Roux-en-Y gastric bypass can be quite variable Our preferenceis to begin with creation of the Roux-limb followed bythe jejuno-jejunostomy and to end with the gastroje-junostomy This sequence allows us to begin with the pa-tient in a supine position and end with the patient in a re-verse Trendelenburg position so that only one positionchange is required during the operation Secondly it al-lows us to begin in the midgut and progress logically tothe foregut with minimal back-and-forth movements

Set-up and positioning

The patient is placed supine on an operating table ca-pable of securely holding someone who may weigh upto 800 lb (Fig 4) and is strapped in above and below thewaist After the induction of general anesthesia and en-dotracheal intubation a bladder catheter is inserted thensequential compression devices are placed around thelower extremities to prevent intraoperative venous throm-bosis An orogastric tube (18F) is temporarily placed todecompress the stomach (Removal before gastric sta-

pling is required) Care is taken to ensure that excessivepressure is not applied to any parts of the limbs or torsoto avoid pressure injuries sustained after a lengthy pro-cedure Intravenous access via the upper extremity is usu-ally sufficient Occasionally central access via the inter-nal jugular or subclavian vein is necessary for monitoringThe monitors with the associated equipment (camera boxlight source insufflator) are placed above the patientrsquosshoulders on each side and aimed at the surgical teamThe skin is prepared with an antibacterial solution suchas Betadine from the breasts to the pubis including thefar right and left flanks Drapes are placed to cover thetorso and limbs excluding the abdominal skin The per-sonnel are positioned as shown We prefer that the sur-geon stand on the right side (as in open surgery) ratherthan between the patientrsquos legs as some surgeons preferThis position appears more comfortable for the surgeon(and patient) and is less cumbersome to set up A roboticcamera holder such as the AESOP (Computer Motion)may be substituted for the camera person (see next fig-ure) and may provide superior laparoscope image con-trol and sturdiness The camera laparoscope light cordand insufflation tubing are all positioned onto the surgi-cal field and the camera lighting and white balance areadjusted

Access pneumoperitoneum and port placement

Initial access is obtained by means of a Veress needletechnique at the left anterior subcostal port site becausethis site is generally safe from visceral injury (Fig 5)Carbon dioxide pneumoperitoneum is established to apressure of 15 mm Hg A 5-mm VersaStep port (US Sur-gical Corporation) with the Veress-style needle withinthe dilating sheath is inserted through the same skin in-cision after the pneumoperitoneum has been establishedWe prefer to use two insufflators to offset potential airleaks The tapered-tip dilator is advanced through the

FIG 1 Univeristy of Pittsburgh Minimally Invasive Operat-ing Theatre

FIG 2 Key Instrumentation for laparoscopic gastric bypass

232 SCHAUER

sheath to avoid direct cutting of muscle The remaining5- to 12-mm VersaStep ports are inserted similarly un-der direct vision by means of the 5-mm (45-degree) scopethrough the anterior left subcostal port (Fig 6) A 10-mm(45-degree) scope is placed in the left paramedian (12-mm) port A liver retractor is placed through the poste-rior right subcostal port The surgeon (standing on theright side) operates through the right upper abdominalport and right anterior subcostal port The assistant sur-geon (standing on the left side) operates through the twoleft subcostal ports With two ports available the assis-tant surgeon is much better able to operate Usually theassistant surgeon holds a grasping instrument in one handand a suction device in the other to maintain a clean fieldFigure 7 shows the complete operating room setup TheAESOP robotic camera holder and the Hermes voice ac-tivation system are used to enhance surgeon control andefficiency A steep reverse Trendelenburg position ex-ploits gravity to facilitate exposure of the stomach dur-ing creation of the gastric pouch and gastrojejunal anas-tomosis

Initial inspection and construction of the Roux-limb

After positioning and port placement have been com-pleted the abdomen is inspected and adhesions are lysedwith blunt and sharp dissection as needed With the pa-tient in the supine position the omentum is advanced to-ward the upper abdomen to expose the ligament of Tre-itz The jejunum is measured 50 cm from the ligamentof Treitz an intestinal grasper is used as a measuring de-vice (it is marked 10 cm from the tip) (Fig 8) The je-junum is positioned in a C configuration to facilitateplacement of the Endo-GIA stapler for division TheEndo-GIA stapler is placed through the right upper ab-dominal 12-mm port and applied perpendicular to the je-junum and parallel to the mesenteric vascular arcade to

