Buchwald's Atlas of Metabolic & Bariatric Surgical Techniques and Procedures

Buchwald’s Atlas of Metabolic & Bariatric Surgical Techniques and Procedures

Buchwald’s Atlas of Metabolic & Bariatric Surgical Techniques and Procedures Henry Buchwald, MD, PhD

Professor of Surgery and Biomedical Engineering Owen H. and Sarah Davidson Wangensteen Chair in Experimental Surgery, Emeritus Department of Surgery University of Minnesota Minneapolis, Minnesota

with illustrations by Michael de la Flor

1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899 BUCHWALD'S ATLAS OF METABOLIC & BARIATRIC SURGICAL TECHNIQUES AND PROCEDURES

ISBN: 978-1-4160-3106-2

Copyright © 2012 by Saunders, an imprint of Elsevier Inc. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher's permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

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To Emilie, my beloved wife and inspiration, my daughters four and their spouses, and my energetic grandchildren, as well as to my late parents, who taught me always to live hopefully. I thank you. You give joy to my work and to my life. Also to the individuals from whom I have learned the craft of surgery—my mentors, in particular Richard L. Varco, my colleagues, my fellows and residents, and most certainly my patients. Henry Buchwald To my father, Michael A. de la Flor Sr. Michael de la Flor

Preface “…medicine [was]… ravaged by having its primary instrument, the application of the hand's work in healing, so neglected that it seemed to have been handed over to common folk and to persons completely untrained in the disciplines that serve the medical art.” Preface to De Humani Corporis Fabrica, 1543, Andreas Vesalius The word surgery is derived from two Greek terms: cheiros, for hand, and ergon, for work. Thus, surgeons are hand laborers and we, as surgeons, must never forget that we practice a manual craft. As craftsmen and craftswomen, we need to take pride in the product of our hand labors, and we must make certain that we produce as durable and complication-free, as well as aesthetic, result. The intent of this atlas is to provide an aid to achieve these goals. This atlas is the work of a single surgeon, in consultation with others, based on personal experience and a lifetime in the operating room. The technical methodology in this volume reflects my biases—how I do it. I have performed most of the open surgical operations detailed, and I have worked with and observed other surgeons, in particular, highly skilled laparoscopic surgeons, performing essentially all of the operations presented. I have also included alternative approaches for many of the operations, and I have consulted world experts who are, as a rule, the original innovators of these procedures, for advice and corrections. This work is not a textbook, but an atlas on how to perform surgery. In keeping with this goal, a review of global obesity and its comorbidities, the preoperative and postoperative care of the metabolic/bariatric patient, and other areas of relevant data or instruction are not offered. It aims to be comprehensive rather than encyclopedic. Every effort has been made to present a clear, focused text accompanied by appropriately detailed, precise illustrations. This is a work for accomplished surgeons as well as surgeons in training. Its focus is metabolic/bariatric surgery; I have assumed that, as a starting point, the reader has mastered the basic techniques of exposure, suturing, stapling, and so forth. This volume is dedicated to performing surgery as an art, stressing the gentle handling of tissues, use of fine suture material, adequate exposure, and safety preferred over speed. Good operative technique and patient safety are complementary and ensure a postoperative course without problems and with prompt patient discharge from the hospital. Adverse events and unsatisfactory outcomes are not generally ordained by providence but are initiated by the surgeon in the operating room, as are good outcomes and a complication-free postoperative course. As a surgeon for more than 50 years, I strive to do my best for every patient who has entrusted me with his or her care. I have learned from all of my patients, and I wish to pass on the knowledge I have gained. I hope this atlas will be of help to other surgeons and, thereby, to many more patients. Henry Buchwald, MD, PhD

Acknowledgments We owe our greatest debt to Jane N. Buchwald, our superlative substantive editor and administrative liaison, who was the mortar for the construction of this atlas. We are particularly grateful to Sayeed Ikramuddin, one of the world's premier metabolic/ bariatric surgeons, for his excellent reviews of sections of this atlas and his wise teaching in and out of the operating room. We express our gratitude to J. Kenneth Champion, Kelvin D. Higa, Nicola Scopinaro, and Alan C. Wittgrove, internationally prominent leaders in metabolic/bariatric surgery, for their most helpful reviews of specific sections of this atlas. We also offer a special thank you to Horacio E. Oria and Carlos Ferrari, who generously invited us into their operating rooms to observe. This work owes its cogency and bibliographic accuracy to the scrupulous manuscript preparation and research of Danette M. Oien. Elsevier, the publisher, deserves our praise and gratitude for their patience and faith in this effort. In particular, we thank Judith Fletcher, who has given us orientation, guidance, strong advice, and friendship.

Introduction In the first decade of the twenty-first century, three unassailable facts concerning obesity became evident. (1) The global epidemic of obesity, in particular morbid obesity, remains unchecked. (2) The disciplines of behavior modification, dietary management, exercise, and drug therapy have not, alone or in combination, been able to halt this epidemic. (3) Surgery has been highly effective, with extremely low operative mortality and morbidity, in achieving long-term lowering of body weight and resolving, decreasing, and preventing obesity comorbidities. What are the origins of this effective surgical therapy? Where did these operative modalities of bariatric, or more accurately, metabolic/bariatric surgery, come from? What are the historical antecedents of this major surgical discipline that has come to occupy a dominant role in operating rooms throughout the world? What operations are metabolic/bariatric surgeons performing? In the Talmud, it is written that Rabbi Eleazar, being morbidly obese, underwent an operation after being given a soporific potion in which his abdomen, or abdominal wall, was opened and a number of “baskets of fat were removed.” This may well have been the first bariatric operation. Ephraim McDowell of Danville, Kentucky, is usually credited as being the first surgeon in modern times (1809) to perform elective entry into the abdominal cavity for an extirpative procedure: ovariotomy of a giant ovarian cyst in 25 minutes with no general anesthesia. From 1846 to 1865, the discipline of surgery made tremendous progress, not because of any technical innovations but because of antisepsis, asepsis, and general anesthesia. Laparoscopic surgery has its origins early in the twentieth century. In 1901, Kelling in Berlin, Germany, insufflated a dog's abdomen and inserted a cystoscope. In 1910, Jacoblaus in Stockholm, Sweden, inspected a human abdomen with a scope. Within 1 year, Bernheim in Baltimore, Maryland, performed minor laparoscopic surgery via a proctoscope and an ordinary external light source. The first laparoscopic tubal ligation was performed in 1936 by Bosch in Bern, Switzerland. In 1938, Veress, in Budapest, Hungary, invented the spring-loaded needle, first advocated for the induction of a pneumothorax in the management of tuberculosis. In 1960, Semm in Munich, Germany, invented the autonomic insufflator; in 1978, Hasson in Chicago, Illinois, invented the Hasson introducer. In 1977, Kok in Gorinchen, The Netherlands, performed the first laparoscopic appendectomy; however, he exteriorized the appendix for ligation. The cardinal events in the development of laparoscopic surgery came in 1978 when Mühe in Boblingen, Germany, performed the first documented laparoscopic cholecystectomy and Mauret in Lyons, France, performed the first laparoscopic cholecystectomy using video technology. Laparoscopic cholecystectomy changed abdominal surgery forever, leading the way for laparoscopic gastric, intestinal, and colonic surgery as well as lymphadectomy and hernia repair. By 2010, approximately 300,000 metabolic/bariatric operations were performed annually worldwide, most of them laparoscopically. How, then, do we define metabolic surgery, bariatric surgery, and metabolic/bariatric surgery? The term metabolic comes from the Greek and means pertaining to or involving transition or a changing of form (state). In a book published in 1978, Richard Varco and I defined metabolic surgery as “the operative manipulation of a normal organ or organ system to achieve a biologic result for a potential health gain.” The practice of metabolic surgery, however, predated its definition. The various procedures performed on normal stomachs and vagal nerves to cure a distal duodenal ulcer, which was not resected or in any manner

xii   Introduction directly treated, are excellent examples of metabolic surgery. So are splenectomy for idiopathic thrombocytopenia purpura, portal diversion for glycogen storage disease, endocrine ablation for malignancy, pancreas transplantation for diabetes, and partial ileal bypass for hypercholesterolemia. The Program on the Surgical Control of the Hyperlipidemias (POSCH), for which I had the privilege of being the Principal Investigator, was the first randomized controlled trial to use a metabolic surgical ­procedure—the partial ileal bypass—as the intervention modality. This $65 million National Heart, Lung, and Blood Institute (NHLBI)-sponsored trial, when published in 1990, established the first proof of the lipid/atherosclerosis hypothesis. In this secondary intervention trial, POSCH demonstrated that the marked total cholesterol and lowdensity lipoprotein cholesterol reductions engendered by the partial ileal bypass decreased the trial's primary endpoint of combined atherosclerotic coronary heart disease mortality and recurrent nonfatal myocardial infarction as well as overall mortality, the incidence of coronary artery bypass grafting and percutaneous transluminal coronary angioplasty, and the development of peripheral vascular disease. Repeat coronary angiography performed at 0, 3, 5, 7, and 10 years of the trial showed a statistically significant decrease in coronary atherosclerotic progression and actual lesion regression in the partial ileal bypass test group. With the long­ est follow-up of any lipid/atherosclerosis trial—25 years—a sustained increase in life expectancy was demonstrated. Because of this study, metabolic surgery played a cardinal role in our knowledge base and in the downward trend of the atherosclerotic epidemic. In the last 50 years, weight loss surgery has become the primary representative of the discipline of metabolic surgery. Apparently normal stomach, intestine, or autonomic nerves are constricted, bypassed, resected, or electrically stimulated to achieve the biologically induced outcome of weight reduction and the health gains of a lower body mass index. The Greek word baros means weight. The term bariatric came into use in 1965, defining a branch of medicine dealing with causes, prevention, and treatment of obesity. The founding of the American Society of Bariatric Surgery (ASBS) in 1983 essentially established use of the term bariatric surgery to designate the discipline. It was not long before bariatric surgeons became cognizant that they were performing metabolic surgery, since their procedures, in addition to solving mechanical problems of gastroesophageal reflux disease, obstructive sleep apnea, and back and joint pain, were resolving metabolic diseases (e.g., type 2 diabetes, hyperlipidemia, hypertension, polycystic ovary syndrome, nonalcoholic steatohepatitis, possibly cancer). This role appreciation was given official recognition in 2008 when the ASBS changed its name to the American Society for Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity (IFSO) became the International Federation for the Surgery of Obesity and Metabolic Disorders. Thus, metabolic surgery encompasses bariatric surgery; bariatric surgery is metabolic surgery. This marriage of disciplines goes even further. Since prehistoric times there have been several distinct cumulative phases of the practice of surgery: incisional, extirpative, reparative, reconstructive and, now, metabolic. The concept of metabolic surgery has come of age; it is the surgery of today and will be developed further in the future. The traditional physiologic mechanisms of action postulated for metabolic/bariatric surgery, namely malabsorptive, malabsorptive/restrictive, primarily restrictive, and other, may be incomplete or not fully accurate. Proposed mechanisms of action for metabolic/bariatric ­surgery have recently involved neural/cerebral, hormonal/cerebral, and neural/hormonal/­cerebral mechanisms. We know that 70% of the vagal fibers are afferent; that there is an intrinsic myoneural network connecting the stomach, intestine, and pancreas; that there are foregut and hindgut hormones that influence satiety, pancreatic function, and peripheral insulin resis­ tance and sensitivity; and that fat cells elaborate energy conservation hormones, influence

Introduction   xiii insulin resistance, and produce inflammatory cytokines. We know there are multiple hypothalamic nuclei and areas dedicated to appetite, hunger, and satiety, and that certain ­neurons (AgRp/MPY) increase appetite and metabolism, whereas others (POMC/CART) do the reverse. Both the traditional classification of metabolic/bariatric procedures and the neural/ hormonal/cerebral interpretation are useful and not incompatible. Not only do the metabolic pathways of metabolic/bariatric surgery influence the occurrence, status, and prevention of metabolic disease, they also can lead to an understanding of the mechanisms of action of the metabolic/bariatric procedures and, possibly, even the underlying bases of obesity and type 2 diabetes. Organization of this atlas of bariatric operations and the selection of procedures are based on current use for each detailing of fundamental principles. The volume starts with the basics of surgical access to, and closure of, the abdomen for metabolic/bariatric surgery by open and laparoscopic techniques. This format is followed for most of the chapters in each section; namely, discussion and illustration of open surgery followed by laparoscopic surgery. Today's aspiring metabolic/bariatric surgeons must be conversant in both the laparoscopic approach and the open technique. If a surgeon performing a laparoscopic procedure has difficulty, he or she must be able to convert to an open approach to complete the operation safely. No surgeon responds to an operative complication or problem by converting from open to laparoscopic surgery; open surgery is the failsafe option for all surgery. Robotics is only briefly covered in this atlas because it is not, and may not become, available outside large specialty centers. This atlas is divided into Section I: Exposure and Closure of the Abdomen; Section II: Primarily Malabsorptive Procedures; Section III: Malabsorptive/Restrictive Procedures: Gastric Bypass; Section IV: Restrictive Procedures; Section V: Other and Investigative Procedures; and Section VI: Revisional Surgery. The presentations within each chapter discuss and illustrate the pertinent metabolic/bariatric procedures. There is some needed overlap across chapters, particularly in the setup descriptions for many procedures, so that the surgeon/reader does not need to flip back and forth between an introductory section with numerous fine variations and the individual procedure instruction. I have refrained from being controversial and present alternative approaches. I do not believe that there is, or ever will be, a “gold standard” or “best” operation. When speaking of best, it is important to ask “best for what?” No single procedure will be the best for weight reduction, comorbidity resolution, safety, simplicity, cosmesis, patient comfort and lack of stress, less time in the operating room and hospital, cost savings, and profitability. Metabolic/bariatric surgery will always be in flux. Certain operations will not stand the test of time, others will evolve, and some will fall into disuse, and new procedures will continuously be introduced. To appreciate the step-by-step outline of how to perform a specific metabolic/bariatric procedure, surgeons will find it helpful, as well as interesting, to know the antecedent history of the procedure—who thought of it, and how it evolved. In the early 1950s, Henrikkson reportedly performed an intestinal resection specifically for the management of obesity. Varco performed the first jejunoileal bypass in 1953, and the first publication of a jejunoileal bypass series for obesity management was in 1954 by Kremen, Linner, and Nelson. Many other surgeons contributed to the development of jejunoileal bypass variations, including Payne, Lewis, Scott, and Salmon. The procedure was discredited because of operation-related complications, and this progenitor procedure of metabolic/bariatric surgery gave way to malabsorptive/restrictive surgery. Malabsorptive metabolic/bariatric surgery was revived, however, by procedures that did not have a long, essentially stagnant, bypassed segment of intestine but divided the intestine into an alimentary limb, a biliopancreatic limb, and a common channel—all active and functioning. Two notable malabsorptive procedures emerged: the Scopinaro biliopancreatic diversion and its duodenal switch variation by Hess and Hess, and Marceau.

xiv   Introduction In the 1960s, Mason introduced the gastric bypass operation, the best example of malabsorptive/restrictive metabolic/bariatric surgery. His work was furthered by Alden, Griffen, Torres, Oca, Linner, Drew, Brolin, and Fobi. The Roux-en-Y gastric bypass was first performed laparoscopically by Wittgrove and Clark in 1994. Mason, in association with Printen, also initiated restrictive metabolic/bariatric surgery in 1971. Other notable contributors to the development of restrictive procedures were Gomez, LaFave, Fabito, and Laws. In 1978, gastric banding was introduced by Wilkinson; in 1986, Kuzmak invented the adjustable gastric band. Laparoscopic adjustable banding was probably first performed by Belachew, and separately by Forsell, in 1993. Since then, we have seen the advent of gastric pacing, vagal blocking, sleeve gastrectomy and other metabolic/bariatric procedures. The reader is referred to more detailed historical resources listed in the bibliography to this introduction. In addition, all sections and chapters start with a referenced brief ­historical outline. A survey of U.S. academic general surgeons, based on relative value units, indicates that metabolic/bariatric operations are ranked No. 1 and No. 3 in their practices. A similar ranking may well prevail for nonacademic surgeons in major clinical centers. Metabolic/bariatric surgery has become an intrinsic component of general surgery; it is, therefore, incumbent upon health care practitioners, medical as well as surgical, to be informed about how metabolic/ bariatric procedures are performed. This atlas is designed with such a need in mind. I intend, and indeed hope, that this work will serve as a source of specific as well as general knowledge of these procedures for surgeons in training, surgeons after training who wish to participate in this discipline, and all students of medicine, regardless of specialty.

Bibliography

Buchwald H: Introduction and current status of bariatric procedures, Surg Obes Relat Dis 4:S1–S6, 2008. Buchwald H, Avidor Y, Braunwald E, et al: Bariatric surgery: a systematic review and meta-analysis, JAMA 292:1724–1737, 2004. Buchwald H, Buchwald JN: Evolution of operative procedures for the management of morbid obesity 1950–2000, Obes Surg 12: 705–717, 2002. Buchwald H, Buchwald JN: Evolution of surgery for morbid obesity. In Pitombo C, Jones KB, Higa KD, Pareja JC, editors: Obesity ­surgery: principles and practice, New York, 2007, McGraw-Hill Medical, pp 4–14. Buchwald H, Campos CT, Varco RL, et al: Effective lipid modification by partial ileal bypass reduced long-term coronary heart disease mortality and morbidity: five-year posttrial follow-up report from the POSCH, Arch Intern Med 158:1253–1261, 1998. Buchwald H, Estok R, Fahrbach K, et al: Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis, Am J Med 122(3):248–256, 2009. Buchwald H, Matts JP, Fitch LL, et al: Changes in sequential coronary arteriograms and subsequent coronary events, JAMA 268: 1429–1433, 1992. Buchwald H, Rudser KD, Williams SE, et al: Overall mortality, incremental life expectancy, and cause of death at 25 years in the Program on the Surgical Control of the Hyperlipidemias (POSCH), Ann Surg 251:1034–1040, 2010. Buchwald H, Varco RL, editors: Metabolic surgery, New York, 1978, Grune & Stratton. Buchwald H, Varco RL, Matts JP, et al: Effect of partial ileal bypass surgery on mortality and morbidity from coronary heart disease in patients with hypercholesterolemia. Report of the Program on the Surgical Control of the Hyperlipidemias (POSCH), N Engl J Med 323:946–955, 1990. Schauer PR, Schirmer BD, Brethauer SA: Minimally invasive bariatric surgery, New York, 2007, Springer.

Section

I

Exposure and Closure of the Abdomen Access to the abdominal cavity can be gained by traditional open incisional surgery and standard laparoscopic techniques, as well as by mini-laparotomy (micro-orifice) or hybrid open/ laparoscopic approaches and natural orifice transluminal endoscopic surgery. This section contains chapters on the general principles of open and laparoscopic exposure and closure of the abdominal cavity that are in common use in metabolic/bariatric surgery today. The mini-laparotomy or hybrid open/laparoscopic operations are just now gaining recognition. These procedures consist of what has been termed “single-orifice” laparoscopic surgery with abdominal insufflation under general anesthesia; open mini-laparotomy (micro-orifice) over the site of surgery for an operation using open surgery instruments and performed under general anesthesia or sedation/local anesthesia; open mini-laparotomy, under general anesthesia or sedation/local anesthesia, using a laparoscope camera for visualization and either open or laparoscopic instruments; and a combination of open and endoscopic access to the peritoneal cavity under general anesthesia or sedation/local anesthesia. These techniques often are associated with a specific operation and may not be applicable for general abdominal entry. Natural orifice transluminal endoscopic surgery, as a unique approach to the abdominal cavity that is independent of upper endoscopic or colonoscopic surgery without gastrointestinal tract penetration, may have potential in the future if it is developed and used with strategic intent and not for the questionable purpose of avoiding a small incision or laparoscopic port placements.

1

Chapter

1

Open Abdominal Access and Closure Obtaining access to and subsequent closure of the abdominal cavity of a living person after battle wounds or other traumas have been sustained is prehistoric. Elective entry into the abdominal cavity or abdominal wall to mitigate obesity is biblical and may well represent the origin of bariatric surgery. In the Talmud it is written that Rabbi Eleazar, being morbidly obese, underwent an operation, after being given a soporific potion, wherein his abdomen or abdominal wall was opened and a number of “baskets of fat were removed.”1 Ephraim McDowell is credited as being the first surgeon in modern times to perform elective entry into the abdominal cavity for an extirpative procedure. In 1809, in Danville, Kentucky, he carried out a successful ovariotomy of a giant ovarian cyst without anesthesia in 25 minutes.2 More than 70 years later, in 1881, Billroth performed the first subtotal gastrectomy and gastroduodenostomy reconstruction with the patient under chloroform anesthesia.3 For his first case, Billroth made a high transverse incision 11 cm in length; in subsequent gastrectomies, he typically used a vertical incision. Because all of today's common bariatric surgery procedures involve the stomach, entry into the ­peritoneal cavity is generally gained by an upper midline incision. As a rule, the incision goes up to the xiphoid and a variable distance down to the umbilicus. Rarely, the incision will need to be extended by an arc-shaped incision around the umbilicus and inferiorly (e.g., to free and measure the ­terminal ileum bound by adhesions in the right lower quadrant for a biliopancreatic diversion or duodenal switch) for a concurrent ovariectomy or tubal ligation performed with inconvenient exposure by the upper midline incision.

References

1. Buchwald H: The arrival of bariatric surgery. In Gillison W, Buchwald H, editors: Pioneers in surgical gastroenterology, Shrewsbury, UK, 2007, tfm Publishing, pp 65–80. 2. Wangensteen OH, Wangensteen SD: Ovariotomy (excision of ovarian cyst). In Wangensteen OH, Wangensteen SD, editors: The rise of surgery, St Paul, MN, 1978, North Central Publishing, pp 227–237. 3. Wangensteen OH, Wangensteen SD: Gastric surgery. In Wangensteen OH, Wangensteen SD, editors: The rise of surgery, St Paul, MN, 1978, North Central Publishing, pp 142–167.

3

4   Section I  •  Exposure and Closure of the Abdomen

Technique

Figure 1-1: A midline incision from the xiphoid to above the umbilicus is the usual abdominal entry site. Some surgeons use a marking pen to indicate the path of incision. s Torso representation of incision site. ◆ Figure 1-2: The incision is made into the subcutaneous fat with the scalpel. Gentle pressure on both sides of the incision by the surgeon and assistant facilitates a straight line of entry. Small subcuticular bleeders are cauterized for hemostasis. ◆

Chapter 1  •  Open Abdominal Access and Closure   5

Figure 1-1

Figure 1-2

6   Section I  •  Exposure and Closure of the Abdomen

Figure 1-3: The surgeon and assistant apply opposing pressure on the sides of the opening and, with considerable force, tear the subcutaneous fat and Scarpa's fascia down to the linea alba. This maneuver requires several applications of subcutaneous pulling in opposite directions along the length of the incision and usually at several depths. This technique typically guarantees precise penetration down to the linea alba, with minimal bleeding and no tissue damage from the use of cautery ­coagulation. The tearing technique may not be feasible in reusing a midline incision for reentry into the abdominal cavity, in which case coagulating cautery is used to reach the linea alba. ◆ Figure 1-4: Using the cautery at a fairly low current (25 amps), the linea alba is incised along its length down to the preperitoneal fat. ◆ Figure 1-5: The preperitoneal fat and fibrous tissue envelope are peeled back by sharp and blunt ­dissection circumferentially for a distance of approximately 3 to 4 cm from the fascial edges. The ­preperitoneal fat pad is entered and excised with cautery from the wound edges, leaving it attached only at the falciform ligament. Removal of the preperitoneal fat pad provides fascial edges that are better defined for wound closure. ◆

Chapter 1  •  Open Abdominal Access and Closure   7

Figure 1-3

Figure 1-4

Figure 1-5

8   Section I  •  Exposure and Closure of the Abdomen

Figure 1-6: The falciform ligament is clamped toward the liver and cut, freeing the preperitoneal fat pad for removal. The falciform ligament is tied with a 2/0 nonabsorbable suture. ◆ Figure 1-7: Wet laparotomy pads are placed around the wound edges with dry folded towels over them on the abdominal surface to absorb spillage, and a plastic wound protector is placed and secured at the corners with clamps. The use of a wound protector guards against wound infection and also provides aesthetic boundaries for the operative field. ◆ Figure 1-8: At the appropriate time in the procedure, exposure of the attic of the abdomen is obtained with the aid of the mechanical bariatric retractor. The straight table bars are fastened to both sides of the operating table as cephalad as feasible, that is, up to the two arm boards. The cross piece is secured and the two large shovel retractors are loosely fastened subcostally, with the blades as ­lateral as possible. The patient is placed into a maximum Trendelenburg position, and the ­subcostal ­retractors are vigorously elevated cephalad and fastened. The patient is then turned into a fairly steep reverse Trendelenburg position, and the side bars of the retractor apparatus are placed up to the elbow turn. The smaller shovel retractors on short retractor arms are placed, retracted laterally, and fastened. s Maximum Trendelenburg position for fastening the upper retractors. ◆

Chapter 1  •  Open Abdominal Access and Closure   9

Falciform ligament

Figure 1-6

Figure 1-7

Figure 1-8

10   Section I  •  Exposure and Closure of the Abdomen

Figure 1-9: Complete exposure of the abdominal attic is obtained by cutting the triangular ligament of the left lobe of the liver, retracting the left lobe of the liver superiorly and to the right, and holding the lobe out of the field with the heart-shaped blade of the bariatric retractor. s Steep reverse Trendelenburg position, the position for the best operative exposure. ◆ Figure  1-10: Proper closure of the abdomen is important to avoid dehiscence, wound infection, and incisional hernia. In closing an open bariatric midline incision, interrupted fascial closure with 1-0 nonabsorbable suture is optimal, approximating and not strangulating the fascial edges, with suture placement approximately 1 cm apart and 2 cm from the fascial edge. ◆

Chapter 1  •  Open Abdominal Access and Closure   11

Figure 1-9

Figure 1-10

12   Section I  •  Exposure and Closure of the Abdomen

Figure 1-11: Alternative closure using a running, 1/0, nonabsorbable or absorbable suture. Figure 1-12: A suprafascial suction drain is placed, exited via a separate lower quadrant stab wound, and fastened by suture to the skin. The subcutaneous tissues are closed in one or two layers with running, 3/0, absorbable sutures. ◆ Figure 1-13: A cosmetic subcuticular closure with a running, 4/0, absorbable suture completes the closure. ◆

◆

Chapter 1  •  Open Abdominal Access and Closure   13

Figure 1-12

Figure 1-11

Figure 1-13

14   Section I  •  Exposure and Closure of the Abdomen

Alternative Approach

Equally suitable exposure can be obtained by using a left subcostal approach with division of the upper linear alba and the left rectus muscle and sheaths and incision into the left oblique muscles. Closure for a subcostal incision is performed in fascial layers, not in muscle layers, as well as in the linea alba, with interrupted, 2/0, nonabsorbable suture.

Chapter

2

Laparoscopic Abdominal Access and Closure Minimally invasive access into the abdominal cavity originated with pelviscopy by gynecologists and changed abdominal surgery forever with the introduction of laparoscopic cholecystectomy in 1985.1 Laparoscopic bariatric surgery was probably first performed in 1992–1993 by Broadbent et al.2 and Catona et al.,3 who placed a nonadjustable gastric band. Belachew et  al.4 and Forsell et al.5 were the first to perform laparoscopic adjustable gastric banding. These laparoscopic roots of bariatric banding may explain the early prevalence of laparoscopic adjustable gastric banding in Europe. In 1994, Wittgrove et al.6 performed the first laparoscopic gastric bypass in the United States, initiating preference for laparoscopic gastric bypass that has come to dominate the country's operative selection in the first decade of the twenty-first century. Also in 1994, Hess and Hess7 performed a laparoscopic vertical banded gastroplasty, and in 1999, Gagner and Matteotti8 undertook the first biliopancreatic diversion/duodenal switch laparoscopically. Positioning, equipment, and instrumentation for laparoscopic metabolic/bariatric surgery,9 as well as laparoscopic access to the peritoneal cavity,10 have been well tested and evaluated.

References



1. Mühe E: Die erste cholezystektomie durch das laparoskop, Langenb Arch Klin Chir 369:804, 1986. 2. Broadbent R, Tracy M, Harrington P: Laparoscopic gastric banding: a preliminary report, Obes Surg 3:63–67, 1993. 3. Catona A, Gossenberg M, La Manna A, et al: Laparoscopic gastric banding: preliminary series, Obes Surg 3:207–209, 1993. 4. Belachew M, Legrand M, Jacquet N: Laparoscopic placement of adjustable silicone gastric banding in the treatment of morbid obesity: an animal model experimental study: a video film: a preliminary report [abstract], Obes Surg 3:140, 1993. 5. Forsell P, Hallberg D, Hellers G: Gastric banding for morbid obesity: initial experience with a new adjustable band, Obes Surg 3:369–374, 1993. 6. Wittgrove AC, Clark GW, Tremblay LJ: Laparoscopic gastric bypass, roux-en-Y: preliminary report of five cases, Obes Surg 4:353–357, 1994. 7. Hess DW, Hess DS: Laparoscopic vertical banded gastroplasty with complete transaction of the staple-line, Obes Surg 4:44–46, 1994. 8. Gagner M, Matteotti R: Laparoscopic biliopancreatic diversion with duodenal switch, Surg Clin North Am 85(1):141–149, 2005. 9. Gourash W, Ramanathan RC, Hamad G, et al: Operating room positioning, equipment, and instrumentation for laparoscopic bariatric surgery. In Schauer PR, Schirmer BD, Brethauer SA, editors: Minimally invasive bariatric surgery, New York, 2007, Springer, pp 87–103. 10. Schlosser CT, Ikramuddin S: Access to the peritoneal cavity. In Schauer PR, Schirmer BD, Brethauer SA, editors: Minimally invasive bariatric surgery, New York, 2007, Springer, pp 108–111.

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16   Section I  •  Exposure and Closure of the Abdomen

Technique

Figure 2-1: Placement of port sites varies with the procedure to be performed and the personal preference of the surgeon. Most bariatric procedures require five to six port sites. The camera port is generally a 12-mm port placed in the midline. Although the location of the other ports varies, as a rule, both sides of the upper abdominal wall are used for placement; they are mostly 5-mm port sites but may include a 10- or a 15-mm port site. ◆ Figure 2-2: Insufflation of the abdominal cavity with carbon dioxide gas (experimentally, helium has been used) can be established via a spring-loaded, tension-sensing Veress needle inserted blindly. The 2-mm needle has a blunt inner cannula that automatically extends beyond the needle point upon entering the abdominal cavity. After insertion, to ensure that no tissue damage has occurred, the surgeon should aspirate the needle for blood, succus, or stool and then perform the “drop of saline” test, allowing a drop of saline placed on the hub of the needle to fall into the peritoneal cavity by gravity or on creating negative intraperitoneal pressure by lifting the abdominal wall. The carbon dioxide gas is infused via a side hole by an automatic, gauged insufflation device to a pressure of 15 mm Hg. ◆ An alternative approach into the peritoneal cavity is the Hasson technique, an open approach via a 1- to 1.5-cm incision at the umbilicus. A blunt obturator cannula is then placed into the abdominal cavity and, in general, anchored in place by fascial sutures. s Alternate site to umbilical or periumbilical site for blind insertion of the insufflation Veress needle. ◆

Chapter 2  •  Laparoscopic Abdominal Access and Closure   17

Camera port

Figure 2-1

Insufflator

Figure 2-2

18   Section I  •  Exposure and Closure of the Abdomen

Figure  2-3: Once pneumoperitoneum is achieved, the access trocars are placed under direct visualization. Initially, a 5-mm optical viewing trocar is used. Once a camera port site is established, placement of the remaining trocars is performed under laparoscopic visual control. Trocar lengths used for bariatric surgery, as a rule, are 100 and 150 mm. Cannulae types include those with pyramidal cutting tips, retractable blades, retractable “safety” shields, conical tapered tips, radial dilating cannulae, and screw devices. The threaded screw cannulae typically are preferred. The trocars should be placed perpendicular to the abdominal wall. ◆ Figure 2-4: In general, the primary surgeon stands on the right side of the patient with the first assistant facing the surgeon on the patient's left and the second assistant/camera operator and the scrub nurse toward the foot of the bed. Placing the arms out on arm boards facilitates access to the abdomen. An alternative configuration of the operating team has the surgeon standing between the abducted legs of the patient. (The introduction of robotics, for the first time in the history of surgery, places the surgeon away from the operating table; indeed, the surgeon can be in another room or facility.) s Having the patient in the reverse Trendelenburg position is preferred for visualization of the attic of the abdomen. ◆

Chapter 2  •  Laparoscopic Abdominal Access and Closure   19

Trocar

Figure 2-3

Anesthetist

Monitor Light Camera Insufflator

Monitor

1st assistant

Surgeon

2nd assistant

Instruments Nurse

Figure 2-4

20   Section I  •  Exposure and Closure of the Abdomen

Figure 2-5: Adequate exposure of the abdominal attic requires liver retraction superiorly and to the right, with or without cutting the triangular ligament of the liver. Various liver retractors are available. They are inserted via a right-sided port and fastened in a fixed position onto a retractor device mounted on the operating table. s Liver retracted superiorly and to the right. ◆ Figure 2-6: At closure, to prevent trocar site hernias, all port sites 10 mm or greater should be closed by sutures; 5-mm ports can be left without a fascial closure. Closure can be carried out by suturing performed subcutaneously (as shown) or intraperitoneally, under laparoscopic visualization. Because one of the attractions of laparoscopic surgery is cosmesis, subcuticular plastic skin closure with a 4/0 absorbable suture is advisable. s If hand-assisted, minimally invasive surgery is performed or a device has been implanted, the small fascial incision must be closed. A running horizontal, 2/0, absorbable or nonabsorbable suture can be used for this purpose. ◆

Chapter 2  •  Laparoscopic Abdominal Access and Closure   21

Liver retractor

Figure 2-5

Figure 2-6

Section

II

Primarily Malabsorptive Procedures Bariatric surgery started with a malabsorptive procedure—the jejunoileal bypass. Malabsorptive procedures are also maldigestive because they limit the small intestinal length and surface area to create decreased digestion of normal foods and decreased absorption of digested food elements. Thus, malabsorptive procedures result in the burning of body mass (preferably fat and not lean body mass). Weight loss ceases when a balance is reached between caloric absorption and expenditure, which is a function of intestinal adaptation and decreased caloric needs for a reduced body mass. The first operations for obesity occurred in 1953, although they were not reported in a timely fashion in the literature. Dr. Victor Henrikson of Gothenburg, Sweden, was credited with performing an intestinal resection specifically for the management of obesity.1 Dr. Richard L. Varco of the University of Minnesota probably performed the first jejunoileal bypass for obesity.2 This operation consisted of an end-to-end jejunoileostomy with a separate ileocecostomy for drainage of the bypassed small intestine. In 1954, Kremen et al.3 published the first case report of a jejunoileal bypass for obesity. In the discussion section of a research article on nutritional aspects of the small intestine, these authors described a patient for whom they had performed an end-to-end jejunoileal bypass for weight loss. After a hiatus of some years, in 1963, Payne et al.4 published results of the first clinical program of massive intestinal bypass for the management of morbidly obese patients. In a series that they had initiated in 1956, they described bypassing nearly the entire small intestine, the right colon, and half of the transverse colon in 10 morbidly obese female patients. Intestinal continuity was restored by a T-shaped end-to-side anastomosis of the proximal 40 cm of jejunum to the mid-transverse colon. This procedure was originally designed by Payne and DeWind5 to lead to unlimited weight loss, requiring a second operation to restore additional intestinal length and weight equilibrium when ideal body weight was attained. However, after their second operation, all the patients in their series regained their previously lost weight.

23

24   Section II  •  Primarily Malabsorptive Procedures Sherman et al.,6 along with Payne and DeWind,5 proposed abandonment of anastomosis to the colon and, instead, restoration of intestinal continuity proximal to the ileocecal valve by endto-side jejunoileostomy. The aim of this less radical bypass was to achieve an eventual balance between caloric intake and body caloric needs, eliminating the necessity for a second operation and minimizing postoperative adverse effects. Along this path, in 1962, Lewis et al.7 reported an end-to-side jejunotransverse colostomy (similar to that of Payne and DeWind) in which the proximal 75 cm of jejunum were anastomosed to the transverse colon. As in Payne's series, significant complications eventually required reversal of these bypasses.8 In 1966, Lewis et al.9 described 11 patients in whom they performed an end-to-side jejunocecostomy, a procedure that foreshadowed implementation of a less radical approach. Completing this evolution, Payne and DeWind5 entirely abandoned bypass to the colon. In 1969, in a series of 80 morbidly obese patients, they established what was to become a standard for the end-to-side jejunoileostomy procedure: anastomosis of the proximal 14 inches of jejunum to the terminal ileum, 4 inches from the ileocecal valve. This operation became the most commonly used bariatric operation in the United States in the early 1970s—the “14 + 4” jejunoileal bypass. Although Payne and DeWind's classic jejunoileal bypass was widely adopted, nearly 10% of patients did not achieve significant weight loss, possibly because of the reflux of nutrients into the bypassed ileum.8 Thus, Scott et al.,10 Salmon,11 and Buchwald and Varco2 independently returned to the original procedure by Varco and Kremen et al.3 of an end-to-end anastomosis to prevent reflux into the terminal ileum. In all these end-to-end operations, the ileocecal valve was preserved to decrease postoperative diarrhea and electrolyte loss. The appendix was removed and the jejunal stump was attached to the transverse mesocolon or the cecum to avoid intussusception. In addition to producing significant weight loss, the Buchwald and Varco operation proved valuable in the management of obese hyperlipidemic patients by demonstrating marked reductions in cholesterol and triglyceride levels.12 The jejunoileal bypass was a highly effective weight-reduction operation but was associated with gasbloat syndrome, steatorrhea, electrolyte imbalance, nephrolithiasis, hepatic fibrosis, cutaneous eruptions, and impaired mentation. With the advent of the gastric bypass in 1967 and its improvement in the 1970s, the jejunoileal bypass fell out of favor and essentially was abandoned in the early 1980s.2 Malabsorptive procedures did not become extinct, only dormant; they reemerged in the 1970s and became prevalent globally in the 1990s. The newer, primarily malabsorptive procedures, which are currently popular, circumvented most of the complications of the jejunoileal bypass by eliminating stasis in the bypassed intestinal segment, which had allowed bacterial overgrowth, predominantly of anaerobic bacteria, causing secondary intestinal complications and systemic toxicity. This evolution was accomplished by the separation of ingested food (alimentary limb) from bile and pancreatic juice (biliopancreatic limb) until the two limbs were joined in a common terminal ileal channel. The two dominant primarily malabsorptive procedures today are the biliopancreatic diversion and the biliopancreatic diversion/duodenal switch or, simply, the duodenal switch. References

1. Henrikson V: Kan tunnfarmsresektion forsvaras som terapi mot fettsot? Nord Med 47:744, 1952. Can small bowel resection be defended as therapy for obesity? Obes Surg 4:54, 1994. 2. Buchwald H, Rucker RD: The rise and fall of jejunoileal bypass. In Nelson RL, Nyhus LM, editors: Surgery of the small intestine, Norwalk, CT, 1987, Appleton Century Crofts, pp 529–541. 3. Kremen AJ, Linner LH, Nelson CH: An experimental evaluation of the nutritional importance of proximal and distal small intestine, Ann Surg 140:439–444, 1954. 4. Payne JH, DeWind LT, Commons RR: Metabolic observations in patients with jejunocolic shunts, Am J Surg 106:272–289, 1963. 5. Payne JH, DeWind LT: Surgical treatment of obesity, Am J Surg. 118:141–147, 1969. 6. Sherman CH, May AG, Nye W: Clinical and metabolic studies following bowel bypassing for obesity, Ann NY Acad Sci 131:614–622, 1965. 7. Lewis LA, Turnbull RB, Page LH: “Short-circuiting” of the small intestine, JAMA 182:77–79, 1962. 8. Deitel M: Jejunocolic and jejunoileal bypass: an historical perspective. In Deitel M, editor: Surgery for the morbidly obese patient, Philadelphia, 1998, Lea & Febiger, pp 81–89. 9. Lewis LA, Turnbull RB, Page LH: Effects of jejunocolic shunt on obesity, serum lipoproteins, lipids, and electrolytes, Arch Intern Med 117:4–16, 1966. 10. Scott HW, Sandstead HH, Brill AB: Experience with a new technic of intestinal bypass in the treatment of morbid obesity, Ann Surg 174:560–572, 1971. 11. Salmon PA: The results of small intestine bypass operations for the treatment of obesity, Surg Gynecol Obstet 132:965–979, 1971. 12. Buchwald H, Varco RL: A bypass operation for obese hyperlipidemic patients, Surgery 70:62–70, 1971.

Chapter

3

Biliopancreatic Diversion Of historical note, two attempts at biliointestinal bypasses were made to provide for the malabsorptive effect of jejunoileal bypass without a segment of intestinal stasis. In 1978, Lavorato et al.1 reported a standard end-to-side jejunoileal bypass, but with the proximal end of the bypassed segment of the small intestine anastomosed to the gallbladder. In 1981, a similar operation was described by Eriksson.2 For practical purposes, the modern malabsorptive era in bariatric surgery was initiated by Scopinaro of Genoa, Italy. After several years of careful laboratory research,3 he reported on his biliopancreatic diversion in humans in 1979.4 More than 3 decades later, the Scopinaro procedure is performed worldwide and has been intensively studied by its originator and colleagues with respect to weight loss achieved, reduction of obesity comorbidities, protein balance, lipid metabolism, and the operation's physiologic mechanisms of action.5-8 Scopinaro et al.9 have published a summation of their work with the biliopancreatic diversion procedure. The current biliopancreatic diversion consists of a horizontal partial gastrectomy, leaving up to 500  mL of proximal stomach, closure of the duodenal stump, a nonrestrictive gastrojejunostomy with a 250-cm Roux alimentary limb, and anastomosis of the long biliopancreatic limb to the Roux limb 50  cm proximal to the ileocecal valve, creating an extremely short common channel.9

References

1. Lavorato F, Doldi SB, Scaramella R: Evoluzione storica della terapia chirurgica della grande obesita, Minerva Med 69: 3847–3857, 1978. 2. Eriksson F: Biliointestinal bypass, Int J Obes 5:437–447, 1981. 3. Scopinaro N, Gianetta E, Civalleri D, et al: Biliopancreatic bypass for obesity: I: an experimental study in dogs, Br J Surg 66: 613–617, 1979. 4. Scopinaro N, Gianetta E, Civalleri D: Biliopancreatic bypass for obesity: II: initial experience in man, Br J Surg 66:618–620, 1979. 5. Scopinaro N, Marinari GM, Adami GF, et al: The influence of gastric volume on energy and protein absorption after BPD, Obes Surg 9:125–126, 1999. 6. Scopinaro N, Marinari GM, Gianetta E, et al: The respective importance of the alimentary limb (AL) and the common limb (CL) in protein absorption (PA) after BPD, Obes Surg 7:108, 1997. 7. Scopinaro N, Marinari GM, Camerini G, et al: Energy and nitrogen absorption after biliopancreatic diversion, Obes Surg 10:436–441, 2000. 8. Scopinaro N, Adami GF, Marinari G, et al: The effect of biliopancreatic diversion on glucose metabolism, Obes Surg 7:296–297, 1997. 9. Scopinaro N, Papadia F, Marinari GM, et al: Biliopancreatic diversion. In Buchwald H, Pories W, Cowan GB Jr, editors: Surgical management of obesity, Philadelphia, 2006, Elsevier, pp 239–251.

25

26   Section II  •  Primarily Malabsorptive Procedures

Open scopinaro technique

Figure 3-1: A midline incision from the xiphoid to above the umbilicus is the usual abdominal entry site. Some surgeons use a marking pen to indicate the path of incision. s Torso representation of incision site. ◆ Figure 3-2: The incision is made into the subcutaneous fat with the scalpel. Gentle pressure on both sides of the incision by the surgeon and assistant facilitate a straight line of entry. The small subcuticular bleeders are cauterized for hemostasis. ◆

Chapter 3  •  Biliopancreatic Diversion   27

Figure 3-1

Figure 3-2

28   Section II  •  Primarily Malabsorptive Procedures

Figure 3-3: The surgeon and assistant apply opposing pressure on the sides of the opening and, with considerable force, tear the subcutaneous fat and Scarpa's fascia down to the linea alba. This maneuver requires several applications of subcutaneous pulling in opposite directions along the length of the incision and usually at several depths. This technique typically guarantees precise penetration down to the linea alba, with minimal bleeding and no tissue damage from the use of cautery coagulation. The tearing technique may not be feasible in reusing a midline incision for reentry into the abdominal cavity, in which case coagulating cautery is used to reach the linea alba. ◆ Figure  3-4: With the cautery at a fairly low current (25 amps), the linea alba is incised along its length down to the preperitoneal fat. (For further review of the technique for open abdominal access, see Section I, Chapter 1.) ◆ Figure 3-5: The common channel is measured proximally from the ileocecal valve by using an umbilical tape calibrated against a ruler. Measurement is preferred along the mesenteric border of the bowel, which is more constant than the antimesenteric border in its measured length. s Scopinaro currently uses a 50-cm common channel. ◆

Chapter 3  •  Biliopancreatic Diversion   29

Figure 3-3

Figure 3-4

50 cm

Figure 3-5

30   Section II  •  Primarily Malabsorptive Procedures

Figure 3-6: The jejunoileostomy site is marked with sutures placed through the mesentery and ­circumferentially around the bowel. ◆ Figure 3-7: The 250-cm Roux limb is measured and the jejunum is divided with the linear intestinal stapler using 3.5-mm staples (blue load). The jejunal mesentery is divided for a distance of 4 to 6  cm to allow for mobility of the cut ends. This mesenteric division can be performed with the linear stapler, cautery, knife or scissor, or a powered tissue divider, along with ligation of vessels if necessary. s Jejunal division at 300  cm from the ileocecal valve (50-cm common channel plus 250-cm Roux limb). ◆

Chapter 3  •  Biliopancreatic Diversion   31

Figure 3-6

300 cm

Figure 3-7

32   Section II  •  Primarily Malabsorptive Procedures

Figure 3-8: The divided, stapled jejunal ends, representing the proximal end of the Roux limb and the distal end of the biliopancreatic limb, are oversewn with interrupted, 5/0, nonabsorbable sutures. The sutures are taken in the Lembert fashion, inverting the staple line of the divided bowel. ◆ Figure 3-9: The jejunoileostomy is created by anastomosis of the distal, stapled end of the biliopancreatic limb, side to side, to the junction of the common channel and the alimentary, or Roux, limb, 50  cm from the ileocecal valve. The illustration shows the orientation of the alimentary, or Roux, limb on the patient's right side, with the biliopancreatic limb on the left and the oversewn stapled end of the biliopancreatic limb facing inferiorly. Marking sutures of 5/0 nonabsorbable material are placed, and 1-cm long enterotomies are made with the cautery. ◆ Figure  3-10: The enterotomies are lengthened with a spreading motion made with a clamp. ◆