create the biliopancreatic limb and Roux-limb (Fig 9A)The ldquowhite vascularrdquo cartridge (25-mm staple height 60-mm cartridge length) is used to minimize staple linebleeding In this and all subsequent staple applicationssix staggered rows of staples (three rows on each side)are used to reduce bleeding and staple line dehiscenceTwo or three applications of the ldquogray cartridgerdquo (20-mm staple height 45-mm cartridge length) across the je-junal mesentery provide sufficient length for the Roux-limb to reach over the colon (antecolic) to the gastricpouch (Fig 9B) Care is taken to avoid devascularizingthe divided jejunal ends by applying the stapler at a pointequidistant from the mesenteric border of each limb Withuse of the EndoStitch suturing device (US Surgical Cor-poration) a 5-cm 14-in Penrose drain is sutured to theRoux-limb end with 2-0 braided polyester (Surgidac USSurgical Corporation) and used subsequently as a handleto advance the Roux-limb toward the gastric pouch tocreate the gastrojejunostomy (Fig 9C) The Roux-limbis measured 75 cm distally (for patients with a body massindex 50) or 150 cm distally (for those with a bodymass index $ 50) (Fig 10)

Jejuno-jejunostomy

An end-side jejuno-jejunostomy is shown in Figure 11The Roux-limb is approximated to the biliopancreaticlimb (1 cm from the end) at the antimesenteric borderswith 2-0 Surgidac (Fig 11A) The stitch is used as a staysuture during creation of the anastomosis (Fig 11B) Bymeans of ultrasonic dissection (Ultrashears US SurgicalCorporation) enterotomies are made at the biliopancre-atic corner and antimesenteric border of the Roux-limb(Fig 12 AndashC) The enterotomy of the Roux-limb is made

FIG 3 Overview of laparoscopic gastric bypass Univeristy ofPittsburgh approach

FIG 4 Setup for laparoscopic gastric bypass

14 mm End-SideGJ anastomosisEndo-GIA stapler

75-150 cm Roux-limbAntecolic Antegastric

Steps1) Setup2) Roux-limb3) J-J anastomosis4) Gastric pouch5) G-J anastomosis

15 ml Gastric Pouch

Isolateddefunctionalizedstomach

End-SideJejuno-jejunostomy

6) Endoscopy7) Closure


1 cm proximal to the biliopancreatic enterotomy to fa-cilitate stapler insertion (Fig 12D) The Endo-GIA sta-pler with the 60-mm white load is inserted through eachenterotomy and applied to create the end-side anastomo-sis (Fig 13 AndashD) Sutures (2-0 Surgidac) are placed toreinforce the crotch of the anastomosis and approximatethe enterotomy for closure (Fig 13D) The enterotomyis secured by three-point fixation (corners grasped by in-struments middle secured by suture and lined up paral-lel to the stapler) (Fig 14A) The Endo-GIA stapler witha 60-mm white load is applied across the enterotomy (Fig14B) Care is taken to ensure that the lumen on the Roux-limb side is not compromised (Fig 14C) An anti-ob-struction stitch (Brolin stitch) is applied to approximate

the Roux-limb to the biliopancreatic limb proximal to theanastomosis (Fig 15 AB) This is intended to preventthe afferent limb from folding back on itself and causingan obstruction The jejuno-jejunostomy is completed byclosing the mesenteric defect with a running suture (2-0Surgidac) (Fig 16 AB) An internal hernia resulting ina bowel obstruction may develop if the defect is left un-closed We recommend a permanent suture to minimizereopening of the defect

Advancement of the Roux-limb

The omentum is divided by mean of ultrasonic dis-section from the transverse mesocolon to its inferior edge(Fig 17 AB) Dividing the omentum reduces tension onthe Roux-limb as it passes in front of the colon up to thegastric pouch Careful attention is paid to ensure that theRoux-limb mesentery is not twisted and its vascular sup-ply compromised

Creation of the gastric pouch

The patient is transferred to a steep reverse Trende-lenburg position to facilitate exposure of the upper ab-domen The upper stomach is exposed by retracting theliver anteriorly with a 5-mm flexible retractor (SnowdenPencer) (Fig 18A) By means of ultrasonic dissection awindow is created in the ldquobare areardquo of the gastrohepaticligament immediately anterior to the caudate lobe of theliver The opening in the gastrohepatic ligament providesquick and direct access to the lesser sac behind the stom-ach (Fig 18B) After it has been ascertained that the oro-gastric tube has been withdrawn the Endo-GIA staplerwith a 60-mm white load is used to divide the lesser