Chapter 3  •  Biliopancreatic Diversion   33

Figure 3-8

Alimentary limb

Biliopancreatic limb

Figure 3-9

Figure 3-10

34   Section II  •  Primarily Malabsorptive Procedures

Figure 3-11: A jejunoileostomy is created with the intestinal linear stapler, using 3.5-mm staples (blue load), set at an anastomotic orifice length of 2.5  cm or longer. ◆ Figure 3-12: The enterotomies and the entire anterior staple line are oversewn with interrupted, 5/0, nonabsorbable sutures taken in the Lembert fashion. ◆ Figure 3-13: The anastomosis is turned over and the entire posterior staple line is oversewn in similar fashion with interrupted, 5/0, nonabsorbable sutures taken in the Lembert fashion. This maneuver, though often omitted, is a valuable safeguard against an anastomotic leak. ◆

Chapter 3  •  Biliopancreatic Diversion   35

Figure 3-11

Figure 3-12

Figure 3-13

36   Section II  •  Primarily Malabsorptive Procedures

Figure 3-14: The mesenteric defect created by the jejunoileostomy must be carefully closed to prevent an internal hernia. A running, 3/0, nonabsorbable or absorbable suture is generally used; interrupted, 5/0, nonabsorbable sutures can be used instead. ◆ Figure 3-15: Attention is now turned to the upper abdominal portion of the procedure. The bariatric retractor is secured to the table. With the patient in the steep Trendelenburg position, the large shovels of the retractor are placed, maximally elevated, and secured below the right and left costal margins. The patient's position is then reversed to the steep reverse Trendelenburg position for the remainder of the operation. The side arms of the retractor are placed, and the wound is opened maximally in the transverse direction. The left lateral ligament of the liver is taken down, and the liver is reflected to the right with the heart-shaped blade of the bariatric retractor. The duodenum is mobilized from above and below until a clear passage beneath the duodenum is established. The vasculature of the tissue plane above the duodenum is extremely rich and requires a powered tissue divider or individual clamping and ligation of the vessels. Care must be taken not to injure the common bile duct or other portal structures. The mesentery below the duodenum is also quite vascular and requires careful dissection and hemostasis. Once a finger can comfortably be inserted underneath the duodenum, about 4  cm from the pylorus, the duodenum is ready for division. s Finger inserted beneath duodenum. ◆ Figure  3-16: When the first portion of the duodenum is cleared, it is divided with the linear stapler and the duodenal stump is inverted and oversewn using interrupted, 4/0, nonabsorbable sutures. Care must be taken to maintain an approximately 2-cm rim of duodenum beyond the pylorus and not to injure the common bile duct. s Duodenal stump staple line inverted and oversewn. ◆

Chapter 3  •  Biliopancreatic Diversion   37

Figure 3-14

Figure 3-15

Figure 3-16

38   Section II  •  Primarily Malabsorptive Procedures

Figure 3-17: Next, the gastric resection is carried out. The lower two-thirds of the greater curvature short gastric vessels are taken down with a powered tissue divider or by clamping and ligation. In a similar fashion, the lesser curvature hepatogastric mesentery is divided from the pylorus to the ­origin of the left gastric artery, including the right gastric artery. The stomach is then divided with the linear stapler by using 3.5-mm staples (blue load); this maneuver usually requires several stapler applications. Alternatively, the laparoscopic linear stapling instrument can be used to perform the gastric division. The line of resection of the stomach is oblique and more inferior on the greater curvature side to facilitate subsequent gastrojejunostomy. The subtotal gastrectomy specimen is removed from the field. s The stomach is divided obliquely below the origin of the left gastric artery. ◆ Figure 3-18: The alimentary Roux limb is brought up to the stomach, antecolic or retrocolic, and the gastrojejunostomy is performed. This maneuver can be performed in a manner similar to the jejunoileostomy described in Figures 3-9 to 3-13, using the linear stapler and oversewing the anterior and posterior staple lines with interrupted, 5/0, nonabsorbable sutures taken in the Lembert fashion. Some surgeons prefer a running closure. Alternatively, a hand-sewn, single- or double-layer gastrojejunostomy can be performed. The size of the gastric pouch can be as large as 500 mL; the gastrojejunostomy orifice diameter is greater than 2 cm and is therefore not restrictive. If the alimentary Roux limb is brought up retrocolic, it is important to close the mesocolon around, and to, the jejunal limb. Closure of Peterson's defect is optional. s Hand-sewn anastomosis alternative. ◆

Chapter 3  •  Biliopancreatic Diversion   39

Figure 3-17

Figure 3-18

40   Section II  •  Primarily Malabsorptive Procedures

◆

Figure 3-19: Completed biliopancreatic diversion with a nonrestrictive, large gastric pouch, a measured common channel, and a measured alimentary Roux limb. A subtotal distal gastrectomy has been performed, the duodenal stump has been carefully closed, and bowel continuity has been restored by gastrojejunostomy and jejunoileostomy, with closure of mesenteric defects.

Laparoscopic scopinaro technique

◆

Figure 3-20: Placement of port sites varies with the procedure to be performed and the personal preference of the surgeon. Most bariatric procedures require five to six port sites. The camera port generally is a 12-mm port placed in the midline. The location of the other ports varies, but as a rule, both sides of the upper abdominal wall are used for placement; they are mostly 5-mm port sites but may include a 10- or a 15-mm port site.

Chapter 3  •  Biliopancreatic Diversion   41

Stomach pouch

Alimentary limb

Biliopancreatic limb

Jejunoileostomy

Common channel

Figure 3-19

Figure 3-20

42   Section II  •  Primarily Malabsorptive Procedures

Figure 3-21: Insufflation of the abdominal cavity with carbon dioxide gas (experimentally, helium has been used) can be established via a spring-loaded, tension-sensing Veress needle inserted blindly. The 2-mm needle has a blunt inner cannula that automatically extends beyond the needle point upon entering the abdominal cavity. After insertion, to ensure that no tissue damage has occurred, the surgeon should aspirate the needle for blood, succus, or stool and then perform the “drop of saline” test, allowing a drop of saline placed on the hub of the needle to fall into the peritoneal cavity by gravity or on creating negative intraper­ itoneal pressure by lifting the abdominal wall. The carbon dioxide gas is infused via a side hole by an automatic gauged insufflation device to a pressure of 15  mm Hg. An alternative approach into the peritoneal cavity is the Hasson technique, which is an open approach via a 1- to 1.5-cm incision at the umbilicus. A blunt obturator cannula is then placed into the abdominal cavity and, in general, anchored in place by fascial sutures. s Alternate site to the umbilical or periumbilical site for blind insertion of the insufflation Veress needle. ◆ Figure  3-22: Once pneumoperitoneum is achieved, the access trocars are placed under direct visualization. A 5-mm optical viewing trocar is initially used. Once a camera port site is established, placement of the remaining trocars is performed under laparoscopic visual control. Trocar lengths used for bariatric surgery, as a rule, are 100 and 150  mm. Cannulae types include those with pyramidal cutting tips, retractable blades, retractable “safety” shields, conical tapered tips, radial dilating cannulae, and screw devices. The threaded screw cannulae are usually preferred. The trocars should be placed perpendicular to the abdominal wall. ◆

Chapter 3  •  Biliopancreatic Diversion   43

Insufflator

Figure 3-21

Trocar

Figure 3-22

44   Section II  •  Primarily Malabsorptive Procedures

Figure 3-23: In general, the primary surgeon stands on the right side of the patient, the first assistant faces the surgeon on the patient's left, and the second assistant/camera operator and the scrub nurse are positioned toward the foot of the bed. Placing the patient's arms out on arm boards facilitates access to the abdomen. An alternative configuration of the operating team has the surgeon standing between the abducted legs of the patient. (The introduction of robotics places the surgeon away from the operating table for the first time in the history of surgery; indeed, the surgeon can be in another room or facility.) (For further review of the technique for laparoscopic abdominal access, see Section I, Chapter 2.) s Having the patient in the reverse Trendelenburg position is preferred for visualization of the attic of the abdomen. ◆ Figure  3-24: The common channel is measured proximally from the ileocecal valve by judgment of 10-cm lengths taken between laparoscopic graspers. The jejunoileostomy site is marked with a suture placed through the mesentery and circumferentially around the bowel. s Scopinaro currently uses a 50-cm common channel. ◆

Chapter 3  •  Biliopancreatic Diversion   45

Anesthetist

Monitor Light Camera Insufflator

Monitor

1st assistant

Surgeon

2nd assistant

Instruments Nurse

Figure 3-23

50 cm

Figure 3-24

46   Section II  •  Primarily Malabsorptive Procedures

Figure 3-25: The 250-cm Roux limb is measured and the jejunum is divided with the linear laparoscopic intestinal cutting stapler with 3.5-mm staples (blue load). Thus, the bowel division is 300  cm from the ileocecal valve (a 50-cm common channel and a 250-cm Roux limb). The jejunal mesentery is divided for a distance of 4 to 6  cm to allow mobility of the cut ends. The mesenteric division is created with the cutting linear stapler. s The divided stapled jejunal ends, representing the proximal end of the Roux limb and the distal end of the biliopancreatic limb, may be oversewn with interrupted or running, 2/0, nonabsorbable sutures. The sutures are taken in the Lembert fashion, inverting the staple line of the divided bowel. Many, if not most, laparoscopic surgeons do not oversew these end-bowel staple lines. ◆ Figure 3-26: The jejunoileostomy is created by anastomosis of the distal, stapled end of the biliopancreatic limb, side to side, to the junction of the common channel and the alimentary, or Roux, limb, 50  cm from the ileocecal valve. The illustration shows the orientation of the alimentary, or Roux, limb on the patient's right side with the biliopancreatic limb on the left and the oversewn stapled end of the biliopancreatic limb facing inferiorly. Marking sutures are placed attaching the two intestinal segments, and 1-cm long enterotomies are made with the cautery instrument. ◆ Figure 3-27: The enterotomies are lengthened with a spreading motion with a laparoscopic grasper. ◆

Chapter 3  •  Biliopancreatic Diversion   47

Figure 3-25

Alimentary limb

Enterotomy Biliopancreatic limb

Figure 3-26

Figure 3-27

48   Section II  •  Primarily Malabsorptive Procedures

Figure 3-28: The jejunoileostomy anastomosis is created with the laparoscopic linear stapler, with 3.5-mm staples (blue load) set at an anastomotic orifice length of 2.5 cm or longer. ◆ Figure 3-29: The orifice of the enterotomies is oversewn with a running, nonabsorbable suture. As an alternative approach, this orifice can be closed with interrupted sutures taken in the Lembert fashion. Some surgeons prefer to oversew both the entire anterior staple line and the entire posterior staple line. s Anastomotic closure with interrupted sutures. ◆

Chapter 3  •  Biliopancreatic Diversion   49

Figure 3-28

Figure 3-29

50   Section II  •  Primarily Malabsorptive Procedures

Figure 3-30: The mesenteric defect created by the jejunoileostomy must be carefully closed to prevent an internal hernia. ◆ Figure 3-31: Attention is now turned to the upper abdominal portions of the procedure. The patient is placed in the reverse Trendelenburg position, and the liver is elevated with the laparoscopic liver retractor. The duodenum is mobilized from above and below until a clear passage beneath the duodenum is established. The vasculature of the tissue plane above the duodenum is extremely rich and requires a powered tissue divider. Care must be taken not to injure the common bile duct or other portal structures. The mesentery below the duodenum is also quite vascular and requires careful dissection and hemostasis. Once a grasper can comfortably be inserted underneath the duodenum, 4  cm from the pylorus and short of the common bile duct, the duodenum is ready for division. s Grasper inserted underneath the duodenum. ◆ Figure 3-32: When the first portion of the duodenum is cleared, it is divided with the linear stapler. Oversewing the duodenal stump is optional but highly recommended. s Duodenal stump staple line inverted and oversewn. ◆

Chapter 3  •  Biliopancreatic Diversion   51

Figure 3-30

Figure 3-31

Figure 3-32

52   Section II  •  Primarily Malabsorptive Procedures

Figure 3-33: Next, the gastric resection is carried out. The lower two-thirds of the greater curvature short gastric vessels are taken down with a powered tissue divider. In a similar fashion, the lesser curvature hepatogastric mesentery is divided from the pylorus to the origin of the left gastric artery, including the right gastric artery. The stomach is then divided with the laparoscopic linear stapler with 3.5-mm staples (blue load); this maneuver usually requires several applications of the linear stapler. The gastric division is taken from the lesser curvature side of the stomach to the greater curvature side. The line of resection of the stomach is oblique and more inferior on the greater curvature side to facilitate subsequent gastrojejunostomy. The subtotal gastrectomy specimen is removed from the field. s Oblique division of the stomach with the lesser curvature side shorter than the greater curvature side. ◆ Figure 3-34: The alimentary, or Roux, limb is brought up to the stomach, antecolic or retrocolic, and the gastrojejunostomy is performed. This maneuver can be performed in a manner similar to the jejunoileostomy, described in Figures 3-9 to 3-12, with the linear stapler. The orifices created for the linear stapler are oversewn with a running suture or interrupted sutures. Most surgeons oversew the entire anterior staple line, and many surgeons oversew the posterior staple line as well. Alternatively, a hand-sewn, single- or double-layer gastrojejunostomy can be performed. The size of the gastric pouch can be as large as 500 mL; the gastrojejunostomy orifice diameter is greater than 2 cm and is therefore not restrictive. If the alimentary limb is brought up retrocolic, it is important to close the mesocolon around, and to, the jejunal limb. Closure of Peterson's defect is optional. s Gastrojejunostomy being hand sewn. ◆ Figure  3-35: Completed biliopancreatic diversion with a nonrestrictive, large gastric pouch, a measured channel, and a measured alimentary limb. A subtotal distal gastrectomy has been performed, the duodenal stump has been carefully closed, and bowel continuity has been restored by gastrojejunostomy and jejunoileostomy, with closure of mesenteric defects. ◆

Chapter 3  •  Biliopancreatic Diversion   53

Figure 3-33

Figure 3-34

Stomach pouch

Alimentary limb

Biliopancreatic limb

Jejunoileostomy

Common channel

Figure 3-35

Chapter

44

Biliopancreatic Diversion/ Duodenal Switch More than a decade after the advent of the biliopancreatic diversion, the procedure was modified to the biliopancreatic diversion/duodenal switch, or just the duodenal switch, in Canada and the United States. In the early 1990s, Marceau et al.1 of Montreal, Canada, and Hess and Hess2 of Bowling Green, Ohio, deviated from the Scopinaro biliopancreatic diversion by performing a vertical gastrectomy with construction of a lesser curvature gastric tube, preserving the pylorus, anastomosing the alimentary limb to the proximal duodenum, and isolating biliopancreatic flow from the alimentary limb. Marceau et  al.1 created the biliopancreatic limb by cross-stapling the duodenum without division distal to the duodenoileostomy. Unlike the stomach, however, the duodenum does not tolerate cross-­stapling, and patients who underwent this procedure displayed disruption of the staple line and regained weight. The Hess and Hess procedure2 divided the duodenum with closure of the distal duodenal stump. The Hess and Hess operation has persisted in today's bariatric surgery armamentarium. The modern duodenal switch, as a rule, creates a vertical gastric pouch with approximately 100-mL capacity and a common channel that varies between 75 and 150  cm, with no general agreement regarding the lengths of the biliopancreatic limb and the alimentary limb.3 The duodenal switch is not strictly a primarily malabsorptive procedure, as was the jejunoileal bypass and as is the biliopancreatic diversion. The sleeve gastrectomy, to accomplish the vertical partial gastrectomy of the duodenal switch, may have a restrictive function and also may have a hormonal, metabolic effect by removing the main ghrelin-secreting area. In addition, the sleeve gastrectomy disrupts the natural gastric pacer and propagation of gastric waves, which may, at least in the short term, stimulate weight loss. Advocacy for a two-stage duodenal switch was originally based on high mortality and morbidity rates after attempting the single-stage duodenal switch.4 Eventually, this thinking led to the advocacy of a sleeve gastrectomy as a simple, freestanding operation (see Section IV, Chapter 10). We prefer the performance of a duodenal switch in a single stage and believe the ­single-stage procedure can be performed safely in super-obese patients (body mass index >50  kg/m2) as well as in morbidly obese patients (body mass index 40, or 35 with comorbidities, to 50  kg/m2).3 References

1. Marceau P, Biron S, Bourque R-A, et al: Biliopancreatic diversion with a new type of gastrectom, Obes Surg 3:29–35, 1993. 2. Hess DW, Hess DS: Biliopancreatic diversion with a duodenal switch, Obes Surg 8:267–282, 1998. 3. Buchwald H, Kellogg TA, Leslie DB, et al: Duodenal switch operative mortality and morbidity are not impacted by BMI, Ann Surg 248:541–548, 2008. 4. Kim WW, Gagner M, Kini S, et al: Laparoscopic vs. open biliopancreatic diversion with duodenal switch: a comparative study, J Gastrointest Surg 7:552–557, 2003.

55

56   Section II  •  Primarily Malabsorptive Procedures

Open technique

Figure 4-1: A midline incision from the xiphoid to above the umbilicus is the usual abdominal entry site. Some surgeons use a marking pen to indicate the path of incision. s Torso representation of incision site. ◆ Figure 4-2: The incision is made into the subcutaneous fat with the scalpel. Gentle pressure on both sides of the incision by the surgeon and assistant facilitate a straight line of entry. The small subcuticular bleeders are cauterized for hemostasis. ◆

Chapter 4  •  Biliopancreatic Diversion/Duodenal Switch   57

Figure 4-1

Figure 4-2

58   Section II  •  Primarily Malabsorptive Procedures

Figure 4-3: The surgeon and assistant apply opposing pressure on the sides of the opening and, with considerable force, tear the subcutaneous fat and Scarpa's fascia down to the linea alba. This maneuver requires several applications of subcutaneous pulling in opposite directions along the length of the incision and usually at several depths. This technique typically guarantees precise penetration down to the linea alba, with minimal bleeding and no tissue damage from the use of cautery coagulation. The tearing technique may not be feasible in reusing a midline incision for reentry into the abdominal cavity, in which case coagulating cautery is used to reach the linea alba. ◆ Figure 4-4: Using the cautery at a fairly low current (25 amps), the linea alba is incised along its length down to the preperitoneal fat. (For further review of the technique for open abdominal access, see Section I, Chapter 1.) ◆ Figure 4-5: The common channel is measured proximally from the ileocecal valve by using an umbilical tape calibrated against a ruler. Measurement is preferred along the mesenteric border of the bowel, which is more constant than the antimesenteric border in its measured length. s We generally use a 75-cm common channel; rarely, we use a 100-cm channel. ◆

Chapter 4  •  Biliopancreatic Diversion/Duodenal Switch   59

Figure 4-3

Figure 4-4

75-100 cm

Figure 4-5

60   Section II  •  Primarily Malabsorptive Procedures

Figure 4-6: The jejunoileostomy site is marked with sutures placed through the mesentery and circumferentially around the bowel. ◆ Figure 4-7: No globally accepted lengths have been established for the alimentary limb or the biliopancreatic limb of a duodenal switch. Various formulas of fixed lengths or percentages have been proposed. We measure the small intestine from the marking suture delineating the upper end of the common channel to the ligament of Treitz and divide this length, whatever it is, in half. The jejunum is divided with the linear intestinal stapler using 3.5-mm staples (blue load). The jejunal mesentery is divided for a distance of 4 to 6 cm to allow for mobility of the cut ends. This mesenteric division can be performed with the linear stapler, cautery, knife or scissor, or powered tissue divider, with ligation of vessels if necessary. s Jejunal division at 75-cm common channel plus half of residual small intestine (approximately 400  cm). ◆

Chapter 4  •  Biliopancreatic Diversion/Duodenal Switch   61

Figure 4-6

~400 cm

Figure 4-7

62   Section II  •  Primarily Malabsorptive Procedures

Figure 4-8: The divided, stapled jejunal ends, representing the proximal end of the Roux limb and the distal end of the biliopancreatic limb, are oversewn with interrupted, 5/0, nonabsorbable sutures. The sutures are taken in the Lembert fashion, inverting the staple line of the divided bowel. ◆ Figure 4-9: The jejunoileostomy is created by anastomosis of the distal, stapled end of the biliopancreatic limb, side to side, to the junction of the common channel and alimentary limb 75  cm from the ileocecal valve. The illustration shows the orientation of the alimentary limb on the patient's right side, with the biliopancreatic limb on the left, and the oversewn stapled end of the biliopancreatic limb facing inferiorly. Marking sutures of 5/0 nonabsorbable material are placed and enterotomies 1 cm in length are made with the cautery. ◆ Figure  4-10: The enterotomies are lengthened with a spreading motion made with a clamp. ◆

Chapter 4  •  Biliopancreatic Diversion/Duodenal Switch   63

Figure 4-8

Alimentary limb

Biliopancreatic limb

Figure 4-9

Figure 4-10

64   Section II  •  Primarily Malabsorptive Procedures

Figure 4-11: The jejunoileostomy is created with the intestinal linear stapler and 3.5-mm staples set at an anastomotic orifice length of 2.5  cm. ◆ Figure 4-12: The enterotomies and the entire anterior staple line are oversewn, closing the anastomosis with interrupted, 5/0, nonabsorbable sutures taken in the Lembert fashion. ◆ Figure 4-13: The anastomosis is turned over and the entire posterior staple line is oversewn in ­similar fashion with interrupted, 5/0, nonabsorbable sutures taken in the Lembert fashion. Although this maneuver is often omitted, it is a valuable safeguard against an anastomotic leak. ◆

Chapter 4  •  Biliopancreatic Diversion/Duodenal Switch   65

Figure 4-11

Figure 4-12

Figure 4-13

66   Section II  •  Primarily Malabsorptive Procedures

Figure 4-14: The bowel is returned to its original position and the mesenteric intestinal defect is closed with a running, 3/0, absorbable suture. Often this step is left to the end of the procedure to provide greater mobility of the alimentary limb and is combined at the end with closure of Peterson's defect. ◆ Figure 4-15: Attention is now turned to the upper abdominal portion of the procedure. The bariatric retractor is secured to the table. With the patient in the steep Trendelenburg position, the large shovels of the retractor are placed, maximally elevated, and secured below the right and left costal margins. The patient's position is then reversed to the steep reverse Trendelenburg for the remainder of the operation. The side arms of the retractor are placed, and the wound is opened maximally in the transverse direction. The left lateral ligament of the liver is taken down, and the liver is reflected to the right with a Harrington blade of the bariatric retractor. s Reverse Trendelenburg position. ◆

Chapter 4  •  Biliopancreatic Diversion/Duodenal Switch   67

Figure 4-14

Figure 4-15

68   Section II  •  Primarily Malabsorptive Procedures

Figure 4-16: The short gastric vessels are divided, starting inferiorly, with a powered tissue divider or individual clamping and ligation of the vessels. This dissection starts at a point opposite the pes anserinus and ascends to the esophagogastric junction. Some surgeons start this division at the pylorus. Dissection of the esophagogastric junction requires careful division of the uppermost short gastric vessels, which often are extremely short between the stomach and the spleen. ◆ Figure 4-17: A linear, cutting stapling instrument with 2.5-mm staples is used to perform the sleeve gastrectomy portion of the procedure. The stapler is first applied inferiorly at the cleared area opposite the pes anserinus or at the pylorus. This maneuver is performed after a bougie is placed by the anesthesia team into the lumen of the stomach; we prefer using a small, #24 Fr bougie. We resect the stomach a loose 2 to 4  cm from the edge of the bougie placed along the lesser curvature of the stomach. Other surgeons prefer using a larger bougie, up to #40 Fr, and cutting/stapling the stomach more tightly on the bougie. Although a standard linear anastomotic stapler can be used (as illustrated), we prefer using the laparoscopic linear/cutting stapler for this maneuver. ◆ Figure 4-18: The stomach is divided by successive applications of the linear stapler; approximately seven applications of the stapler are required. We end this dissection just short of the esophagogastric fat pad. The sleeve gastrectomy specimen is passed off the operative field. ◆

Chapter 4  •  Biliopancreatic Diversion/Duodenal Switch   69

Figure 4-16

Figure 4-17

Figure 4-18

70   Section II  •  Primarily Malabsorptive Procedures

Figure 4-19: We always oversew the sleeve gastrectomy staple line in the firm conviction that this step prevents staple line leaks. We use a running, 4/0, nonabsorbable suture taken in the Lembert fashion, inverting the entire staple line. ◆ Figure  4-20: The duodenum is mobilized from above and below until a clear passage beneath the duodenum is established. The vasculature of the tissue plane above the duodenum is extremely rich and requires a powered tissue divider or individual clamping and ligation of the vessels. Care must be taken to not injure the common bile duct or other portal structures. The mesentery below the duodenum is also quite vascular and requires careful dissection and hemostasis. Once a finger can comfortably be inserted underneath the duodenum, approximately 4  cm from the pylorus, the duodenum is ready for division. s Finger inserted beneath the duodenum. ◆

Chapter 4  •  Biliopancreatic Diversion/Duodenal Switch   71

Figure 4-19

Figure 4-20

72   Section II  •  Primarily Malabsorptive Procedures

Figure 4-21: When the first portion of the duodenum is cleared, it is divided with the linear stapler and the duodenal stump is inverted and oversewn with interrupted, 4/0, nonabsorbable sutures. Care must be taken to have a 2- to 4-cm rim of duodenum beyond the pylorus and to not injure the common bile duct. s Duodenal stump staple line inverted and oversewn. ◆ Figure 4-22: The proximal end of the alimentary limb is delivered into the field via a retrocolic window. Care is taken to approximate this limb with the postpyloric duodenum in a tension-free manner. The duodenojejunostomy anastomosis can be performed in various ways. We prefer a two-layer, end-to-side anastomosis. s Step A: Corner sutures and the posterior row of interrupted, 5/0, nonabsorbable sutures are placed in the Lembert manner, tied, and cut. We prefer to use a bisecting technique to achieve appropriate suture separation. The stapled duodenal cuff is resected and an incision is made into the jejunal limb. s Step B: The posterior, inner row of running, 4/0, absorbable sutures is started in the middle of the anastomosis. We prefer to run two separate sutures from the middle to each corner in a whip-lock fashion. s Step C: The anterior, inner row of running, 4/0, absorbable sutures is carried around the corners, and the anterior row is completed in the Connell fashion and tied in the middle. s Step D: The anterior, outer row of interrupted, 5/0, nonabsorbable sutures is placed in the Lembert manner, tied, and cut. s Before the anterior closure, a multiperforated nasogastric tube, passed by the anesthesia team, is placed under direct visualization from the stomach through the anastomosis and, for a short distance, into the Roux limb. ◆

Chapter 4  •  Biliopancreatic Diversion/Duodenal Switch   73

Figure 4-21

A

B

C

D

Figure 4-22

74   Section II  •  Primarily Malabsorptive Procedures

Figure 4-23: The duodenal switch is completed by closure of the mesocolic window from below with three interrupted, 5/0, nonabsorbable sutures. Peterson's defect and the mesenteric defect separating the alimentary and the biliopancreatic small intestinal limbs (previously shown) are also closed. These maneuvers can be carried out with a single, running, 3/0, absorbable suture. Closure of mesenteric defects is essential to prevent internal herniation at a later date. ◆ Figure 4-24: Completed duodenal switch with a moderately restrictive sleeve gastrectomy, a measured common channel, careful closure of the duodenal stump, and bowel continuity restored by a duodenojejunostomy and jejunoileostomy, with closure of mesenteric defects. ◆

Laparoscopic technique

◆

Figure 4-25: Placement of port sites varies with the procedure to be performed and the personal preference of the surgeon. Most bariatric procedures require five to six port sites. The camera port is generally a 12-mm port placed in the midline. The location of the other ports varies, but as a rule, both sides of the upper abdominal wall are used for placement; they are mostly 5-mm port sites but may include a 10- or a 15-mm port site.

Chapter 4  •  Biliopancreatic Diversion/Duodenal Switch   75

Figure 4-23

Sleeve gastrectomy

Alimentary limb

Biliopancreatic limb

Jejunoileostomy

Common channel

Figure 4-24

Figure 4-25

76   Section II  •  Primarily Malabsorptive Procedures

Figure 4-26: Insufflation of the abdominal cavity with carbon dioxide gas (experimentally, helium has been used) can be established via a spring-loaded, tension-sensing Veress needle inserted blindly. The 2-mm needle has a blunt inner cannula that automatically extends beyond the needle point upon entering the abdominal cavity. After insertion, to ensure that no tissue damage has occurred, the surgeon should aspirate the needle for blood, succus, or stool, and then perform the drop of saline test, allowing a drop of saline placed on the hub of the needle to fall into the peritoneal cavity by gravity or on creating negative intraperitoneal pressure by lifting the abdominal wall. The ­carbon dioxide gas is infused via a side hole by an automatic, gauged insufflation device to a pressure of 15 mm Hg. An alternative approach into the peritoneal cavity is the Hasson technique, an open approach via a 1- to 1.5-cm incision at the umbilicus. A blunt obturator cannula is then placed into the abdominal cavity and, in general, anchored in place by fascial sutures. s Alternate site to umbilical or periumbilical site for blind insertion of the insufflation Veress needle. ◆ Figure  4-27: Once pneumoperitoneum is achieved, the access trocars are placed under direct visualization. A 5-mm optical viewing trocar is initially used. Once a camera port site is established, placement of the remaining trocars is performed under laparoscopic visual control. Trocar lengths used for bariatric surgery, as a rule, are 100 and 150  mm. Cannulae types include those with pyramidal cutting tips, retractable blades, retractable “safety” shields, conical tapered tips, radial dilating cannulae, and screw devices. The threaded screw cannulae are usually preferred. The trocars should be placed perpendicular to the abdominal wall. ◆

Chapter 4  •  Biliopancreatic Diversion/Duodenal Switch   77

Insufflator

Figure 4-26

Trocar

Figure 4-27

78   Section II  •  Primarily Malabsorptive Procedures

Figure 4-28: In general, the primary surgeon stands on the right side of the patient, the first assistant faces the surgeon on the patient's left, and the second assistant/camera operator and the scrub nurse are positioned toward the foot of the bed. Placing the patient's arms out on arm boards facilitates access to the abdomen. An alternative configuration of the operating team has the surgeon standing between the abducted legs of the patient. (The introduction of robotics places the surgeon away from the operating table for the first time in the history of surgery; indeed, the surgeon can be in another room or facility.) (For further review of the technique for laparoscopic abdominal access, see Section I, Chapter 2.) s Having the patient in the reverse Trendelenburg position is preferred for visualization of the attic of the abdomen. ◆ Figure 4-29: The patient is placed in the reverse Trendelenburg position. The short gastric vessels are divided, starting inferiorly, with a powered tissue divider or with individual clamping and ligation of the vessels. This dissection starts at a point opposite the pes anserinus and ascends to the esophagogastric junction. Some surgeons start this division at the pylorus. Dissection of the esophagogastric junction requires careful division of the uppermost short gastric vessels, which often are extremely short between the stomach and the spleen. ◆

Chapter 4  •  Biliopancreatic Diversion/Duodenal Switch   79

Anesthetist

Monitor Light Camera Insufflator

Monitor

1st assistant

Surgeon

2nd assistant

Instruments Nurse

Figure 4-28

Figure 4-29

80   Section II  •  Primarily Malabsorptive Procedures

Figure 4-30: The laparoscopic linear stapling instrument with 3.5-mm staples (blue load) is used to perform the sleeve gastrectomy portion of the procedure. The stapler is first applied inferiorly at the cleared area opposite the pes anserinus or at the pylorus. This maneuver is performed after a bougie is placed by the anesthesia team into the lumen of the stomach; we prefer using a small, #24 Fr bougie. We resect the stomach a loose 2 to 4  cm from the edge of the bougie placed along the lesser curvature of the stomach. Other surgeons prefer using a larger bougie, up to #40 Fr, and cutting/stapling the stomach more tightly on the bougie. The sleeve gastrectomy specimen is passed off the operative field. ◆ Figure 4-31: We always oversew the sleeve gastrectomy staple line in the firm conviction that this step prevents staple line leaks. We use a running, nonabsorbable suture taken in the Lembert fashion, inverting the entire staple line. ◆ Figure  4-32: The duodenum is mobilized from above and below until a clear passage beneath the duodenum is established. The vasculature of the tissue plane above the duodenum is extra rich and requires a powered tissue divider or individual clamping and ligation of the vessels. Care must be taken to not injure the common bile duct or other portal structures. The mesentery below the duodenum is also quite vascular and requires careful dissection and hemostasis. Once an instrument can comfortably be inserted underneath the duodenum, 4  cm from the pylorus, the duodenum is ready for division. s Instrument inserted beneath duodenum. ◆

Chapter 4  •  Biliopancreatic Diversion/Duodenal Switch   81

Figure 4-30

Figure 4-31

Figure 4-32

82   Section II  •  Primarily Malabsorptive Procedures

Figure 4-33: When the first portion of the duodenum is cleared, it is divided with the laparoscopic linear stapler, and the duodenal stump can be inverted and oversewn with nonabsorbable sutures. Care must be taken to have a 2- to 4-cm rim of duodenum beyond the pylorus and to not injure the common bile duct. s Duodenal stump staple line inverted and oversewn. ◆ Figure 4-34: As a rule, the patient is now placed into a level position to facilitate the intestinal portion of the procedure. The common channel is measured proximally from the ileocecal valve by using an umbilical tape calibrated against the ruler. Measurement is preferred along the mesenteric border of the bowel, which is more constant than the antemesenteric border in its measured length. The site for the jejunoileostomy is marked with sutures placed through the mesentery and circumferentially around the bowel. s We use a 75- to 100-cm common channel. ◆

Chapter 4  •  Biliopancreatic Diversion/Duodenal Switch   83

Figure 4-33

75-100 cm

Figure 4-34

84   Section II  •  Primarily Malabsorptive Procedures

Figure 4-35: No globally accepted lengths have been established for the alimentary limb or the biliopancreatic limb of a duodenal switch. Various formulas of fixed lengths or percentages have been proposed. We measure the small intestine from the marking suture, delineating the upper end of the common channel to the ligament of Treitz, and divide this length, whatever it is, in half. Alternatively, we have used a measured 150 cm for the alimentary limb. The jejunum is divided with the laparoscopic linear intestinal stapler and 3.5-mm staples (blue load). The jejunal mesentery is divided for a distance of 4 to 6 cm to allow mobility of the cut ends. The divided, stapled jejunal ends, representing the proximal end of the Roux limb and the distal end of the biliopancreatic limb, may be oversewn with a running, 2/0, nonabsorbable suture or interrupted sutures. Most laparoscopic surgeons do not perform this step. s Staple lines oversewn. s An alternative approach we have used is to bring up a loop of jejunum, 250 cm from the ileocecal valve, suspended by a Penrose drain. The mesenteric border is sewn to the duodenum with running 2/0 suture. The bowel is then divided with 3.5-mm staples (blue load) to the left of the pending anastomosis. The free end is the terminal portion of the biliopancreatic limb and is attached 75 to 100 cm from the ileocecal valve. ◆ Figure 4-36: The jejunoileostomy is created by an anastomosis of the distal, stapled end of the biliopancreatic limb, side to side, to the junction of the common channel and alimentary limb 75 cm from the ileocecal valve. The illustration shows the orientation of the alimentary limb on the patient's right side, with the biliopancreatic limb on the left and the stapled end of the biliopancreatic limb facing inferiorly. Marking sutures of nonabsorbable material are placed, and enterotomies 1 cm in length are made with cautery or a powered tissue divider. ◆

Chapter 4  •  Biliopancreatic Diversion/Duodenal Switch   85

Figure 4-35

Alimentary limb

Enterotomy Biliopancreatic limb

Figure 4-36

86   Section II  •  Primarily Malabsorptive Procedures

Figure 4-37: The enterotomies are lengthened with a spreading motion with a laparoscopic grasper. ◆ Figure 4-38: The jejunoileostomy is created with the laparoscopic intestinal linear stapler and 3.5-mm staples (blue load), set at an anastomotic orifice length longer than 4.0 cm for the laparoscopic procedure. ◆

Chapter 4  •  Biliopancreatic Diversion/Duodenal Switch   87

Figure 4-37

Figure 4-38

88   Section II  •  Primarily Malabsorptive Procedures

Figure 4-39: The enterotomies, and usually the entire anterior staple line, are oversewn with nonabsorbable sutures taken in the Lembert fashion. We prefer using interrupted sutures; however, a running suture can be used as well. Most laparoscopic surgeons do not oversew the posterior staple line, although such a maneuver does increase anastomotic integrity. s Interrupted closure of staple line. ◆ Figure  4-40: The intestinal mesentery defect is carefully closed by using interrupted or running permanent suture. ◆ Figure 4-41: The proximal end of the alimentary, or Roux, limb is delivered into the field via a retrocolic window, although some surgeons prefer to bring this limb up antecolic. Whatever manner is used, care must be taken to approximate this limb with the postpyloric duodenum in a tension-free manner. The duodenojejunostomy anastomosis can be performed in various ways. Most surgeons prefer a linear stapled anastomosis, similar to the creation of the jejunoileostomy. Others use the end-to-end, anvil and hammer stapling device taken through the open end of the alimentary, or Roux, limb, which is subsequently staple resected. We prefer a two-layer, end-to-side, hand-sewn anastomosis. We have recently performed this anastomosis with the instrumentation of the surgical robot device. s Step A: Corner sutures and the posterior row of interrupted, nonabsorbable sutures are placed in the Lembert manner, tied, and cut. We prefer to use a bisecting technique to achieve appropriate suture separation. The stapled duodenal cuff is resected and an incision is made into the jejunal limb. s Step B: The posterior, inner row of running, absorbable or nonabsorbable sutures is started in the middle of the anastomosis. We prefer to run two separate sutures from the middle to each corner in a whip-lock fashion. s Step C: The anterior, inner row of running sutures is carried around the corners, and the anterior row is completed in the Connell fashion and tied in the middle. s Step D: The anterior, outer row of interrupted, nonabsorbable sutures is placed in the Lembert manner, tied, and cut. s Before the anterior closure, a multiperforated nasogastric tube, passed by the anesthesia team, is placed under direct visualization from the stomach through the anastomosis and for a short distance into the Roux limb. ◆

Chapter 4  •  Biliopancreatic Diversion/Duodenal Switch   89

Figure 4-39

Figure 4-40

A

B

C

D

Figure 4-41

90   Section II  •  Primarily Malabsorptive Procedures

Figure 4-42: The duodenal switch is completed by closure of the mesocolic window, from below, with three interrupted, nonabsorbable sutures. Peterson's defect is also meticulously closed, usually with a running suture. ◆ Figure 4-43: Completed laparoscopic duodenal switch with a moderately restrictive sleeve gastrectomy, a measured common channel, careful closure of the duodenal stump, and bowel continuity restored by a duodenojejunostomy and jejunoileostomy, with closure of mesenteric defects. ◆

Chapter 4  •  Biliopancreatic Diversion/Duodenal Switch   91

Figure 4-42

Sleeve gastrectomy

Alimentary limb

Biliopancreatic limb

Jejunoileostomy

Common channel

Figure 4-43

Section

III

Malabsorptive/ Restrictive Procedures: Gastric Bypass The evolution of bariatric surgery proceeded from primarily malabsorptive procedures to malabsorptive/restrictive procedures. These operations encompass all variations of gastric bypass, which was the first operation for morbid obesity involving the stomach. The restrictive element of the gastric bypass operation consists of the creation of a small upper gastric pouch with a narrow outlet. The minimal amount of intestinal tract bypassed consists of the distal stomach (gastric remnant), the entire duodenum, and a short segment of the proximal jejunum (~40 cm), which contribute the malabsorptive element to the standard Roux-en-Y gastric bypass. Bowel continuity is achieved by a gastrojejunostomy and a jejunojejunostomy by using, as a rule, a Roux or enteric limb that is 75 cm in length. More extensive malabsorptive variations consist of gastric bypasses with a longer Roux limb (100 to 150 cm) or a longer biliopancreatic limb, with both limbs culminating in a shorter common channel. Also, the gastric bypass can be combined with a measured terminal ileal common channel of 75 to 125 cm and varying lengths for the biliopancreatic limb and the alimentary Roux limb. These more extensive operations are referred to as a long-limb or a very long-limb Roux-en-Y gastric bypass. The mechanical classification of the gastric bypasses and attribution of their mechanism(s) of action to the altered postoperative anatomy may not be accurate or may be only partially accurate. The initial and sustained weight loss achieved, as well as the resolution of certain metabolic comorbidities of obesity (e.g., type 2 diabetes), may instead depend on neuronal and gut hormonal perturbations. 93

94   Section III  •  Malabsorptive/Restrictive Procedures: Gastric Bypass The first gastric bypass was developed by Mason and Ito1 in 1966. They divided the stomach horizontally and created a loop (not Roux) gastrojejunostomy between the proximal gastric pouch and the proximal jejunum, all without the benefit of any stapling instrument. Mason's original upper gastric pouch was 100 to 150 mL with a stoma 12 mm in diameter. Later, Mason and Printen reduced the pouch size to 50 mL or less to increase weight loss and, by including the acid-secreting mucosa in the distal stomach, reduce ulcer formation.2 Ten years later, Alden3 performed a horizontal staple-line segmentation of the stomach without separation of the upper gastric pouch from the gastric remnant. This simplification of the operation with the use of a stapler hastened transition from the jejunoileal bypass to the gastric bypass and irrevocably altered the field of bariatric surgery. In 1977, Griffen et al.4 followed Alden's landmark procedure with a report on the significant innovation of constructing a Roux-en-Y gastrojejunostomy rather than a loop gastrojejunostomy. This gastric bypass had the advantages of avoiding tension on the loop and preventing bile reflux into the upper gastric pouch.5 Both Griffen et al.4 and Buckwalter6 reported randomized studies demonstrating that patients who underwent Roux-en-Y gastric bypass achieved weight loss equivalent to that previously seen after the jejunoileal bypass. During the next several years, variations of the Roux-en-Y gastric bypass were introduced. Torres et al.7 stapled the stomach vertically rather than horizontally. Linner and Drew8 reinforced the gastrojejunal outlet with a fascial band. Torres and Oca9 reported a modification of the vertical Roux-en-Y, nondivided gastric bypass by the creation of a long Roux limb for persons in whom the original procedure had failed. The long-limb Roux-en-Y gastric bypass was later popularized as a primary operation for the super-obese by Brolin et al.10 Salmon11 combined two procedures: a vertical banded gastroplasty and a distal Roux-en-Y gastric bypass. In 1989, Fobi12 introduced the Silastic ring vertical Roux-en-Y gastric bypass, creating a small vertical pouch drained by a gastrojejunostomy and containing a restrictive Silastic ring proximal to the gastrojejunostomy. Fobi13 later modified this gastric bypass by dividing the stomach and interposing the jejunal Roux limb between the gastric pouch and the bypassed stomach to ensure maintenance of the gastric division. In 1994, Wittgrove et al.14 reported their results with laparoscopic Roux-en-Y gastric bypass, the landmark introduction of gastric bypass performed laparoscopically. They performed their gastrojejunostomy with the end-to-end stapler; the anvil was introduced endoscopically. Their procedure was modified by de la Torre and Scott,15 who introduced the anvil of the stapler intraabdominally to allow greater precision in anvil placement and avoid esophageal complications. Several laparoscopic surgeons, notably Schauer et al.,16 revised the procedure by using the linear endostapler to create both the jejunojunostomy and the gastrojejunostomy. To avoid the relatively high incidence of gastrointestinal anastomotic leaks from the gastrojejunostomy, Higa et al.17 described a method for hand sewing the gastrojejunostomy anastomosis in 2000. Several other clinical modifications of the gastric bypass have been made, including the ­mini-laparotomy return to a loop gastrojejunostomy of Rutledge18 and possibly the single laparoscopic incision transabdominal approach of Nguyen et al.,19 as well as experimental proposals for a gastric bypass via a natural orifice transluminal endoscopic surgery approach20 or by mini-laparotomy (micro-orifice) under intravenous sedation/local anesthesia.21,22

References



1. Mason EE, Ito C: Gastric bypass in obesity, Surg Clin North Am 47:1345–1352, 1967. 2. Mason EE, Printen KJ: Optimizing results of gastric bypass, Ann Surg 182:405–413, 1975. 3. Alden JF: Gastric and jejuno-ileal bypass: a comparison in the treatment of morbid obesity, Arch Surg 112:799–806, 1977. 4. Griffen WO, Young VL, Stevenson CC: A prospective comparison of gastric and jejunoileal bypass procedures for morbid obesity, Ann Surg 186:500–507, 1977. 5. McCarthy HB, Rucker RD, Chan EK, et al: Gastritis after gastric bypass surgery, Surgery 98:68–71, 1985.

Section III  •  Malabsorptive/Restrictive Procedures: Gastric Bypass   95 6. Buckwalter JA: Clinical trial of jejunoileal and gastric bypass for the treatment of obesity: four-year progress report, Am Surg 46:377–381, 1980. 7. Torres JC, Oca CF, Garrison RN: Gastric bypass: Roux-en-Y gastrojejunostomy from the lesser curvature, South Med J 76: 1217–1221, 1983. 8. Linner JR, Drew RL: New modification of Roux-en-Y gastric bypass procedure, Clin Nutr 5:33–34, 1986. 9. Torres J, Oca C: Gastric bypass lesser curvature with distal Roux-en-Y, Bariatric Surg 5:10–15, 1987. 10. Brolin RE, Kenler HA, Gorman JH, et al: Long-limb gastric bypass in the superobese: a prospective randomized study, Ann Surg 21:387–395, 1992. 11. Salmon PA: Gastroplasty with distal gastric bypass: a new and more successful weight loss operation for the morbidly obese, Can J Surg 31:111–113, 1988. 12. Fobi MA: The surgical technique of the banded Roux-en-Y gastric bypass, J Obes Weight Reg 8:99–102, 1989. 13. Fobi MA: Why the operation I prefer is Silastic ring vertical banded gastric bypass, Obes Surg 1:423–426, 1991. 14. Wittgrove AC, Clark GW, Tremblay LJ: Laparoscopic gastric bypass, Roux-en-Y: preliminary report of five cases, Obes Surg 4:435–437, 1994. 15. de la Torre RA, Scott JS: Laparoscopic Roux-en-Y gastric bypass: a totally intra-abdominal approach—technique and preliminary report, Obes Surg 9:492–497, 1999. 16. Schauer PR, Ikramuddin S, Gourash W, et al: Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity, Ann Surg 232:515–529, 2000. 17. Higa KD, Boone KB, Ho T: Laparoscopic Roux-en-Y gastric bypass for morbid obesity in 850 patients: technique and follow-up [abstract], Obes Surg 10:146, 2000. 18. Rutledge R: The mini-gastric bypass: experience with the first 1,274 cases, Obes Surg 11:276–280, 2001. 19. Nguyen NT, Hinojosa MW, Smith BR, et al: Single laparoscopic incision transabdominal (SLIT) surgery-adjustable gastric banding: a novel minimally invasive surgical approach, Obes Surg 18:1628–1631, 2008. 20. Pearl JP, Ponsky JL: Natural orifice transluminal endoscopic surgery: a critical review, J Gastroinest Surg 12:1293–1300, 2008. 21. Buchwald H: Metabolic/bariatric surgery: after laparoscopic surgery there is and will be open surgery, presented at the International Federation for the Surgery of Obesity and Metabolic Disorders Meeting, Buenos Aires, Argentina, September 27, 2008. 22. Buchwald H, Menchaca HJ, Michalek VN, et al: Micro-orifice metabolic/bariatric surgery under IV sedation/local anesthesia: porcine feasibility study, Obes Surg 20:500–505, 2010.