FIG 5 Veress needle access

FIG 6 Trocar placement

Veress needle approach in Left UpperAbdomen (150mm vs 100mm)

Routine use of multiple insufflators

VersaStep radially expandable blunt tiptrocar system (USSC Norwalk Conn)

FIG 7 Operating room setup

234 SCHAUER

omentum 1 cm distal to the gastroesophageal junction(demarcated by the epigastric fat pad) (Fig 19A) The tipof the stapler overlaps the lesser curve by 1 cm Divid-ing the lesser omentum does transect the nerve of Latar-jet but this has not resulted in any short- or long-termadverse affects in more than 1000 cases The Endo-GIAstapler with 60-mm blue loads is then applied two to threetimes across the gastric cardia (1 cm from the gastro-esophageal junction) toward the angle of His to create agastric pouch of approximately 15 mL (Fig 19 B-E) Areticulating staple cartridge (US Surgical Corporation) issometimes helpful here especially when it is difficult toreach the angle of His The staple lines on both sides of

the transected stomach are examined to ensure that theyare intact and not bleeding (Fig 19F) The Roux-limb isthen advanced toward the gastric pouch in preparationfor the first layer of the end-side gastrojejunal anasto-mosis

Creation of the gastrojejunostomy

The antimesenteric border of the Roux-limb is ap-proximated to the posterior wall of the gastric pouch withrunning 2-0 Surgidac sutures (Fig 20 AB) A gastro-tomy and then an enterotomy are made by means of ul-trasonic dissection to provide access for the stapler (Fig20 CD) The Endo-GIA stapler with a 45-mm blue loadis inserted 15 cm into the gastric and jejunal lumina andthen applied to create the end-side gastrojejunal anasto-mosis (Fig 20 EF) The resultant enterotomy is closedwith absorbable suture (2-0 Polysorb US Surgical Cor-poration) Sutures are placed at each corner then tied inthe middle after the 30F flexible endoscope has been in-serted and used as a stent (Fig 21 AndashC) The sutures aretied down tightly against the endoscope like a purse stringto achieve a 30F lumen (12- to 14-mm diameter) A sec-ond layer of suture (2-0 Surgidac) is applied anteriorlyto oversew the entire anastomosis and gastric pouch sta-ple line thus completing the two-layer anastomosis (Fig22 AB) A clamp is placed distal to the endoscope andinsufflation with the endoscope is performed with theanastomosis submerged in saline solution to examine foroccult air leaks If a leak is present it is oversewn with

FIG 8 Roux-limb creation FIG 10 Measurement of roux-limb

FIG 9 Division of jejunum and mesentery

A B

C


2-0 Surgidac The gastric pouch is then covered with anomental patch (ldquoshower caprdquo) to protect against leakageand a No 15 round suction drain is placed posterior tothe anastomosis The drain is usually withdrawn on post-operative day 7 All port sites 10 mm and larger are closedwith fascia stitches of 0 Polysorb All carbon dioxide isevacuated and the skin incisions are closed with inter-rupted 4-0 Polysorb

OUTCOMES

The results of our first 275 patients with up to 25 yearsof follow-up were published in 20005 In most of the op-erations in this series the circular stapler technique wasused for the gastrojejunostomy and all the patients re-ceived a retrocolic retrogastric Roux-limb The conver-

sion rate to open gastric bypass was 1 An oral diet wasbegun at a mean of 158 days after surgery with a me-dian hospital stay of 2 days and return to work at 21 daysThe incidence of early major complications was 33and for minor complications it was 27 One death oc-curred related to a pulmonary embolus (04) The her-nia rate was 07 and wound infections requiring out-patient drainage only were uncommon (5) Excessweight loss was 83 at 24 months and 77 at 30 monthsIn patients with more than 1 year of follow-up most ofthe comorbid conditions had abated or resolved and 95reported a significant improvement in quality of life Ourcurrent experience involves approximately 2000 patientswith up to nearly 6 years of follow-up Most of them un-derwent the gastrojejunostomy with linear stapler tech-nique and received an antecolic antegastric Roux-limbMean excess weight loss appears to be maintained at 65to 70 at 5 years (unpublished data) Our experience sug-gests that laparoscopic Roux-en-Y gastric bypass effec-tively achieves sustained weight loss relieves comorbidconditions improves quality of life and reduces recov-ery time and perioperative complications