Chapter

5

Open Roux-en-Y Gastric Bypass Technique

Figure 5-1: A midline incision from the xiphoid to above the umbilicus is the usual abdominal entry site. Some surgeons use a marking pen to indicate the path of incision. s Torso representation of incision site. ◆ Figure 5-2: The incision is made into the subcutaneous fat with the scalpel. Gentle pressure on both sides of the incision by the surgeon and assistant facilitate a straight line of entry. The small subcuticular bleeders are cauterized for hemostasis. ◆

96

Chapter 5  •  Open Roux-en-Y Gastric Bypass   97

Figure 5-1 

Figure 5-2 

98   Section III  •  Malabsorptive/Restrictive Procedures: Gastric Bypass

Figure 5-3: The surgeon and assistant apply opposing pressure on the sides of the opening and with considerable force tear the subcutaneous fat and Scarpa's fascia down to the linea alba. This maneuver will require several applications of subcutaneous pulling in opposite directions along the length of the incision and usually at several depths. This technique typically guarantees precise penetration down to the linea alba, with minimal bleeding and no tissue damage from the use of cautery coagulation. The tearing technique may not be feasible in reusing a midline incision for reentry into the abdominal cavity, in which case coagulating cautery is used to reach the linea alba. ◆ Figure 5-4: Using the cautery at a fairly low current (25 amps), the linea alba is incised along its length down to the preperitoneal fat. (For further review of the technique for open abdominal access, see Section I, Chapter 1.) ◆ Figure 5-5: After removal of the preperitoneal fat pad, placement of the wound protector, and a preliminary inspection of the abdominal contents, we begin the Roux-en-Y gastric bypass with the construction of the Roux limb. At a point approximately 30 cm from the ligament of Treitz, a convenient area of jejunal mesentery is identified with maximum available spacing between the mesenteric vessels. This area is cleared close to the bowel with scissors, and the mesentery is divided for a distance of approximately 6 cm perpendicular to the bowel. This mesenteric division can be done by cautery or by a powered tissue divider but may require clamping and ligation of vessels. s Site for bowel division for the Roux limb. ◆

Chapter 5  •  Open Roux-en-Y Gastric Bypass   99

Figure 5-4 

Figure 5-3 

Ligament of Treitz

30 cm

Figure 5-5 

100   Section III  •  Malabsorptive/Restrictive Procedures: Gastric Bypass

Figure 5-6: The jejunum is divided with an intestinal linear stapler and 3.5-mm staples (blue load). This division separates the distal end of the biliopancreatic limb (proximal end) from the proximal end of the Roux, or enteric, limb (distal end). ◆ Figure 5-7:The ends of the jejunal division are cauterized. ◆ Figure  5-8: The biliopancreatic and enteric, or Roux, limb staple lines are inverted and oversewn. In our open approach, we use interrupted, 5/0, nonabsorbable sutures taken in the Lembert fashion. Two corner sutures and a middle suture are placed first, providing the inversion of the staple line; additional sutures are added as required. ◆ Figure 5-9: Next, the Roux limb is measured from the divided proximal end with an umbilical tape calibrated against a ruler. We measure along the mesenteric rather than the antemesenteric margin of the bowel because it is more constant. The standard length of the Roux limb, in our hands, is 75 cm. s 75-cm Roux limb measured from the site of jejunal division. ◆

Chapter 5  •  Open Roux-en-Y Gastric Bypass   101

Figure 5-6 

Figure 5-7 

Roux limb

75 cm

Figure 5-8 

Figure 5-9 

102   Section III  •  Malabsorptive/Restrictive Procedures: Gastric Bypass

Figure 5-10: With the closed end facing caudally, the proximal jejunal segment (biliopancreatic limb) is brought down to the left of the Roux limb. Stay sutures are placed at the previously identified 75-cm mark, and enterotomies are made with the cautery for the anastomosis into both segments of the bowel. ◆ Figure 5-11: The enterotomy openings are spread with a clamp in the plane of the cautery incisions. ◆ Figure 5-12: The jejunojejunostomy is created with the intestinal linear stapler and 3.5mm staples (blue load). The orifice of the jejunojejunostomy in the open approach does not have to be large. We construct our orifice set at 2.5 cm on the ruled stapler markings. ◆ Figure  5-13: The anastomosis is oversewn circumferentially with interrupted, 5/0, nonabsorbable sutures; that is, we oversew the entire suture line as well as the orifices of the anastomosis made for passage of the stapler blades. We have never had a leak at this anastomosis in thousands of cases, and we believe that oversewing the staple line is the primary reason for this result. Oversewing of the anterior aspect of the anastomosis is illustrated. ◆ Figure 5-14: The anastomosis is turned over and the posterior staple line is oversewn with interrupted, 5/0, nonabsorbable sutures. An area approximately 2 cm in length is always present where the staples partially protrude because a linear stapler cannot make a curved anastomotic corner. Failure to oversew this particular area may be the cause of jejunojejunostomy leaks in other series. ◆

Chapter 5  •  Open Roux-en-Y Gastric Bypass   103

Alimentary limb

Biliopancreatic limb

Figure 5-10 

Figure 5-11 

Figure 5-12 

Figure 5-13 

Figure 5-14 

104   Section III  •  Malabsorptive/Restrictive Procedures: Gastric Bypass

Figure 5-15: The divisional mesenteric defect is closed next to prevent internal herniation. We prefer using a running, 3/0, absorbable suture in a purse-string manner, augmented by one or more Z stitches toward the end of the biliopancreatic segment. After this maneuver, the proximal end of the Roux limb and its mesentery are mobile and free to be moved cephalad. ◆ Figure 5-16: Next, exposure of the attic of the abdomen is obtained with a mechanical bariatric retractor. The straight table bars are fastened to both sides of the operating table as cephalad as feasible, that is, up to the two arm boards. The cross piece is secured and the two large shovel retractors are loosely fastened subcostally, with the blades as lateral as possible. The patient is placed into the maximum Trendelenburg position and the subcostal retractors are vigorously elevated cephalad and fastened. The patient is then turned into a fairly steep reverse Trendelenburg position and the side bars of the retractor apparatus are placed up to the elbow turn. The smaller shovel retractors on short retractor arms are then placed, retracted laterally, and fastened. s Maximum Trendelenburg position for fastening the upper retractors. ◆ Figure 5-17: Complete exposure of the abdominal attic is obtained by cutting the triangular ligament of the left lobe of the liver, retracting the left lobe of the liver superiorly and to the right, and holding the left lobe out of the field with the heart-shaped blade of the bariatric retractor. s Steep reverse Trendelenburg position, the position for the best operative exposure. ◆

Chapter 5  •  Open Roux-en-Y Gastric Bypass   105

Mesenteric defect

Figure 5-15 

Figure 5-16 

Figure 5-17 

106   Section III  •  Malabsorptive/Restrictive Procedures: Gastric Bypass

Figure 5-18: Once exposure of the attic of the abdomen has been achieved, the upper third of the short gastric vessels is divided. As a rule, this maneuver is performed with a powered tissue divider, but this step can be accomplished by basic clamping, division, and ligation. The uppermost short gastric vessels may present a problem because of minimal space separating the stomach and the spleen. To facilitate separation of this tissue plane, sharp dissection entry into the retroperitoneal space at the level of the left crus and extension of this entry with superficial peritoneal elevation with a right angle clamp and cautery dissection, followed by blunt dissection and finger encirclement of the short gastric vessels, allow division of the last short gastric vessels. The esophageal fat pad is dissected back to clear the area of the esophagogastric junction. ◆ Figure 5-19: The stomach is encircled with a Penrose drain to establish the site for future gastric cross stapling. The path for the Penrose drain is prepared by combined sharp dissection and tissue spreading to establish entry into the lesser sac along the lesser curvature of the stomach between the first and second sets of lesser curvature feeding vessels. ◆ Figure  5-20: We next prepare to perform the gastrojejunostomy by bringing the Roux limb up to the cleared uppermost area of the fundus in a retrocolic, retrogastric manner via an opening in the mesocolon. This elevation of the Roux limb provides for minimal tension, if any, at the anastomotic site. Some surgeons prefer the antecolic approach to avoid the mesocolic opening and a potential site for ­internal herniation. ◆

Chapter 5  •  Open Roux-en-Y Gastric Bypass   107

Gastric vessels divided

Figure 5-18 

Figure 5-19 

Figure 5-20 

108   Section III  •  Malabsorptive/Restrictive Procedures: Gastric Bypass

Figure 5-21: To initiate the gastrojejunostomy, 5/0 stay sutures are placed approximately 2  cm apart, high on the gastric fundus, just inferior to the esophagogastric junction and to the patient's left. Small enterotomies are created with cautery and spread with a clamp. The Roux limb, if brought up retrocolic and retrogastric, emerges anteriorly through the window created by the take-down of the upper third of the short gastric vessels, placing it essentially antegastric for the performance of the gastrojejunostomy. ◆ Figure  5-22: The gastrojejunostomy is performed with the intestinal linear stapler and 3.5-mm staples (blue load). We set the size for this anastomosis at 1 cm on the ruled side of the stapler, which creates an orifice between 8 and 12 mm, as a function of gastric and intestinal wall thickness and subsequent suture placement. As a rule, at this stage of the operation, we pass a soft nasogastric tube with holes placed in the gastric pouch and into the Roux limb. ◆ Figure 5-23: The entire anterior surface of the anastomosis, the enterotomy sites, and the adjacent staple line are oversewn with interrupted, 5/0, nonabsorbable sutures taken in the Lembert fashion. ◆ Figure 5-24: The gastrojejunostomy is turned over by pulling through the uppermost stay suture inferiorly. The entire posterior staple line is oversewn with interrupted, 5/0, nonabsorbable sutures in the Lembert manner. Placement of the final sutures may require a superior approach with sutures placed horizontally, in a box fashion, on the back side of the staple line to accommodate the surgeon's sewing hand. ◆ Figure 5-25: The gastric pouch is now constructed. By using the previously placed Penrose drain as a guide, the noncutting, four-row, 90-mm stapler with 3.5-mm staples (blue load) is placed around the stomach from left to right. The pin of the stapler is inserted and secured. The upper gastric pouch is fashioned to be as small as feasible, approximately 15 mL in volume, by pulling down on the gastric remnant and setting the stapler just below the gastrojejunostomy anastomosis. Care must be taken to not include the nasogastric tube, if a nasogastric tube is used, within the staple line. The position of the stapler is confirmed. It is fired and removed from the field, leaving a four-row, cross stapled, undivided stomach with a gastrojejunostomy draining the upper gastric pouch. Two 5/0 nonabsorbable sutures are placed from the Roux limb to the gastric remnant to ensure that no kinking occurs at the anastomotic site. The procedure is completed by closure of the mesocolon with three interrupted sutures. ◆

Chapter 5  •  Open Roux-en-Y Gastric Bypass   109

Figure 5-22 

Figure 5-21 

Figure 5-23 

Figure 5-24 

Figure 5-25 

110   Section III  •  Malabsorptive/Restrictive Procedures: Gastric Bypass

Figure  5-26: The completed standard Roux-en-Y gastric bypass. A small upper gastric pouch, with bowel continuity restored by an 8- to 12-mm gastrojejunostomy, a 75-cm Roux limb, and a distal jejunojejunostomy. s An alternative approach is to perform a divided Roux-en-Y gastric bypass with separation of the upper gastric pouch from the gastric remnant. This maneuver is performed with the intestinal linear stapler or a suitable laparoscopic stapling instrument. Advocates of this variation avoid staple line breakdown, but their preparation is more subject to leaks and gastro-gastric fistulas than is the undivided stomach approach. ◆ Figure 5-27: By altering the lengths of the Roux limb, a long-limb Roux-en-Y gastric bypass (approximately a 150-cm Roux limb) or a very long-limb Roux-en-Y gastric bypass (common channel 75 to 125 cm) is created. Other length variations can be achieved by initially dividing the jejunum further inferiorly than 30 cm, thereby creating a longer biliopancreatic limb. ◆

Chapter 5  •  Open Roux-en-Y Gastric Bypass   111

15 mL stomach pouch

Alimentary (Roux) limb 75 cm

Biliopancreatic limb Jejunojejunostomy

Common channel

Figure 5-26 

Alimentary (Roux) limb 150 cm

Common channel 100-125 cm

Figure 5-27 

112   Section III  •  Malabsorptive/Restrictive Procedures: Gastric Bypass

Alternative Approaches

Vertical Roux-en-Y Gastric Bypass The open Roux-en-Y gastric bypass can be accomplished with a vertical pouch as a matter of preference. Figures 5-1 to 5-17 describe this step-by-step technique until the attic of the abdomen has been exposed. Figure 5-28: It is now not necessary to divide the upper third of the short gastric vessels. Instead, entrance is gained into the lesser sac at the lesser curvature approximately 8 cm inferior to the esophagogastric junction. This maneuver is performed by sharp dissection and spreading of the tissue plane between vessel sets. A counter-incision into the lesser sac is made at the angle of His, and the two lesser sac openings are connected by blunt dissection. A catheter is passed between the orifices to serve as a guide for the 90-mm stapler. Connecting the lesser curve and angle of His openings can be done in separate steps by opening into the lesser sac along the greater curvature for direct visualization of the placement of the catheter. ◆ Figure 5-29: The vertical pouch is next established with the noncutting, four-row, 90-mm stapler with 3.5-mm staples (blue load). The inferior blade of the stapler is inserted into the opening of the catheter and thereby delivered around the stomach with the stapler secured with the device's pin at the angle of His. ◆ Figure 5-30: The pouch is shaped within the stapler to achieve a volume of approximately 15 mL. The stapler is fired, and an undivided separation of the vertical upper gastric pouch and the gastric remnant is achieved. ◆ Figure 5-31: The Roux limb is brought into the field in antecolic fashion. If lesser sac entry is performed by take-down of short gastric vessels for a length of approximately 4 to 6 cm, the surgeon can choose to bring the Roux limb up in a retrocolic, antegastric fashion. ◆ Figure 5-32: The gastrojejunostomy is created in much the same manner as illustrated in Figures 5-21 to 5-24 with the Roux limb placed vertically. s Alternative divided pouch procedure. ◆

FOBI II Vertical Banded Roux-en-Y Gastric Bypass Figure 5-33: This alternative variation differs from the vertical Roux-en-Y gastric bypass by careful placement of the Roux limb between the divided upper gastric pouch and the gastric remnant to prevent a gastrogastric fistula and by encirclement of the upper gastric pouch with a Silastic ring just above the gastric bypass orifice. The Silastic ring adds an additional constrictive element to the procedure. A means to fashion this ring is illustrated in Section IV, Chapter 9.

Chapter 5  •  Open Roux-en-Y Gastric Bypass   113

Figure 5-28  Figure 5-29 

Figure 5-30 

Figure 5-31 

Figure 5-33  Figure 5-32 

Chapter

6

Laparoscopic Roux-en-Y Gastric Bypass Technique

Figure 6-1: Placement of port sites varies with the procedure to be performed and the personal preference of the surgeon. Most bariatric procedures require five to six port sites. The camera port is generally a 12-mm port placed in the midline. The location of the other ports varies, but as a rule, both sides of the upper abdominal wall are used for placement; they are mostly 5-mm port sites but may include a 10- or a 15-mm port site. ◆ Figure 6-2: Insufflation of the abdominal cavity with carbon dioxide gas (experimentally, helium has been used) can be established via a spring-loaded, tension-sensing Veress needle inserted blindly. The 2-mm needle has a blunt inner cannula that automatically extends beyond the needle point upon entering the abdominal cavity. After insertion, to ensure that no tissue damage has occurred, the surgeon should aspirate the needle for blood, succus, or stool and then perform the drop of saline test, allowing a drop of saline placed on the hub of the needle to fall into the peritoneal cavity by gravity or on creating negative intraperitoneal pressure by lifting the abdominal wall. The carbon dioxide gas is infused via a side hole by an automatic gauged insufflation device to a pressure of 15 mm Hg. An alternative approach into the peritoneal cavity is the Hasson technique, which is an open approach via a 1- to 1.5-cm incision at the umbilicus. A blunt obturator cannula is then placed into the abdominal cavity and, in general, anchored in place by fascial sutures. s Alternate site to umbilical or periumbilical site for blind insertion of the insufflation Veress needle. ◆

114

Chapter 6  •  Laparoscopic Roux-en-Y Gastric Bypass   115

Obturator externus

Figure 6-1

Insufflator

Figure 6-2

116   Section III  •  Malabsorptive/Restrictive Procedures: Gastric Bypass

Figure  6-3: Once pneumoperitoneum is achieved, the access trocars are placed under direct visualization. A 5-mm optical viewing trocar is initially used. Once a camera port site is established, placement of the remaining trocars is performed under laparoscopic visual control. Trocar lengths used for bariatric surgery, as a rule, are 100 and 150 mm. Cannulae types include those with pyramidal cutting tips, retractable blades, retractable “safety” shields, conical tapered tips, radial dilating cannulae, and screw devices. The threaded screw cannulae are usually preferred. The trocars should be placed perpendicular to the abdominal wall. ◆ Figure 6-4: In general, the primary surgeon stands on the right side of the patient, the first assistant faces the surgeon on the patient's left, and the second assistant/camera operator and the scrub nurse are positioned toward the foot of the bed. Placing the arms out on arm boards facilitates access to the abdomen. An alternative configuration of the operating team has the surgeon standing between the abducted legs of the patient. (The introduction of robotics places the surgeon away from the operating table for the first time in the history of surgery; indeed, the surgeon can be in another room or facility.) (For further review of the technique for laparoscopic abdominal access, see Section I, Chapter 2.) s Having the patient in the reverse Trendelenburg position is preferred for visualization of the attic of the abdomen. ◆

Chapter 6  •  Laparoscopic Roux-en-Y Gastric Bypass   117

Trocar

Figure 6-3

Anesthetist

Monitor Light Camera Insufflator

Monitor

1st assistant

Surgeon

2nd assistant

Instruments Nurse

Figure 6-4

118   Section III  •  Malabsorptive/Restrictive Procedures: Gastric Bypass

Figure 6-5: The laparoscopic Roux-en-Y gastric bypass can be initiated by either construction of the gastric pouch (Figures 6-11 to 6-32) or the Roux limb. For the latter approach, the proximal jejunum is measured and moved distally from the ligament of Treitz using laparoscopic graspers and the estimation of segments 10 cm in length. ◆ Figure 6-6: The bowel is divided approximately 30 to 50 cm beyond the ligament of Treitz with the laparoscopic linear stapler and 3.5-mm staples (blue load). This division separates the distal end of the biliopancreatic limb (proximal end) from the proximal end of the enteric Roux limb (distal end). The mesentery of the small intestine is divided with a powered tissue divider. ◆

Chapter 6  •  Laparoscopic Roux-en-Y Gastric Bypass   119

10 cm

Figure 6-5

Duodenum

30-50 cm of proximal jejunum

Figure 6-6

120   Section III  •  Malabsorptive/Restrictive Procedures: Gastric Bypass

Figure 6-7: With the closed end facing caudally, the proximal jejunal segment (biliopancreatic limb) is brought down to the left of the Roux limb at the measured, designated anastomotic site. Stay sutures are placed above and below the planned anastomotic site on the antemesenteric border. Enterotomies are made side to side in both bowel limbs with the cautery. The enterotomy openings can be widened with a laparoscopic grasper or cautery. ◆ Figure 6-8: The jejunojejunostomy is created with the laparoscopic stapler by using the full length of the stapling instrument and 3.5-mm staples (blue load). ◆ Figure 6-9: The anastomosis is oversewn with a running, 2/0, absorbable or nonabsorbable suture. The entire jejunojejunostomy staple line, anteriorly and posteriorly, is rarely oversewn in the laparoscopic Roux-en-Y gastric bypass approach; however, such an effort, although it prolongs operating time, safeguards against an anastomotic leak. Some surgeons prefer closing the enterotomies with a longitudinal staple line using the laparoscopic stapling instrument with 3.5-mm staples (blue load). s An alternative method is to close the enterotomies with interrupted, 3/0, Lembert sutures. ◆

Chapter 6  •  Laparoscopic Roux-en-Y Gastric Bypass   121

Figure 6-7

Figure 6-8

Figure 6-9

122   Section III  •  Malabsorptive/Restrictive Procedures: Gastric Bypass

Figure  6-10: The mesenteric defect is carefully closed with a running, 2/0, absorbable suture to prevent internal herniation. Care must be taken to leave the proximal end of the Roux limb and its mesentery mobile and free to be moved cephalad. ◆ Figure 6-11: Adequate exposure of the abdominal attic requires liver retraction superiorly and to the right, with or without cutting the triangular ligament of the liver. Various liver retractors are available. They are inserted via a right-sided port and fastened in a fixed position onto a retractor device mounted on the operating table. s Liver retractor in place. ◆

Chapter 6  •  Laparoscopic Roux-en-Y Gastric Bypass   123

Figure 6-10

Liver retractor

Figure 6-11

124   Section III  •  Malabsorptive/Restrictive Procedures: Gastric Bypass

Figure  6-12: The hepatogastric ligament below the right esophageal crus is incised and entry is gained into the lesser sac through a powered tissue divider. Care is taken to avoid injury to an accessory hepatic artery, if present. ◆ Figure  6-13: By retrogastric blunt dissection with a tissue grasper, the esophagogastric junction is freed from its attachments and the angle of His is opened. ◆ Figure 6-14: A laparoscopic stapling device with a 3.5-mm staples (blue load) is used to divide the blood supply of the lesser curvature just below the left gastric artery and is fired high across the upper stomach to start the creation of the gastric pouch. ◆

Chapter 6  •  Laparoscopic Roux-en-Y Gastric Bypass   125

Figure 6-13

Figure 6-12

Figure 6-14

126   Section III  •  Malabsorptive/Restrictive Procedures: Gastric Bypass

Figure  6-15: Several 3.5-mm staple cartridges (blue load) are applied, first horizontally and then vertically, into the opening next to the angle of His to divide the stomach. A small upper gastric pouch of about 10 to 15 mL is created. A laparoscopic grasper(s) is used to help visualize this dissection and hold the stomach taut for division. ◆ Figure  6-16: The Roux limb can either be brought up antecolic or tunneled retrocolic. Many laparoscopic surgeons prefer to bring the Roux limb up to the gastric pouch in an antecolic fashion with articulating graspers. If an antecolic approach is used, the extremely large Peterson's defect is usually not closed. If a retrocolic approach is used, however, closing the smaller Peterson's defect (which is then more likely to be the site of an internal hernia) and the mesocolic window before the end of the procedure is imperative. s The retrocolic tunnel is created by grasping the mesocolon just anterior and to the left of the ligament of Treitz and incising the mesentery with a powered tissue divider. The lesser sac is entered and the Roux limb is passed, attached to the end of an articulating grasper. Filmy posterior adhesions in the lesser sac are taken down by sharp dissection. ◆

Chapter 6  •  Laparoscopic Roux-en-Y Gastric Bypass   127

Figure 6-15

Figure 6-16

128   Section III  •  Malabsorptive/Restrictive Procedures: Gastric Bypass

Figure 6-17: Next, the gastrojejunostomy is created. Several techniques are used to accomplish this anastomosis. One method is to start by creating a gastrotomy in the posterior wall of the gastric pouch with cautery or a powered tissue divider for subsequent placement of the anvil of a 21-mm, circular laparoscopic stapling device. ◆ Figure 6-18: The anvil of the 21-mm, circular laparoscopic stapler is guided into the abdomen through the largest of the abdominal ports and inserted into the orifice of the upper gastric pouch. ◆ Figure 6-19: Some surgeons prefer to place the anvil by mouth. A snare is placed into the pouch via endoscopy and then, facilitated by cautery from the peritoneal side, through its posterior wall. A wire is passed into the abdomen, grasped with the snare, pulled through the mouth, and connected to the anvil of the stapler. The anvil is pulled into the pouch, assisted by gentle anterior traction on the mandible. ◆

Chapter 6  •  Laparoscopic Roux-en-Y Gastric Bypass   129

Figure 6-18

Figure 6-17

Figure 6-19

130   Section III  •  Malabsorptive/Restrictive Procedures: Gastric Bypass

Figure 6-20: The end of the Roux limb is excised or an enterotomy is made into the Roux limb just above the closed end by using tissue graspers to hold the bowel in place and a powered tissue divider to create the opening into the Roux limb. ◆ Figure 6-21: The hammer part of the 21-mm, circular laparoscopic stapler is inserted into the abdomen through one of the lateral port sites. The stapler is inserted into the orifice in the Roux limb and advanced for a short distance. The spike of the stapler head is exited through the antemesenteric surface of the limb and connected to the stapler anvil. ◆ Figure 6-22: Stapler alignment is checked and the stapler is fired, creating a circular anastomosis. The stapling instrument is removed from the field via an abdominal port. A port protector may be used to attempt to decrease the incidence of wound infections created by the exiting stapler. ◆

Chapter 6  •  Laparoscopic Roux-en-Y Gastric Bypass   131

Figure 6-20

Figure 6-21

Figure 6-22

132   Section III  •  Malabsorptive/Restrictive Procedures: Gastric Bypass

Figure 6-23: The anastomosis is completed by excising the end of the Roux limb with the laparoscopic stapler and 3.5-mm staples (blue load). ◆ Figure 6-24: The gastrojejunostomy is completed. To ensure its integrity, the anastomosis can be circumferentially oversewn. The integrity of the anastomosis may be tested by endoscopic insufflation with the anastomosis under laparoscopically injected saline solution or by the endoscopic injection of methylene blue dye. At the preference of the surgeon, a nasogastric tube may be inserted and threaded through the gastrojejunostomy. s Oversewing the anastomosis. ◆

Chapter 6  •  Laparoscopic Roux-en-Y Gastric Bypass   133

Figure 6-23

Figure 6-24

134   Section III  •  Malabsorptive/Restrictive Procedures: Gastric Bypass

Alternative Approaches

Linear Roux-en-Y Gastric Bypass ◆ Figure 6-25: Another common approach to constructing the gastrojejunostomy is the linear stapling technique. To perform the anastomosis in this fashion, we first place a running, 2/0, absorbable or nonabsorbable suture between the posterior aspect of the gastric pouch and the Roux limb. If antecolic placement of the Roux is used, it is important to ensure the tension is minimal, which may be accomplished by increasing the length of the mesenteric division of the small bowel. ◆ Figure 6-26: Enterotomies are made in the gastric pouch staple line and in the antemesenteric portion of the Roux limb, 2 cm distal to the Roux staple line. For this purpose, cautery and a tissue grasper or a powered tissue divider are used.