THE LEARNING CURVE

The laparoscopic gastric bypass is associated with asignificant learning curve perhaps more than many otheradvanced laparoscopic procedures In our experience thecomplication rates and operating times approached thelevels reported for open gastric bypass after an experi-ence of 100 cases9 The acquisition of advanced laparo-scopic skills is essential for the safe and effective per-formance of laparoscopic gastric bypass Surgeons

FIG 11 Setup for end-side Jejunostomy

FIG 12 Enterotomies for the Jejuno-Jejunostomy

A

A

C

B

B

D

236 SCHAUER

FIG 13 Staple application for Jojuno-Jojunostomy

FIG 14 Stapled closure of enterotomy

FIG 15 Anti-obstruction stitch

A

C

B

D

A B

C

A B


FIG 16 Closure of mesentery

FIG 17 Division of omentum

FIG 18 Exposure of stomach and accessto retrogastric space

FIG 19 Gastric pouch creation

A

A

A

B

B

B

D E F

CBA

238 SCHAUER

FIG 20 Gastro-Jejunostomy

FIG 21 Completion of Grastro-Jejunostomy

FIG 22 Second layer closure

A B C

FED

A

A B

B

C


without experience in at least some of the other advancedlaparoscopic procedures will be at a significant disad-vantage Furthermore surgeons not experienced in theperioperative management of bariatric patients may beequally vulnerable For surgeons entering laparoscopicbariatric surgery either fellowship training or extendedmentoring by an experienced surgeon may be the opti-mal strategy to reduce patient morbidity related to thelearning curve

REFERENCES

1 Wittgrove AC Clark GW Laparoscopic gastric bypass Afive-year prospective study of 500 patients followed from 3to 60 months Obes Surg 19999123ndash143

2 Higa KD Boone KB et al Laparoscopic Roux-en-Y gas-tric bypass for morbid obesity Technique and preliminaryresults of our first 400 patients Arch Surg 20001351029ndash1033

3 Champion JK Hunt T DeLisle N Laparoscopic verticalbanded gastroplasty and Roux-en-Y gastric bypass in mor-bid obesity Obes Surg 19999123

4 Gagner M Garcia-Ruiz A Arca MJ Heniford TB Laparo-scopic isolated gastric bypass for morbid obesity Surg En-dosc 199913S6

5 Schauer PR Ikramuddin S et al Outcomes after laparo-scopic Roux-en-Y gastric bypass for morbid obesity AnnSurg 2000232515ndash529

6 Schauer PR Ikramuddin S Laparoscopic surgery for mor-bid obesity Surg Clin North Am 2001811145ndash1179

7 Nguyen NT Goldman C Rosenquist CJ et al Laparoscopicversus open gastric bypass A randomized study of out-comes quality of life and costs Ann Surg 2001234279ndash289

8 DeMaria EJ Sugerman HJ Kellum JM et al Results of 281consecutive total laparoscopic Roux-en-Y gastric bypassesto treat morbid obesity Ann Surg 2002235640ndash647

9 Schauer PR Ikramuddin SI Hamad G Gourash W Thelearning curve for laparoscopic Roux-en-Y gastric bypass is100 cases Surg Endosc 200317212ndash215

Address reprint requests toPhilip R Schauer MD

Magee Womenrsquos HospitalSuite 5500

300 Halket StreetPittsburgh PA 15213-2582

E-mail schauerprmsxupmcedu

230 SCHAUER

munications technology allows two-way live audiovisualcommunication to specialty services such as radiologyand pathology For teaching purposes images can bebroadcast locally regionally and internationally

INSTRUMENTS FOR LAPAROSCOPICROUX-EN-Y GASTRIC BYPASS

Many specialized instruments make laparoscopic gas-tric bypass feasible (Fig 2) A high-quality three-chip

camera (Stryker Endoscopy) and a 10-mm 45-degreelaparoscope are critical to obtaining a clear bright im-age Extra-long (55 cm) scopes trocars and instrumentsare available for these super-obese patients Trocars thatprovide a tight seal and allow the use of instruments withmultiple diameters are essential A variety of grasping in-struments enable delicate and firm handling of tissue En-doscopic stapling devices such as the Endo-GIA (US Sur-gical Corporation Norwalk Connecticut) are absolutelyessential for laparoscopic gastric bypass A variety of car-tridges with multiple staple heights (20 25 35 and 48

TABLE 1 LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS VARIATIONS IN TECHNIQUE

Operative technique Description Potential advatages Potential disadvantages

EEA end-to-end anastomosis GERD gastroesophageal reflux disease GIA gastrointestinal anastomosis G-J gastrojejunos-tomy J-J jejuno-jejunostomy

Patient positionSupine legs apart

Supine legs together

Operation sequenceForegut-midgut-foregut

Midgut-foregutPouch creation15 mL

15ndash30 mL verticalGastrojejunostomyStapled

Circular transesophageal

Circular transabdominal

Linear end-side

Hand-sewn

Banded outlet

Roux-limb constructionLength

OrientationRetrocolic retrogastric

Antecolic antegastric

Jejuno-jejunostomyStapled

Stapled plus hand-sewn

Surgeon between legs

Surgeon on right side

Pouch Roux J-J G-J

Roux J-J pouch G-J

Isolated small pouch

Slightly longer larger pouch

Anvil passed downesophagus

Anvil passed throughabdominal wall

Endo-GIA for anastomosissuture for enterotomyclosure (or stapler)

Constructed with suture only

Silastic or Marlex bandreinforced outlet

75 cm standard150ndash250 cm long-limb

Passes through mesocolondefect below colon andstomach

Passes anterior to colon andstomach no mesocolondefect

Endo-GIA stapler foranastomosis andenterotomy closure

Endo-GIA for anastomosisbut enterotomy closed withsuture

Surgeon preference

Easy setup

Allows earlier assessment ofpouch and earlierconversion

Fewer table position changesquicker

Better weight loss decreasedGERD

Easier G-J less tension onG-J

Small pouch small andconstant stoma

Avoids esophageal passage

Avoids EEA stapler andlarge opening in skin andreduces infection

Reduced cost

May enhance long-termweight loss

Enhanced weight loss withlonger Roux

Less tension on G-J

No mesocolon defectreduced risk for internalhernia

Stapled closure faster

Hand-sewn enterotomyclosure lower risk forstenosis

Longer setup time possiblepressure injury

None

More position changes

May delay conversion ifrequired

More difficult G-J increasedtension on G-J

Less weight loss increasedGERD

Potential esophageal injuryduring anvil passage

EEA stapler requires largeopening in abdominal walland risks infection

Stoma size less likelyuniform requires somesuturing

Suturing skill requiredlonger operative time

Band may erode into lumenand require removal

Smaller jejunal lumen withlonger Roux may increaserisk for J-J stenosis

Higher risk for internalhernia must closemesocolon defect

Increased risk for tension onG-J

Higher risk of stenosis

Increased operating time












232 SCHAUER





Jejuno-jejunostomy







15 ml Gastric Pouch

















234 SCHAUER







A B

C



OUTCOMES



THE LEARNING CURVE




A

A

C

B

B

D

236 SCHAUER




A

C

B

D

A B

C

A B






A

A

A

B

B

B

D E F

CBA

238 SCHAUER




A B C

FED

A

A B

B

C



REFERENCES

























232 SCHAUER





Jejuno-jejunostomy







15 ml Gastric Pouch

















234 SCHAUER







A B

C



OUTCOMES



THE LEARNING CURVE




A

A

C

B

B

D

236 SCHAUER




A

C

B

D

A B

C

A B






A

A

A

B

B

B

D E F

CBA

238 SCHAUER




A B C

FED

A

A B

B

C



REFERENCES



























234 SCHAUER







A B

C



OUTCOMES



THE LEARNING CURVE




A

A

C

B

B

D

236 SCHAUER




A

C

B

D

A B

C

A B






A

A

A

B

B

B

D E F

CBA

238 SCHAUER




A B C

FED

A

A B

B

C



REFERENCES
















OUTCOMES



THE LEARNING CURVE




A

A

C

B

B

D

236 SCHAUER




A

C

B

D

A B

C

A B






A

A

A

B

B

B

D E F

CBA

238 SCHAUER




A B C

FED

A

A B

B

C



REFERENCES














236 SCHAUER




A

C

B

D

A B

C

A B






A

A

A

B

B

B

D E F

CBA

238 SCHAUER




A B C

FED

A

A B

B

C



REFERENCES



















A

A

A

B

B

B

D E F

CBA

238 SCHAUER




A B C

FED

A

A B

B

C



REFERENCES














238 SCHAUER




A B C

FED

A

A B

B

C



REFERENCES
















REFERENCES














laparoscopic gastric bypass surgery: current technique

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