Chapter 6  •  Laparoscopic Roux-en-Y Gastric Bypass   135

Figure 6-25

Figure 6-26

136   Section III  •  Malabsorptive/Restrictive Procedures: Gastric Bypass

Figure 6-27: A laparoscopic linear stapler with 3.5-mm staples (blue load) is inserted to 1.5 cm and fired to create the gastrojejunostomy. Minor staple line bleeding is controlled with cautery. ◆ Figure 6-28: The anastomotic open edge is closed in two layers of running, 2/0, absorbable or nonabsorbable sutures. Alternatively, the anastomosis can be completed with the interrupted suture technique. It also is optimal to oversew the entire gastrojejunostomy staple line to decrease the risk of a leak and a gastrogastric fistula. Again, the anastomosis is tested via air insufflation or gastric infusion of methylene blue dye. ◆

Chapter 6  •  Laparoscopic Roux-en-Y Gastric Bypass   137

Figure 6-27

Figure 6-28

138   Section III  •  Malabsorptive/Restrictive Procedures: Gastric Bypass

Hand-Sewn Roux-en-Y Gastric Bypass ◆ Figure 6-29: To minimize gastrojejunostomy leaks, Higa has used an entirely hand-sewn technique. This technique most closely approximates open bariatric procedures but without the use of a stapling instrument. Higa usually performs a two-layer anastomosis with 3/0 absorbable sutures. The first posterior layer of running sutures incorporates the staple line of the gastric pouch and the antemesenteric surface of the Roux limb, constituting the most posterior, exterior layer. An alternative to running sutures is interrupted sutures taken in the Lembert manner; this technique is illustrated. ◆ Figure 6-30: After making enterotomies into the gastric pouch and the Roux limb, a second posterior running or interrupted layer of sutures is hand sewn.

Chapter 6  •  Laparoscopic Roux-en-Y Gastric Bypass   139

Figure 6-29

Figure 6-30

140   Section III  •  Malabsorptive/Restrictive Procedures: Gastric Bypass

Figure 6-31: To complete the procedure, two anterior layers of sutures, either running or interrupted, are placed to close the enterotomies and the entire anterior staple line. The running technique is illustrated. ◆ Figure 6-32: The alternative interrupted sutures technique is illustrated. ◆

Chapter 6  •  Laparoscopic Roux-en-Y Gastric Bypass   141

Figure 6-31

Figure 6-32

Section

IV

Restrictive Procedures Restrictive surgical procedures came into the bariatric surgery armamentarium after malabsorptive and malabsorptive/restrictive procedures. From the historical perspective, restrictive bariatric procedures were an attempt to create a more lasting effect on the intake of food than was feasible with wiring of the jaws. These operations are more preservative of normal anatomy and physiology than are the malabsorptive or malabsorptive/restrictive procedures because no part of the gastrointestinal tract is bypassed or rerouted. Because they are relatively simple to perform and require minimal time in the operating room, the restrictive procedures generally have been rapidly accepted into practice and have catapulted into popularity. Individually, they have fallen out of favor just as rapidly, only to be recycled as a different form of gastric access. The following operations are illustrated in this section: adjustable gastric banding, vertical Silastic ring and banded gastroplasty, and sleeve gastrectomy as well as modifications of these primary procedures. Mason is again the pioneering name in restrictive bariatric surgery. In 1971, in association with Printen, Mason performed the first restrictive procedure for weight loss.1 His vertical banded gastroplasty and its less invasive adaptation, the vertical Silastic ring gastroplasty,2,3 leapt into dominance in bariatric surgery in the 1980s and then, based on unfavorable reports of loss of long-term efficacy, fell into disfavor. Furthermore, the principle of gastric restriction per se was condemned as ineffectual and, according to many persons, the gastric bypass achieved gold standard bariatric procedure status. Yet in the 1980s and 1990s, the gastric band was introduced,4-6 followed by the adjustable gastric band,7 and then the laparoscopic adjustable gastric band.8,9 Restrictive bariatric surgery was back and again gained popularity. In the first 5 years of the twenty-first century, laparoscopic adjustable gastric banding was the most popular procedure in Europe and Australia.10 In the second 5 years of this century, the procedure of laparoscopic adjustable gastric banding in the United States challenged the gastric bypass, which fell into decline.10 (So much for the conviction that restrictive bariatric surgery had no future and the concept that a single gold standard operation had or will 143

144   Section IV  •  Restrictive Procedures be achieved.) Rising to challenge the laparoscopic adjustable gastric band in recent years has been sleeve gastrectomy,11,12 a serendipitous offshoot of the duodenal switch (see Section II). The pace of change in bariatric surgery is accelerating. New experimental procedures, many of them restrictive in nature, are continuously being proposed.

References

1. Printen KJ, Mason EE: Gastric surgery for relief of morbid obesity, Arch Surg 106:428–431, 1973. 2. Laws HL, Piatadosi S: Superior gastric reduction procedure for morbid obesity: a prospective, randomized trial, Am J Surg 193:334–336, 1981. 3. Eckhout GV, Willbanks OL, Moore JT: Vertical ring gastroplasty for obesity: five year experience with 1463 patients, Am J Surg 152:713–716, 1986. 4. Wilkinson LH, Peloso OA: Gastric (reservoir) reduction for morbid obesity, Arch Surg 116:602–605, 1981. 5. Kolle K: Gastric banding [abstract 145], presented at the In OMGI 7th Congress, Stockholm, Sweden, 1982. 6. Molina M, Oria HE: Gastric segmentation: a new, safe, effective, simple, readily revised and fully reversible surgical procedure for the ­correction of morbid obesity [abstract], presented at the 6th Bariatric Surgery Colloquium, Iowa City, IA, 1983. 7. Kuzmak LI: Silicone gastric banding: a simple and effective operation for morbid obesity, Contemp Surg 28:13–18, 1986. 8. Belachew M, Legrand M, Jacquet N: Laparoscopic placement of adjustable silicone gastric banding in the treatment of morbid ­obesity: an animal model experimental study: a video film: a preliminary report [abstract 5], Obes Surg 3:140, 1993. 9. Forsell P, Hallberg D, Hellers G: Gastric banding for morbid obesity: initial experience with a new adjustable band, Obes Surg 3:369–374, 1993. 10. Buchwald H, Oien D: Metabolic/bariatric surgery worldwide 2008, Obes Surg 19:1605–1611, 2009. 11. Moy J, Pomp AL, Dakin G, et al: Laparoscopic sleeve gastrectomy for morbid obesity, Am J Surg 196:e56–e59, 2008. 12. Stroh C, Birk D, Flade-Kuthe R, et al: Results of sleeve gastrectomy—data from a nationwide survey on bariatric surgery in Germany, Obes Surg 19:632–640, 2009.

Chapter

7

Laparoscopic Adjustable Gastric Banding The preceding chapters have begun with a description of the open approach, followed by the laparoscopic approach. Although, as with most metabolic/bariatric surgery, adjustable gastric banding started as an open operation, few practitioners of bariatric surgery today perform adjustable gastric banding via an open incision. This situation may change in the future (see Section VI, Chapter 22). However, this chapter focuses only on the laparoscopic adjustable gastric banding procedure. Adjustable gastric banding is the least invasive of the current gastric restrictive procedures. A small pouch and a small stoma are created by a band around the upper stomach. The stomach is not cut, crushed, or resected, and no anastomoses are made. The precursors of gastric bypass are found in the fundoplication procedure of Tretbar et al.1 (1976) and the mesh wrapping of the entire stomach by Wilkinson2 (1980). Independently, Wilkinson and Peloso3 (1978), Kolle4 (1982), and Molina and Oria5 (1983) initiated actual gastric banding. Their bands were placed during open surgery and were not adjustable, similar to the “gastro-clip” of Bashour and Hill6 (1985). In 1986, Kuzmak7 introduced the inflatable Silastic band connected to a subcutaneous port, which was used for the percutaneous introduction or removal of fluid to adjust the caliber of the gastric band. In 1992–1993, Broadbent et al.8 and Catona et al.9 were probably the first to perform gastric banding laparoscopically, and in 1993, Belachew et al.10 and Forsell et al.11 were the first to perform adjustable gastric banding laparoscopically. Niville et al.12 reported placing the posterior aspect of the band at the distal esophagus and constructing an extremely small anterior gastric pouch. Currently, optimal results have been reported with the pars flaccida approach and a nearly virtual 15-mL upper pouch.13

References



1. Tretbar LL, Taylor TL, Sifers EC: Weight reduction: gastric plication for morbid obesity, J Kans Med Soc 77:488–490, 1976. 2. Wilkinson LH: Reduction of gastric reservoir capacity, J Clin Nutr 33:515–517, 1980. 3. Wilkinson LH, Peloso OA: Gastric (reservoir) reduction for morbid obesity, Arch Surg 116:602–605, 1981. 4. Kolle K: Gastric banding, [abstract 145], presented at the OMGI 7th Congress, Stockholm, Sweden, 1982. 5. Molina M, Oria HE: Gastric segmentation: a new, safe, effective, simple, readily revised and fully reversible surgical procedure for the ­correction of morbid obesity [abstract], presented at the 6th Bariatric Surgery Colloquium, Iowa City, IA, 1983. 6. Bashour SB, Hill RW: The gastro-clip gastroplasty: an alternative surgical procedure for the treatment of morbid obesity, Tex Med 81:35–38, 1985. 7. Kuzmak LI: Silicone gastric banding: a simple and effective operation for morbid obesity, Contemp Surg 28:13–18, 1986. 8. Broadbent R, Tracy M, Harrington P: Laparoscopic gastric banding: a preliminary report, Obes Surg 3:63–67, 1983. 9. Catona A, Gossenberg M, La Manna A, et al: Laparoscopic gastric banding: preliminary series, Obes Surg 3:207–209, 1993.

145

146   Section IV  •  Restrictive Procedures 10. Belachew M, Legrand M, Jacquet N: Laparoscopic placement of adjustable silicone gastric banding in the treatment of morbid ­obesity: an animal model experimental study: a video film: a preliminary report [abstract 5], Obes Surg 3:140, 1993. 11. Forsell P, Hallberg D, Hellers G: Gastric banding for morbid obesity: initial experience with a new adjustable band, Obes Surg 3:369–374, 1993. 12. Niville E, Vankeirsblick J, Dams A, et al: Laparoscopic adjustable esophagastric banding: a preliminary experience, Obes Surg 8:39–42, 1998. 13. Miller KA: Evolution of gastric band implantation and port fixation techniques, Surg Obes Relat Dis 4:S22–S30, 2008.

Technique

This operation has undergone several phases in its evolution. Certain principles are currently fairly standard: s

The upper gastric pouch (the “virtual pouch”) is made very small, approximately 15 mL in volume, and is placed primarily anteriorly. s A minimal posterior dissection is carried out above the peritoneal reflection of the bursa omentalis, at a level where the esophagogastric junction and the immediately adjacent stomach are fixed to the crura of the diaphragm. s The dissection on the lesser curvature includes the neurovascular bundle of the lesser ­omentum—the pars flaccida approach. This approach has superceded the technically more difficult perigastric approach and is associated with a lower rate of gastric prolapse. A combined technique also has been described, consisting of an initial pars flaccida dissection, which is then converted to a perigastric placement of the band. s Suture fixation of the anterior wall of the stomach, with gastrogastric sutures, completes band placement. This maneuver has recently become controversial. s The balloon is deflated within the band at the time of operation. This precaution prevents tightness of the stoma and perioperative edema and reduces the risk of immediate postoperative emesis. s The system is assembled, and the port for inflation and deflation of the band is secured onto the rectus fascia of the anterior abdominal wall. ◆ Figure 7-1: Placement of port sites varies with the procedure to be performed and the personal preference of the surgeon. Most bariatric procedures require five to six port sites. The camera port is generally a 12-mm port placed in the midline. The location of the other ports varies, but as a rule, both sides of the upper abdominal wall are used for placement; they are mostly 5-mm port sites but may include a 10- or a 15-mm port site. ◆ Figure 7-2: Insufflation of the abdominal cavity with carbon dioxide gas (experimentally, helium has been used) can be established via a spring-loaded, tension-sensing Veress needle inserted blindly. The 2-mm needle has a blunt inner cannula that automatically extends beyond the needle point upon entering the abdominal cavity. After insertion, to ensure that no tissue damage has occurred, the surgeon should aspirate the needle for blood, succus, or stool and then perform the drop of saline test, allowing a drop of saline placed on the hub of the needle to fall into the peritoneal cavity by gravity or on creating negative intraperitoneal pressure by lifting the abdominal wall. The carbon dioxide gas is infused via a side hole by an automatic, gauged insufflation device to a pressure of 15 mm Hg. An alternative approach into the peritoneal cavity is the Hasson technique, which is an open approach via a 1- to 1.5-cm incision at the umbilicus. A blunt obturator cannula is then placed into the abdominal cavity and, generally, anchored in place by fascial sutures. s Alternate site to umbilical or periumbilical site for blind insertion of the insufflation Veress needle.

Chapter 7  •  Laparoscopic Adjustable Gastric Banding   147

Figure 7-1

Insufflator

Figure 7-2

148   Section IV  •  Restrictive Procedures

Figure 7-3: Once pneumoperitoneum is achieved, the access trocars are placed under direct vision. Initially, a 5-mm optical viewing trocar is used. Once a camera port site is established, placement of the remaining trocars is performed under laparoscopic visual control. Trocar lengths used for bariatric surgery, as a rule, are 100 and 150 mm. Cannulae types include those with pyramidal cutting tips, retractable blades, retractable “safety” shields, conical tapered tips, radial dilating cannulae, and screw devices. The threaded screw cannulae are usually preferred. The trocars should be placed perpendicular to the abdominal wall. ◆ Figure 7-4: Generally, the primary surgeon stands on the right side of the patient, the first assistant faces the surgeon on the patient's left, and the second assistant/camera operator and the scrub nurse are positioned toward the foot of the bed. Placing the arms out on arm boards facilitates access to the abdomen. An alternative configuration of the operating team has the surgeon standing between the abducted legs of the patient. (The introduction of robotics places the surgeon away from the operating table for the first time in the history of surgery; indeed, the surgeon can be in another room or facility.) (For further review of the technique for laparoscopic abdominal access, see Section I, Chapter 2.) s Having the patient in the reverse Trendelenburg position is preferred for visualization of the attic of the abdomen. ◆

Chapter 7  •  Laparoscopic Adjustable Gastric Banding   149

Trocar

Figure 7-3

Anesthetist

Monitor Light Camera Insufflator

Monitor

1st assistant

Surgeon

2nd assistant

Instruments Nurse

Figure 7-4

150   Section IV  •  Restrictive Procedures

Figure 7-5: The liver is retracted superiorly and to the right with a liver retractor. The entry point for the retractor is usually made with a 5-mm port just below the xiphoid process; the port is subsequently removed. Adequate liver retraction is essential to expose the esophagogastric angle and spleen to allow for safe dissection at the angle of His. ◆ Figure 7-6: The procedure starts with the dissection at the angle of His. A grasper is placed on the anterior gastric wall for downward traction. A sweeping motion with a closed grasper is used to expose the angle of His. Dissection into the retroperitoneal space superior to the fundus of the stomach is carried out above the first short gastric vessel, lateral to the esophagogastric junction. ◆ Figure 7-7: The superficial anterior esophagogastric fat pad is excised, along with other posterolateral, medial, and perigastric fat pads, if present. The esophagogastric junction should be cleaned down to serosa. These fat pads can be quite vascular, and a hemostatic technique, using cautery or a powered tissue divider, should be used. ◆

Chapter 7  •  Laparoscopic Adjustable Gastric Banding   151

Figure 7-5

Figure 7-6

Figure 7-7

152   Section IV  •  Restrictive Procedures

Figure 7-8: The next step to gain retroperitoneal access for passage of the adjustable gastric band is dissection of the lesser omentum. Most surgeons today prefer the pars flaccida approach, with the thin area of the lesser omentum divided over the caudate lobe of the liver. A large aberrant left hepatic artery coming off the left gastric artery is occasionally encountered; care should be taken to leave this vessel intact. s The perigastric approach (which currently is rarely used because of a greater incidence of complications) is illustrated. Some surgeons start with the pars flaccida approach and, once this dissection has been accomplished, switch to the perigastric exposure for band placement. ◆ Figure 7-9: The peritoneum next to the right crus of the diaphragm is incised and a long grasper is passed behind the esophagogastric junction, from the patient's right to the patient's left, at a 45-degree angle, emerging at the angle of His. ◆

Chapter 7  •  Laparoscopic Adjustable Gastric Banding   153

Figure 7-8

Figure 7-9

154   Section IV  •  Restrictive Procedures

Figure 7-10: The grasper is now used to pass the adjustable gastric band around the stomach, the band having been introduced into the abdominal cavity via the 15-mm port. ◆ Figure 7-11: The adjustable gastric band is positioned to allow for a smooth contouring of the band around the fundus of the stomach inferior to the esophagogastric junction. The tab of the adjustable gastric band is inserted through the locking mechanism. ◆ Figure 7-12: The band is secured and locked. The band contains no fluid during this placement and should not constrict the stomach. ◆

Chapter 7  •  Laparoscopic Adjustable Gastric Banding   155

Figure 7-10

Figure 7-11

Figure 7-12

156   Section IV  •  Restrictive Procedures

Figure 7-13: Starting from the patient's left and going to the patient's right, two to three nonabsorbable, gastrogastric sutures are taken around the anterior surface of the band to prevent slippage and herniation. The gastric plication should be tension free and not cover the locking mechanism of the band. At present, the need for gastric plication is being questioned. ◆ Figure 7-14: The adjustable gastric band is in place, leaving a virtual 10- to 15-mL functioning upper gastric pouch. ◆

Chapter 7  •  Laparoscopic Adjustable Gastric Banding   157

Figure 7-13

Figure 7-14

158   Section IV  •  Restrictive Procedures

Figure 7-15: The tubing tab and tubing are withdrawn via an appropriately placed port, leaving the majority of the tubing within the abdominal cavity. All trocars and the liver retractor can now be removed. The tubing is tunneled laterally to a 3- to 4-cm incision site and withdrawn. Deep subcutaneous retractors are used to maintain exposure. The tubing tab is cut free and the tubing is connected to the port with use of the proprietary connecting mechanism of the adjustable gastric band. The port is fixed to the rectus fascia with four nonabsorbable sutures or a stapling instrument. ◆ Figure 7-16: Schematic of the laparoscopic adjustable gastric banding in place. The band is not filled for at least 8 weeks. ◆

Chapter 7  •  Laparoscopic Adjustable Gastric Banding   159

Figure 7-15

Figure 7-16

Chapter

8

Open Gastric Segmentation The precursor to the laparoscopic adjustable gastric band, the nonadjustable gastric band placed by open surgery, did not become a historical procedure but continues to be used in Europe and the United States. Molina and Oria1 are credited with the inception of gastric segmentation and Oria2 with its current use. Approximately 8000 gastric segmentation operations have been performed, the majority with the open technique, which is described.

References

1. Molina M, Oria HE: Gastric segmentation: a new, safe, effective, simple, readily revised and fully reversible surgical procedure for the correction of morbid obesity [abstract], presented at the 6th Bariatric Surgery Colloquium, Iowa City, IA, 1983. 2. Oria HE: Gastric segmentation: nonadjustable banding by minilaparotomy: historical review, Surg Obes Relat Dis 5:365–370, 2009.

161

162   Section IV  •  Restrictive Procedures

Technique

Figure 8-1: Entrance is gained into the abdominal cavity by a mini-laparotomy midline incision, 6 to 8  cm in length, starting at the xiphoid process. The site for the incision has been drawn and local anesthetic injected. s Location of the incision site. ◆ Figure 8-2: Making the incision. ◆

Chapter 8  •  Open Gastric Segmentation   163

Figure 8-1 

Figure 8-2 

164   Section IV  •  Restrictive Procedures

Figure 8-3: The surgeon's hand is inserted into the abdomen and, starting at the angle of His, a retrogastric tunnel is created by blunt dissection toward the lesser omentum. ◆ Figure 8-4: By using blunt dissection, the retrogastric plane is exited in a perigastric fashion 3 to 4 cm below the esophagogastric junction. ◆

Chapter 8  •  Open Gastric Segmentation   165

Figure 8-3 

Figure 8-4 

166   Section IV  •  Restrictive Procedures

Figure 8-5: The gastric band is introduced into the abdomen on a curved ring forceps or a curved clamp and is placed through the retrogastric tunnel with manual guidance. ◆ Figure 8-6: With clamps at both ends of the band, the upper stomach is lifted upward into the operative field. ◆ Figure 8-7: With a #36 Fr orogastric bougie in place to calibrate the stoma of approximately 12 mm, a right-angle clamp is used to secure the band snugly around the orogastric bougie for the placement of two nonabsorbable sutures, creating a small pouch above the band. ◆

Chapter 8  •  Open Gastric Segmentation   167

Figure 8-5 

Figure 8-6  Figure 8-7 

168   Section IV  •  Restrictive Procedures

Figure 8-8: The redundant band material is excised, the right angle clamp is removed, and a third nonabsorbable suture is placed between the two previously placed sutures. ◆ Figure 8-9: Two absorbable sutures are used to secure the lower rim of the band to the stomach to diminish the risk of slippage. ◆ Figure 8-10: Completed gastric segmentation. ◆

Chapter 8  •  Open Gastric Segmentation   169

Figure 8-8 

Figure 8-9 

Figure 8-10 

Chapter

9

Vertical Silastic Ring and Banded Gastroplasty The evolution of vertical Silastic ring and banded gastroplasty procedures was not straightforward and involved several failures before successful operations were devised. In their 1971 gastroplasty ­operation, Printen and Mason1 divided the stomach horizontally from lesser curvature to greater ­curvature, ­leaving a gastric conduit at the greater curvature. This procedure was unsuccessful in ­maintaining weight loss. In 1979, Gomez2 introduced the horizontal gastric stapling modification of the divided ­gastroplasty and, in addition, the practice of reinforcing the greater curvature outlet with a running suture. This ­procedure did not result in lasting success either. Similarly, the gastric ­partitioning ­operation of Pace et al.3 (1979) was unsuccessful because the partitioning created by the removal of several staples from the middle of the stapling instrument was followed by widening of the ­gastrogastrostomy outlet. To overcome this problem, LaFave and Alden4 performed a total gastric cross-stapling and a sewed anterior gastrogastrostomy; however, this operation resulted in no substantial weight loss in the long term. In 1981, Fabito5 was the first to perform a vertical gastroplasty by using a modified stapler and ­reinforcing the outlet with seromuscular sutures. That same year, Laws and Piantadosi6 were probably the first to use a Silastic ring as a permanent, nonexpandable support for the vertical gastroplasty outlet. In 1980, Mason7 performed his last gastroplasty variation— the vertical banded gastroplasty. This vertical banded gastroplasty involved a novel concept: namely, making a window (a through-and-through perforation in both walls of the stomach) with the end-to-end stapler just above the pes anserinus (crow's foot) on the lesser curvature. This window was used for the insertion of a noncutting, four-row, 90-mm stapler to the angle of His to create a small stapled vertical pouch. The lesser curvature outlet was banded with a 1.5-cm wide polypropylene mesh collar through the gastric window and around the lesser curvature conduit. A more recent and popular innovation of gastroplasty is the 1986 Silastic ring vertical gastroplasty by Eckhout et al.8 with a specially constructed notched stapler to avoid the window of the Mason vertical banded gastroplasty. Also, the nonreactive, far narrower (2.5-mm ­diameter) Silastic ring prevents the formation of granulation tissue sometimes induced by the polypropylene mesh with subsequent outlet obstruction. In 1994, Hess and Hess9 performed the vertical banded gastroplasty laparoscopically, and Chua and Mendiola10 performed it in 1995. In essence, they used the Mason open technique by creating a gastric window, placing a linear noncutting, four-row, 90-mm staple line through that window to the angle of His, and banding the outlet with polypropylene mesh. 171

172   Section IV  •  Restrictive Procedures Champion's novel laparoscopic variation of the vertical banded gastroplasty consists of a wedge resection of the greater curvature portion of the upper stomach with the endostapler instrument—creating, in essence, a Collis-like lesser curvature gastric tube, around which the constricting ring or band is placed.11

References



1. Printen KJ, Mason EE: Gastric surgery for relief of morbid obesity, Arch Surg 106:428–431, 1973. 2. Gomez CA: Gastroplasty in morbid obesity, Surg Clin North Am 59:1113–1129, 1979. 3. Pace WG, Martin EW, Tetirick CE, et al: Gastric partitioning for morbid obesity, Ann Surg 190:392–400, 1979. 4. LaFave JW, Alden JF: Gastric bypass in the operative revision of the failed jejuno-ileal bypass, Arch Surg 114:438–444, 1979. 5. Fabito DC: Gastric vertical stapling, presented at the Bariatric Surgery Colloquium, Iowa City, IA, 1981. 6. Laws HL, Piantadosi S: Superior gastric reduction procedure for morbid obesity: a prospective, randomized trial, Am J Surg 193:334–346, 1981. 7. Mason EE: Vertical banded gastroplasty, Arch Surg 117:701–706, 1982. 8. Eckhout GV, Willbanks OL, Moore JT: Vertical ring gastroplasty for obesity: five year experience with 1463 patients, Am J Surg 152:713–716, 1986. 9. Hess DW, Hess DS: Laparoscopic vertical banded gastroplasty with complete transaction of the staple-line, Obes Surg 4:44–46, 1994. 10. Chua TY, Mendiola RM: Laparoscopic vertical banded gastroplasty: the Milwaukee experience, Obes Surg 5:77–80, 1995. 11. Champion JK: Laparoscopic vertical banded gastroplasty, Curr Surg 60:37–39, 2003.

Open vertical silastic ring gastroplasty technique

Figure 9-1: A midline incision from the xiphoid to above the umbilicus is the usual abdominal entry site. Some surgeons use a marking pen to indicate the path of incision. s Torso representation of incision site. ◆ Figure 9-2: The incision is made into the subcutaneous fat with the scalpel. Gentle pressure on both sides of the incision by the surgeon and assistant facilitates a straight line of entry. The small ­subcuticular bleeders are cauterized for hemostasis. ◆

Chapter 9  • Vertical Silastic Ring and Banded Gastroplasty   173

Figure 9-1

Figure 9-2

174   Section IV  •  Restrictive Procedures

Figure 9-3: The surgeon and assistant apply opposing pressure on the sides of the opening and, with considerable force, tear the subcutaneous fat and Scarpa's fascia down to the linea alba. This ­maneuver will require several applications of subcutaneous pulling in opposite directions along the length of the incision and usually at several depths. This technique typically guarantees ­precise ­penetration down to the linea alba, with minimal bleeding and no tissue damage from the use of ­cautery ­coagulation. The tearing technique may not be feasible in reusing a midline incision for ­reentry into the abdominal cavity, in which case coagulating cautery is used to reach the linea alba. ◆ Figure 9-4: Using the cautery at a fairly low current (25 amps), the linea alba is incised along its length down to the preperitoneal fat. (For further review of the technique for open abdominal access, see Section I, Chapter 1.) ◆ Figure 9-5: Anatomy for the open vertical Silastic ring gastroplasty with the liver retracted to expose the esophagogastric junction and the angle of His. The gastrohepatic ligament incision site is indicated. ◆ Figure 9-6: Scissors are used to make a 2-cm incision in the gastrohepatic ligament in the lesser ­curvature next to the gastric wall, midway between the esophagogastric junction and the pes ­anserinus (crow's foot); this incision is deepened into the lesser sac through a spreading motion. ◆ Figure 9-7: The tissue is cleared away for entrance into the lesser sac at the angle of His using sharp scissor dissection with incision into the peritoneal tissue just to the left of the left crus of the esophagus. ◆ Figure 9-8: Fingers are inserted from below (area of incision into the lesser sac on the lesser curvature) and above (area of the angle of His), with the fingers meeting and forming a passage through the lesser sac. ◆

Chapter 9  • Vertical Silastic Ring and Banded Gastroplasty   175

Figure 9-3

Figure 9-4

2 cm incision

Figure 9-5

Figure 9-7

Figure 9-6

Figure 9-8

176   Section IV  •  Restrictive Procedures

Figure 9-9: A catheter is inserted from the angle of His to the lesser curvature with the flange of the catheter facing inferiorly; the catheter can be inserted from below if this approach is more feasible. ◆ Figure 9-10: Insertion of the notched, noncutting, four-row, 90-mm stapler, with the inferior tip of the stapler in the opening of the catheter used as a guide to place the anvil of the stapler behind the stomach in the lesser sac. ◆ Figure 9-11: With a #24 Fr dilator in the stomach, the vertical pouch is structured by the surgeon on the right of the patient, who holds the intragastric dilator within the notch of the TA-90 stapler, and the surgeon on the left of the patient, who pulls the stomach laterally to the left to create a ±15-mL pouch. ◆ Figure 9-12: The stapler is closed, the position of the bougie guide is confirmed, and the stapler is fired. ◆ Figure 9-13: The vertical pouch has been created. ◆

Chapter 9  • Vertical Silastic Ring and Banded Gastroplasty   177

Figure 9-9

Figure 9-10

Figure 9-11

Figure 9-12

Figure 9-13

178   Section IV  •  Restrictive Procedures

Figure 9-14: Next, the Silastic ring is placed. This procedure involves five steps: A. A 2/0 nylon suture on a straight Keith needle is threaded from a previously placed central hole (cut at the midpoint of a 44-mm Silastic tube) out one end of the ring and through the staple line; the needle is held at an inclined angle with a needle holder aimed toward the back of a clamp on the other side of the staple line that has been placed to protect the vascular bundle at the lesser curvature. B. The needle and suture are passed through the entire ring from the end not previously used for passage of the suture to the end of the ring from which the suture previously exited. C. A second pass is made through the staple line, which is identical in location to the first pass except for the alignment of the suture through the ring. D. The needle and suture are now inserted back through the ring and out the middle orifice. E. The ring is secured in place with 10 knots in the nylon suture so that the ends of the ring are on either side of the staple line but the ring is not snugged down on the exit of the vertical pouch. s The course of the suture through the ring and stapled gastric wall. ◆ Figure 9-15: A single 5/0 nonabsorbable suture is taken in Lembert fashion around the ring to create a fold of stomach to secure the ring in place. ◆ Figure 9-16: Completed vertical Silastic ring gastroplasty. ◆

Chapter 9  • Vertical Silastic Ring and Banded Gastroplasty   179

Suture path

Stomach pouch

Silastic ring

Figure 9-14

Figure 9-15

Figure 9-16

180   Section IV  •  Restrictive Procedures

Open vertical banded gastroplasty technique (mason procedure)

◆

Figure  9-17: A midline incision from the xiphoid to above the umbilicus is the usual abdominal entry site. Some surgeons use a marking pen to indicate the path of incision. s Torso representation of incision site.

Chapter 9  • Vertical Silastic Ring and Banded Gastroplasty   181

Figure 9-17

182   Section IV  •  Restrictive Procedures

Figure 9-18: The incision is made into the subcutaneous fat with the scalpel. Gentle pressure on both sides of the incision by the surgeon and assistant facilitate a straight line of entry. The small ­subcuticular bleeders are cauterized for hemostasis. ◆ Figure 9-19: The surgeon and assistant apply opposing pressure on the sides of the opening and, with considerable force, tear the subcutaneous fat and Scarpa's fascia down to the linea alba. This ­maneuver will require several applications of subcutaneous pulling in opposite directions along the length of the incision and usually at several depths. This technique typically guarantees ­precise ­penetration down to the linea alba, with minimal bleeding and no tissue damage from the use of ­cautery coagulation. The tearing technique may not be feasible in reusing a midline incision for ­reentry into the abdominal cavity, in which case coagulating cautery is used to reach the linea alba. ◆ Figure 9-20: Using the cautery at a fairly low current (25 amps), the linea alba is incised along its length down to the preperitoneal fat. (For further review of the technique for open abdominal access, see Section I, Chapter 1.) ◆

Chapter 9  • Vertical Silastic Ring and Banded Gastroplasty   183

Figure 9-18

Figure 9-19

Figure 9-20

184   Section IV  •  Restrictive Procedures

Figure 9-21: Anatomy for the open vertical banded gastroplasty with the liver retracted to expose the esophagogastric junction and the angle of His. The gastrohepatic ligament incision site is indicated. ◆ Figure 9-22: Scissors are used to make a 2-cm incision in the gastrohepatic ligament in the lesser curvature right next to the gastric wall, midway between the esophagogastric junction and the pes anserinus (crow's foot); this incision is deepened into the lesser sac through a spreading motion. ◆ Figure 9-23: The tissue is cleared away for entrance into the lesser sac at the angle of His using sharp scissor dissection with incision into the peritoneal tissue just to the left of the left crus of the esophagus. ◆ Figure 9-24: The surgeon, on the right side of the patient, bluntly tunnels behind the stomach through the opening in the lesser curvature. ◆ Figure 9-25: The anvil of the end-to-end circular stapler is held against the posterior wall of the ­stomach just above the crow's foot toward the lesser curvature of the stomach. The trocar, or spike, of the stapler is inserted through both walls of the stomach. Depending on the stapler being used, the trocar is assembled attached, either to the body or the anvil (head) of the instrument. The stapler is engaged. ◆

Chapter 9  • Vertical Silastic Ring and Banded Gastroplasty   185

2 cm incision

Figure 9-21

Figure 9-22

Figure 9-24

Figure 9-23

Figure 9-25

186   Section IV  •  Restrictive Procedures

Figure 9-26: The stapler is fired, creating a circular stapled orifice through-and-through the stomach. The stapler is checked for the presence of intact tissue rings, and the circular orifice is examined for staple line integrity. s Lateral view of the stomach and stapler in the firing position. ◆ Figure 9-27: Completion of the creation of the gastric window. ◆ Figure 9-28: An unnotched, noncutting, four-row, 90-mm stapler, with the anvil portion of the stapler retrogastric, is placed from the gastric window to the angle of His. The stapler is fired to create a ­vertical ±15-mL gastric pouch along the lesser curvature. ◆

Chapter 9  • Vertical Silastic Ring and Banded Gastroplasty   187

Figure 9-26

Figure 9-27

Figure 9-28

188   Section IV  •  Restrictive Procedures

Figure 9-29: Completed vertical gastric pouch. Figure 9-30: The lesser curvature pouch outlet is banded with a polypropylene mesh collar 1.5 cm in width, which is taken through the gastric window and around the lesser curvature. Two nonabsorbable sutures are used to secure the band, with the excess band material trimmed away. ◆ Figure 9-31: Completed vertical banded gastroplasty. ◆ ◆

Chapter 9  • Vertical Silastic Ring and Banded Gastroplasty   189

Figure 9-29

Figure 9-30

Figure 9-31

190   Section IV  •  Restrictive Procedures

Laparoscopic vertical banded gastroplasty technique (mason approach)

Figure 9-32: Placement of port sites varies with the procedure to be performed and the personal ­preference of the surgeon. Most bariatric procedures require five to six port sites. The camera port is generally a 12-mm port placed in the midline. The location of the other ports varies, but as a rule, both sides of the upper abdominal wall are used for placement; they are mostly 5-mm port sites but may include a 10- or a 15-mm port site. ◆ Figure 9-33: Insufflation of the abdominal cavity with carbon dioxide gas (experimentally, helium has been used) can be established via a spring-loaded, tension-sensing Veress needle inserted blindly. The 2-mm needle has a blunt inner cannula that automatically extends beyond the needle point upon entering the abdominal cavity. After insertion, to ensure that no tissue damage has occurred, the surgeon should aspirate the needle for blood, succus, or stool, and then perform the drop of saline test, allowing a drop of saline placed on the hub of the needle to fall into the peritoneal cavity by gravity or on creating negative intraperitoneal pressure by lifting the abdominal wall. The carbon dioxide gas is infused via a side hole by an automatic, gauged insufflation device to a pressure of 15 mm Hg. An alternative approach into the peritoneal cavity is the Hasson technique, which is an open approach via a 1- to 1.5-cm incision at the umbilicus. A blunt obturator cannula is then placed into the abdominal cavity and, generally, anchored in place by fascial sutures. s Alternate site to umbilical or periumbilical site for blind insertion of the insufflation Veress needle. ◆

Chapter 9  • Vertical Silastic Ring and Banded Gastroplasty   191

X

Liver retractor port 5-15 mm trocars

Camera port

Figure 9-32

Insufflator

Figure 9-33

192   Section IV  •  Restrictive Procedures

Figure  9-34: Once pneumoperitoneum is achieved, the access trocars are placed under direct vision. A 5-mm optical viewing trocar is used. Once a camera port site is established, placement of the remaining trocars is performed under laparoscopic visual control. Trocar lengths used for bariatric surgery, as a rule, are 100 and 150 mm. Cannulae types include those with pyramidal cutting tips, retractable blades, retractable “safety” shields, conical tapered tips, radial dilating cannulae, and screw devices. The threaded screw cannulae are usually preferred. The trocars should be placed ­perpendicular to the abdominal wall. ◆ Figure 9-35: In general, the primary surgeon stands on the right side of the patient, the first assistant faces the surgeon on the patient's left, and the second assistant/camera operator and the scrub nurse are positioned toward the foot of the bed. Placing the arms out on arm boards facilitates access to the abdomen. An alternative configuration of the operating team has the surgeon standing between the abducted legs of the patient. (The introduction of robotics places the surgeon away from the ­operating table for the first time in the history of surgery; indeed, the surgeon can be in another room or facility.) (For further review of the technique for laparoscopic abdominal access, see Section I, Chapter 2.) s Having the patient in the reverse Trendelenburg position is preferred for visualization of the attic of the abdomen. ◆

Chapter 9  • Vertical Silastic Ring and Banded Gastroplasty   193

Trocar

Figure 9-34

Anesthetist

Monitor Light Camera Insufflator

Monitor

1st assistant

Surgeon

2nd assistant

Instruments Nurse

Figure 9-35

194   Section IV  •  Restrictive Procedures

Figure 9-36: The liver is retracted. Using a grasper to stabilize the stomach, entry is gained into the area of the angle of His by sharp and blunt dissection. This maneuver may require division of one or more short gastric vessels with an oscillating or other powered tissue divider. ◆ Figure 9-37: Using sharp and blunt dissection, entry is gained into the lesser sac from the lesser ­curvature at a distance midway between the esophagogastric junction and the pes anserinus (crow's foot). ◆ Figure 9-38: A #32 Fr bougie (dotted line) is inserted orally and placed along the lesser curvature. ◆

Chapter 9  • Vertical Silastic Ring and Banded Gastroplasty   195

Figure 9-37

Figure 9-36

Figure 9-38

196   Section IV  •  Restrictive Procedures

Figure 9-39: The anvil or head of a 22-mm laparoscopic circular stapler with the trocar, or spike, attached is passed behind the stomach. s Detail of securing the passage of the anvil with a flexible catheter. ◆ Figure 9-40: The trocar of the stapler is passed from behind the stomach through both walls of the stomach and connected to the head of the body of the instrument. Depending on the stapler used, the trocar is assembled attached, either to the body or the anvil of the instrument. ◆

Chapter 9  • Vertical Silastic Ring and Banded Gastroplasty   197

Figure 9-39

Figure 9-40

198   Section IV  •  Restrictive Procedures

Figure 9-41: The stapler is fired and a circular through-and-through opening in the stomach is created. s Stapler shown in the firing position. ◆ Figure 9-42: A vertical pouch is created with the laparoscopic cutting stapler by several passes of the instrument up from the transgastric circular orifice to the angle of His. The intragastric bougie is used as a guide. ◆

Chapter 9  • Vertical Silastic Ring and Banded Gastroplasty   199

Figure 9-41

Figure 9-42

200   Section IV  •  Restrictive Procedures

Figure 9-43: The completed construction of the divided upper gastric pouch. Figure 9-44: The lesser curvature pouch outlet is banded with a polypropylene mesh collar that is 1.5 cm in width; it is taken through the gastric window and around the lesser curvature. Two ­nonabsorbable sutures are used to secure the band, with the excess band material trimmed away. ◆ Figure 9-45: Completed laparoscopic Mason vertical banded gastroplasty. ◆ ◆

Chapter 9  • Vertical Silastic Ring and Banded Gastroplasty   201

Figure 9-43

Figure 9-44

Figure 9-45

202   Section IV  •  Restrictive Procedures

Laparoscopic vertical banded gastroplasty technique (champion approach)

Figure 9-46: Placement of port sites varies with the procedure to be performed and the personal ­preference of the surgeon. Most bariatric procedures require five to six port sites. The camera port is ­generally a 12-mm port placed in the midline. The location of the other ports varies but, as a rule, both sides of the upper abdominal wall are used for placement; they are mostly 5-mm port sites but may include a 10- or a 15-mm port site. ◆ Figure 9-47: Insufflation of the abdominal cavity with carbon dioxide gas (experimentally, helium has been used) can be established via a spring-loaded, tension-sensing Veress needle inserted blindly. The 2-mm needle has a blunt inner cannula that automatically extends beyond the needle point upon entering the abdominal cavity. After insertion, to ensure that no tissue damage has occurred, the surgeon should aspirate the needle for blood, succus, or stool, and then perform the drop of saline test, allowing a drop of saline placed on the hub of the needle to fall into the peritoneal cavity by gravity or on creating negative intraperitoneal pressure by lifting the abdominal wall. The carbon dioxide gas is infused via a side hole by an automatic, gauged insufflation device to a pressure of 15 mm Hg. An alternative approach into the peritoneal cavity is the Hasson technique, which is an open approach via a 1- to 1.5-cm incision at the umbilicus. A blunt obturator cannula is then placed into the abdominal cavity and, in general, anchored in place by fascial sutures. s Alternate site to umbilical or periumbilical site for blind insertion of the insufflation Veress needle. ◆

Chapter 9  • Vertical Silastic Ring and Banded Gastroplasty   203

X

Liver retractor port 5-15 mm trocars

Camera port

Figure 9-46

Insufflator

Figure 9-47

204   Section IV  •  Restrictive Procedures

Figure  9-48: Once pneumoperitoneum is achieved, the access trocars are placed under direct vision. A 5-mm optical viewing trocar is initially used. Once a camera port site is established, placement of the remaining trocars is performed under laparoscopic visual control. Trocar lengths used for ­bariatric surgery, as a rule, are 100 and 150 mm. Cannulae types include those with pyramidal cutting tips, retractable blades, retractable “safety” shields, conical tapered tips, radial dilating cannulae, and screw devices. The threaded screw cannulae are usually preferred. The trocars should be placed ­perpendicular to the abdominal wall. ◆ Figure 9-49: In general, the primary surgeon stands on the right side of the patient, the first assistant faces the surgeon on the patient's left, and the second assistant/camera operator and the scrub nurse are positioned toward the foot of the bed. Placing the arms out on arm boards facilitates access to the abdomen. An alternative configuration of the operating team has the surgeon standing between the abducted legs of the patient. (The introduction of robotics places the surgeon away from the ­operating table for the first time in the history of surgery; indeed, the surgeon can be in another room or facility.) (For further review of the technique for laparoscopic abdominal access, see Section I, Chapter 2.) s Having the patient in the reverse Trendelenburg position is preferred for visualization of the attic of the abdomen. ◆

Chapter 9  • Vertical Silastic Ring and Banded Gastroplasty   205

Trocar

Figure 9-48

Anesthetist

Monitor Light Camera Insufflator

Monitor

1st assistant

Surgeon

2nd assistant

Instruments Nurse

Figure 9-49

206   Section IV  •  Restrictive Procedures

Figure 9-50: The liver is retracted. With a grasper to stabilize the stomach, a powered tissue divider is used to divide the greater omentum and short gastric vessels of the upper third of the stomach as well as the essentially avascular tissue beneath the peritoneal reflection of the angle of His. ◆ Figure 9-51: Using sharp and blunt dissection, entry is gained into the lesser sac from the lesser ­curvature at a distance midway between the esophagogastric junction and the pes anserinus (crow's foot). ◆ Figure 9-52: A #32 Fr bougie (dotted line) is inserted orally and placed along the lesser curvature. ◆

Chapter 9  • Vertical Silastic Ring and Banded Gastroplasty   207

Figure 9-50

Figure 9-51

Figure 9-52

208   Section IV  •  Restrictive Procedures

Figure 9-53: The stomach is rotated 45 degrees to the right with a grasper and, with a laparoscopic cutting stapler, the stomach is divided horizontally starting on the greater curvature approximately 5 to 6 cm below the angle of His. ◆ Figure 9-54: Using the intragastric bougie as a guide, the horizontal staple line is extended vertically with the laparoscopic cutting stapler to the angle of His. ◆ Figure 9-55: The wedge resection of the upper third of the stomach is completed. The gastric wedge is removed via the 12-mm port with use of a specimen bag. The stapled stomach usually is not ­oversewn; however, stapler buttressing strips to protect against bleeding and/or a leak are often used. ◆ Figure 9-56: The lesser curvature pouch outlet is banded with a 1.5-cm-wide polypropylene mesh ­collar taken through the gastric window and around the lesser curvature. Two nonabsorbable sutures are used to secure the band, with the excess band material trimmed away. Alternatively, a 44-mm Silastic ring can be used to maintain the outlet diameter. ◆ Figure 9-57: Completed laparoscopic Champion vertical banded gastroplasty. ◆

Chapter 9  • Vertical Silastic Ring and Banded Gastroplasty   209

Figure 9-53 Figure 9-54

Figure 9-55

Figure 9-56

Figure 9-57

Chapter

10

Sleeve Gastrectomy The sleeve gastrectomy—by the standard classification of malabsorptive, malabsorptive/restrictive, and restrictive bariatric operations—is a restrictive procedure. The stomach is reduced to a vertical tube with a volume of 100 mL or less. With the appreciation that bariatric surgery is metabolic surgery came the recognition that resection of the greater gastric curvature also alters the hormonal milieu of the gut, in particular decreasing ghrelin production,1 and that these hormonal changes may affect hunger and satiety.2,3 Furthermore, little attention, if any, has been paid to the fact that resection of the greater curvature of the stomach removes the natural gastric pacemaker and the nerve syncytium responsible for normal gastric propulsion.4 In our own series of biliopancreatic diversion/duodenal switch procedures, which include a generous retained gastric conduit, we have had patients who for several weeks have distress upon eating, the inability to pass food through the gastric tube, and vomiting, all without any demonstrable obstruction on contrast studies or endoscopic examination. This transient phenomenon may well be credited to loss of normal gastric pacing and propulsion. Two predecessors of the sleeve gastrectomy had restriction of overall gastric volume as their goal: gastric plication, as described by Tretbar et al.,5 and gastric wrapping, as described by Wilkinson and Peloso.6 Currently, gastric volume reduction by plication is once again undergoing investigative exploration (see Section V).7,8 Hess and Hess9 and Marceau et al.10 were the first to use an actual vertical sleeve gastrectomy as part of their introduction of the biliopancreatic diversion/duodenal switch procedure. Hamoui et al.11 performed open sleeve gastrectomies from 1997 to 2001 in high-risk patients with super-morbid obesity. De Csepel et al.12 developed the laparoscopic biliopancreatic diversion/duodenal switch, including sleeve gastrectomy, in a porcine model, but because of a high complication rate when they attempted to perform the biliopancreatic diversion/ duodenal switch clinically,13 they advocated a two-stage procedure with the sleeve gastrectomy as the initial stage.14 Although the performance of open, laparoscopic, and even robotic biliopancreatic diversion/­ duodenal switch procedures has now been mastered with minimal complications, even in persons who are super obese,15 it became apparent that certain patients with a first-stage sleeve gastrectomy had good weight loss at 1 year, causing indefinite postponement and subsequent abandonment of the second stage of the biliopancreatic diversion/duodenal switch.16 In recent years, advocates of laparoscopic sleeve gastrectomy as a stand-alone procedure have markedly increased17-19; however, it will take several more years of careful assessment of longterm outcomes to establish whether the sleeve gastrectomy can, indeed, be advocated as a stand-alone operation. 211

212   Section IV  •  Restrictive Procedures In 2003, an incontinuity variation of a sleeve gastrectomy was advocated by Johnston et al.20 as the Magenstrasse and Mill operation, which consists of an elongation of a vertical gastroplasty with a prepyloric conduit to drain the greater curvature gastric remnant. This procedure is briefly illustrated in this chapter.

References

1. Camilleri M, Papathanasopoulos A, Odusi ST: Actions and therapeutic pathways of ghrelin for gastrointestinal disorders, Nat Rev Gastroent Hepat 6:343–352, 2009. 2. Neary MT, Batterham RL: Gut hormones: implications for the treatment of obesity, Pharmacol Ther 124:44–56, 2009. 3. Vincent RP, le Roux CW: Changes in gut hormones after bariatric surgery, Clin Endocrinol (Oxf) 69:17317–17319, 2008. 4. Tepperman J: Metabolic and endocrine physiology: an introductory text, Chicago, 1987, Year Book Medical Publishers. 5. Tretbar LL, Taylor TL, Sifers EC: Weight reduction: gastric plication for morbid obesity, J Kans Med Soc 77:488–490, 1976. 6. Wilkinson LH, Peloso OA: Gastric (reservoir) reduction for morbid obesity, Arch Surg 116:602–605, 1981. 7. Menchaca HJ, Harris JL, Thompson S, et al: Gastric plication: a preclinical study of the durability of serosa-to-serosa apposition, Surg Obes Relat Dis 7:8–14, 2011. 8. Schweitzer M: Endoscopic intraluminal suture plication of the gastric pouch and stoma in postoperative Roux-en-Y gastric bypass patients, J Laparoendosc Adv Surg Tech A 14:223–226, 2004. 9. Hess DW, Hess DS: Biliopancreatic diversion with a duodenal switch, Obes Surg 8:267–282, 1998. 10. Marceau P, Biron S, Bourque R-A, et al: Biliopancreatic diversion with a new type of gastrectomy, Obes Surg 3:29–35, 1993. 11. Hamoui H, Anthone GJ, Kaufman HS, et al: Sleeve gastrectomy in the high-risk patient, Obes Surg 16:14451–14459, 2006. 12. De Csepel J, Burpee S, Jossart GJ, et al: Laparoscopic biliopancreatic diversion with a duodenal switch for morbid obesity: a feasibility study in pigs, J Laparoendosc Adv Surg Tech A 11:79–83, 2001. 13. Kim WW, Gagner M, Kini S, et al: Laparoscopic vs. open biliopancreatic diversion with a duodenal switch: a comparative study, J Gastrointest Surg 7:552–557, 2003. 14. Regan JP, Inabnet WB, Gagner M: Early experience with two-stage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient, Obes Surg 13:861–864, 2003. 15. Buchwald H, Kellogg TA, Leslie DB, et al: Duodenal switch operative mortality and morbidity are not impacted by BMI, Ann Surg 248:541–548, 2008. 16. Moy J, Pomp A, Dakin G, et al: Laparoscopic sleeve gastrectomy for morbid obesity, Am J Surg 196:e56–e59, 2008. 17. Lee CM, Cirangle PT, Jossart GH: Vertical gastrectomy for morbid obesity in 216 patients: report of two-year results, Surg Endosc 21:1810–1816, 2007. 18. Sanchez-Santos R, Masdevall C, Baltasar A, et al: Short- and mid-term outcomes of sleeve gastrectomy for morbid obesity: the experience of the Spanish National Registry, Obes Surg 19:1203–1210, 2009. 19. Aries E, Martinez PR, Ka Ming Li V, et al: Mid-term follow-up after sleeve gastrectomy as a final approach for morbid obesity, Obes Surg 19:544–548, 2009. 20. Johnston D, Dachtler J, Sue-Ling HM, et al: The Magenstrasse and Mill operation for morbid obesity, Obes Surg 13:10–16, 2003.

Open technique

Figure  10-1: A midline incision from the xiphoid to above the umbilicus is the usual abdominal entry site. Some surgeons use a marking pen to indicate the path of incision. s Torso representation of incision site. ◆ Figure 10-2: The incision is made into the subcutaneous fat with the scalpel. Gentle pressure on both sides of the incision by the surgeon and assistant facilitates a straight line of entry. The small subcuticular bleeders are cauterized for hemostasis. ◆

Chapter 10  •  Sleeve Gastrectomy   213

Figure 10-1 

Figure 10-2 

214   Section IV  •  Restrictive Procedures

Figure 10-3: The surgeon and assistant apply opposing pressure on the sides of the opening and, with considerable force, tear the subcutaneous fat and Scarpa's fascia down to the linea alba. This maneuver requires several applications of subcutaneous pulling in opposite directions along the length of the incision and usually at several depths. This technique typically guarantees precise penetration down to the linea alba, with minimal bleeding and no tissue damage from the use of cautery coagulation. The tearing technique may not be feasible in reusing a midline incision for reentry into the abdominal cavity, in which case, coagulating cautery is used to reach the linea alba. ◆ Figure 10-4: Using the cautery at a fairly low current (25 amps), the linea alba is incised along its length down to the preperitoneal fat. (For further review of the technique for open abdominal access, see Section I, Chapter 1.) ◆

Chapter 10  •  Sleeve Gastrectomy   215

Figure 10-3 

Figure 10-4 

216   Section IV  •  Restrictive Procedures

Figure 10-5: The bariatric retractor is secured to the table. With the patient in the steep Trendelenburg position, the large shovels of the retractor are placed, maximally elevated, and secured below the right and left costal margins. The patient's position is then reversed to the steep reverse Trendelenburg for the remainder of the operation. The side arms of the retractor are placed and the wound is opened maximally in the transverse direction. The left lateral ligament of the liver is taken down, and the liver is reflected to the right with the heart-shaped blade of the bariatric retractor. s Reverse Trendelenburg position. ◆ Figure 10-6: The short gastric vessels are divided, starting inferiorly, with a powered tissue divider or by individual clamping and ligation of the vessels. This dissection starts at a point opposite the pes anserinus (crow's foot) and ascends to the esophagogastric junction. Some surgeons start this division at the pylorus. Dissection of the esophagogastric junction requires careful division of the uppermost short gastric vessels, which often are extremely short between the stomach and the spleen. ◆

Chapter 10  •  Sleeve Gastrectomy   217

Figure 10-5 

Figure 10-6 

218   Section IV  •  Restrictive Procedures

Figure 10-7: A linear, cutting, stapling instrument with 3.5-mm staples (blue load) is used to perform the sleeve gastrectomy portion of the procedure. The stapler is first applied inferiorly at the cleared area opposite the pes anserinus or at the pylorus. This maneuver is performed after a bougie is placed by the anesthesia team into the lumen of the stomach; we prefer using a small, #24 Fr bougie. We resect the stomach a loose 2 to 4 cm from the edge of the bougie placed along the lesser curvature of the stomach. Other surgeons prefer using a larger bougie, up to #40 Fr, and cutting/stapling the stomach more tightly on the bougie. Although a standard linear anastomotic stapler can be used (as illustrated), we prefer using the laparoscopic linear/cutting stapler for this maneuver. ◆ Figure 10-8: The stomach is divided by successive applications of the linear stapler; approximately seven applications of the stapler are required. We end this dissection just short of the esophagogastric fat pad. The sleeve gastrectomy specimen is passed off the operative field. ◆ Figure 10-9: We always oversew the sleeve gastrectomy staple line in the firm conviction that this step prevents staple-line leaks. We use a running, 4/0, nonabsorbable suture taken in the Lembert fashion, inverting the entire staple line. Alternatively, a hemostatic strip designed to prevent leaks may be applied with the linear stapler. ◆ Figure 10-10: Completed open sleeve gastrectomy. ◆

Chapter 10  •  Sleeve Gastrectomy   219

Figure 10-7 

Figure 10-9 

Figure 10-8 

Figure 10-10 

220   Section IV  •  Restrictive Procedures

Magenstrasse and mill operation

Figure 10-11: The Magenstrasse and Mill procedure is usually done in open fashion and can be performed in several ways with modern instrumentation. Much in the manner of the open Mason vertical banded gastroplasty, the circular stapler can be used to create a window in the stomach close to the pylorus and the lesser curvature. A linear cutting stapler then can be applied upward from this orifice to the angle of His. This maneuver leaves the greater curvature side of the stomach detached from the lesser curvature side, except for the small prepyloric connection. ◆ Figure 10-12: Alternative option of oversewing the staple lines. ◆

Laparoscopic technique

◆

Figure 10-13: Placement of port sites varies with the procedure to be performed and the personal preference of the surgeon. Most bariatric procedures require five to six port sites. The camera port is generally a 12-mm port placed in the midline. The location of the other ports varies, but as a rule, both sides of the upper abdominal wall are used for placement; they are mostly 5-mm port sites but may include a 10- or a 15-mm port site.

Chapter 10  •  Sleeve Gastrectomy   221

Figure 10-12 

Figure 10-11 

Figure 10-13 

222   Section IV  •  Restrictive Procedures

Figure 10-14: Insufflation of the abdominal cavity with carbon dioxide gas (experimentally, helium has been used) can be established via a spring-loaded, tension-sensing Veress needle inserted blindly. The 2-mm needle has a blunt inner cannula that automatically extends beyond the needle point upon entering the abdominal cavity. After insertion, to ensure that no tissue damage has occurred, the surgeon should aspirate the needle for blood, succus, or stool, and then perform the drop of saline test, allowing a drop of saline placed on the hub of the needle to fall into the peritoneal cavity by gravity or on creating negative intraperitoneal pressure by lifting the abdominal wall. The carbon dioxide gas is infused via a side hole by an automatic, gauged insufflation device to a pressure of 15 mm Hg. An alternative approach into the peritoneal cavity is the Hasson technique, which is an open approach via a 1- to 1.5-cm incision at the umbilicus. A blunt obturator cannula is then placed into the abdominal cavity and, generally, anchored in place by fascial sutures. s Alternate site to umbilical or periumbilical site for blind insertion of the insufflation Veress needle. ◆ Figure 10-15: Once pneumoperitoneum is achieved, the access trocars are placed under direct vision. Initially, a 5-mm optical viewing trocar is used. Once a camera port site is established, placement of the remaining trocars is performed under laparoscopic visual control. Trocar lengths used for bariatric surgery, as a rule, are 100 and 150 mm. Cannulae types include those with pyramidal cutting tips, retractable blades, retractable “safety” shields, conical tapered tips, radial dilating cannulae, and screw devices. The threaded screw cannulae are usually preferred. The trocars should be placed perpendicular to the abdominal wall. ◆

Chapter 10  •  Sleeve Gastrectomy   223 Insufflator

Figure 10-14 

Trocar

Figure 10-15 

224   Section IV  •  Restrictive Procedures

Figure 10-16: In general, the primary surgeon stands on the right side of the patient, the first assistant faces the surgeon on the patient's left, and the second assistant/camera operator and the scrub nurse are positioned toward the foot of the bed. Placing the arms out on arm boards facilitates access to the abdomen. An alternative configuration of the operating team has the surgeon standing between the abducted legs of the patient. (The introduction of robotics places the surgeon away from the operating table for the first time in the history of surgery; indeed, the surgeon can be in another room or facility.) (For further review of the technique for laparoscopic abdominal access, see Section I, Chapter 2.) s Having the patient in the reverse Trendelenburg position is preferred for visualization of the attic of the abdomen. ◆ Figure 10-17: The patient is placed in the reverse Trendelenburg position. The short gastric vessels are divided, starting inferiorly, with a powered tissue divider or by individual clamping and ligation of the vessels. This dissection starts at a point opposite the pes anserinus (crow's foot) and ascends to the esophagogastric junction. Some surgeons start this division at the pylorus. Dissection of the esophagogastric junction requires careful division of the uppermost short gastric vessels, which often are extremely short between the stomach and the spleen. ◆

Chapter 10  •  Sleeve Gastrectomy   225

Anesthetist

Monitor Light Camera Insufflator

Monitor

1st assistant

Surgeon

2nd assistant

Instruments Nurse

Figure 10-16 

Figure 10-17 

226   Section IV  •  Restrictive Procedures

Figure 10-18: The laparoscopic linear stapling instrument with 3.5-mm staples (blue load) is used to perform the sleeve gastrectomy portion of the procedure. The stapler is first applied inferiorly at the cleared area opposite the pes anserinus or at the pylorus. This maneuver is performed after a bougie is placed by the anesthesia team into the lumen of the stomach; we prefer using a small, #24 Fr bougie. We resect the stomach a loose 2 to 4 cm from the edge of the bougie placed along the lesser curvature of the stomach. Other surgeons prefer using a larger bougie, up to #40 Fr, and cutting/stapling the stomach more tightly on the bougie. The sleeve gastrectomy specimen is passed off the operative field. ◆ Figure 10-19: We always oversew the sleeve gastrectomy staple line in the firm conviction that this step prevents staple-line leaks. We use a running, nonabsorbable suture taken in the Lembert fashion, inverting the entire staple line. Alternatively, and especially in the laparoscopic approach, a hemostatic strip designed to prevent leaks may be applied with the linear stapler. ◆ Figure 10-20: Completed laparoscopic sleeve gastrectomy. ◆

Chapter 10  •  Sleeve Gastrectomy   227

Figure 10-18 

Figure 10-19 

Figure 10-20 

Section

v

Other and Investigative Procedures Innovative procedures and approaches are continuously being introduced into the armamentarium of metabolic/bariatric surgery. Some procedures achieve permanence and may replace established operations; others occupy a unique, but limited, niche. Many procedures receive short periods of attention and, for one reason or another, are discarded. Ten of these innovative procedures or approaches currently of interest and undergoing investigation have been selected for discussion and illustration in this section: intragastric balloon, gastric and vagal pacing, endoluminal sleeves, ileal transposition, ­duodenal-jejunal exclusion, endoluminal procedures, external gastric plication, transgastric procedures, robotics, and microorifice surgery.

229

Chapter

11

Intragastric Balloon Intragastric balloons are free-floating, space-occupying gastric bezoars. The overt mechanism of action of intragastric balloons is the creation of the sensation of a full stomach, thereby triggering, by neuro-chemical-hormonal pathways, a cessation of appetite and a sense of satiety. The first balloons placed intragastrically for weight loss were introduced in the 1980s—the Garren-Edwards (United States) and Ballobes (Denmark).1,2 These devices had sharp edges, and because of structural and placement difficulties, they had excessive failure and complication rates. More recent models of the intragastric balloon have demonstrated minimal complications as a result of better design, endoscopic balloon insertion under direct vision, easy endoscopic removability, and intra-balloon placement of a methylene blue solution to detect balloon rupture immediately by urinary excretion of the dye.3-5 The ease of reversibility of this procedure enhances its attractiveness. Postplacement care usually includes control of immediate nausea and, possibly, longer term proton pump blocker therapy. The precise roles of intragastric balloon therapy have not been defined; it has been advocated as a free-standing procedure in overweight and minimally obese patients, as a first-stage intervention in superobese patients, as an immediate preoperative bariatric surgery adjunct for patient preparation, and as a test of patient compliance for a more permanent restrictive procedure.

References

1. Garren L: Garren gastric bubble, Bariatr Surg 3:14–15, 1985. 2. Mathus Vliegen EMH, Tytgat GNJ, Veldhuizen-Offermans EAML: Intragastric balloon in the treatment of super-morbid obesity: double blind, sham controlled, crossover evaluation of 500 milliliter balloon, Gastroenterology 99:362–369, 1990. 3. Meshkinpour H, Hsu D, Farivar S: Effect of gastric bubble as a weight reduction device: a controlled, crossover study, Gastroenterology 95:589–592, 1988. 4. Tsesmeli N, Coumaros D: Review of endoscopic devices for weight reduction: old and new balloons and implantable prostheses, Endoscopy 41:1082–1089, 2009. 5. Imaz I, Martínez-Cervell C, García-Alverex EE, et al: Safety and effectiveness of the intra-gastric balloon for obesity: a meta-analysis, Obes Surg 18:841–846, 2008.

231

232   Section V  •  Other and Investigative Procedures

Insertion technique

Various intragastric balloons currently exist and several new ones are expected to be introduced, each with a specific insertion protocol. The general principles of balloon insertion are illustrated. Figure 11-1: With the patient under intravenous sedation and local anesthesia, the gastric endoscope is passed and the stomach is examined for potential pathology. ◆ Figure 11-2: The collapsed intragastric balloon is introduced under endoscopic guidance. ◆ Figure  11-3: A balloon-specific proprietary mechanism is used to fill the balloon, or a ­balloon compartment, with air, saline solution, or another fluid, and usually with methylene blue dye. The catheter connected to the balloon is removed. ◆ Figure 11-4: Intragastric balloon in place in the stomach. ◆

Chapter 11  •  Intragastric Balloon   233

Figure 11-1 

Figure 11-2 

Figure 11-3 

Figure 11-4 

Chapter

12

Gastric and Vagal Pacing Electrical current stimulation of the stomach wall or the vagus nerves interferes with gastric myoelectrical activity, which consists of gastric slow waves and spike potentials.1 The slow wave is propagated antegrade from the fundic pacemaker toward the pylorus. It determines the maximum frequency, propagation velocity, and propagation direction of gastric muscular contractions. The normal rhythmic frequency of a gastric slow wave in humans is approximately three cycles per minute. A spike potential, when superimposed on the slow wave, results in a strong, lumen-occluding contraction. Electrical currents can be directed to enhance antegrade wave propagation2 or stimulate retrograde wave propagation.3 Enhanced amplitude and contractile force also can be induced by pacer-coordinated gastric stimulation during the refractory stage of myoelectrical activity.4 These perturbations may have an effect on satiety and, possibly, independently, on the severity of type 2 diabetes. The mechanisms of action to explain these phenomena are presently open to speculation and may involve gastric distention, retrograde vagal stimulation (or lack thereof) of a central nervous system nucleus, an intrinsic gastric-duodenal-pancreatic neuronetwork, or the release or inhibition of certain hormones or clinical mediators. In 1996, Cigaina et al.5 introduced the field of electric stimulation for the treatment of morbid obesity. Gastric stimulation in the refractory period of the contraction cycle, triggered by a fundic sensing electrode that detects the onset of a meal, is under development.6 Vagal stimulation for satiety was initiated by Reddy et al.7 in 2000. Vagal blocking by electronic stimulation also has been explored. Over time, other concepts will enter this field, each with its own proprietary system, in an effort to achieve weight loss and influence type 2 diabetes. This chapter illustrates certain generic techniques for electrode implantation.

References

1. Chen JDZ, McCallum RW, editors: Electrogastrography: principles and applications, New York, 1995, Raven. 2. Lin ZY, McCallum RW, Schirmer BD, et al: Effects of pacing parameters in the entrainment of gastric slow waves in patients with gastroparesis, Am J Physiol 37:G186–G191, 1998. 3. Eagon JC, Kelly KA: Effects of gastric pacing on canine gastric motility and emptying, Am J Physiol 265:G767–G774, 1993. 4. Peles S, Petersen J, Aviv R, et al: Enhancement of antral contractions and vagal afferent signaling with synchronized electrical ­stimulation, Am J Physiol Gastrointest Liver Physiol 285:G577–G585, 2003. 5. Cigaina V, Pinato G, Rigo V: Gastric peristalsis control by mono situ electrical stimulation: a preliminary study, Obes Surg 6:247–249, 1996. 6. Bohdjalian A, Prager G, Aviv R, et al: One-year experience with TANTALUS™: a new surgical approach to treat morbid obesity, Obes Surg 16:627–634, 2006. 7. Reddy R, Horovitz J, Roslin M: Chronic bilateral vagus nerve stimulation (VNS) changes eating behavior resulting in weight loss in a canine model, Surg Forum 51:24–26, 2000.

235

236   Section V  •  Other and Investigative Procedures

Laparoscopic electrode placement technique

Clinical preference for laparoscopic placement of electrode leads for gastric stimulation is almost exclusive today, although an open technique has certain advantages. These advantages include use of a single incision for the procedure and placement of the subcutaneous pacer along with the ability to perform the open procedure via a single micro-orifice, 6-cm incision with the patient under propofol sedation/local anesthesia, without general anesthesia, abdominal insufflation, and tracheal intubation (see Section V, Chapter 20). The laparoscopic technique is primarily illustrated in this chapter, with some figures on open placement included at the end. A hypothetical lesser curvature location for placement of an electrode lead is shown. Various systems for electronic implantation use lead implantations in the fundus, anterior antrum, and posterior antrum.

Technique

Figure 12-1: Placement of port sites varies with the procedure to be performed and the preference of the surgeon. Most bariatric procedures require five to six port sites. The camera port is generally a 12-mm port placed in the midline. The location of the other ports varies but, as a rule, they are placed on both sides of the upper abdominal wall; they are mostly 5-mm port sites but may include a 10- or a 15-mm port site. ◆ Figure 12-2: Insufflation of the abdominal cavity with carbon dioxide gas can be established via a spring-loaded, tension-sensing Veress needle inserted blindly. The 2-mm needle has a blunt inner cannula that automatically extends beyond the needle point upon entering the abdominal cavity. The carbon dioxide gas is infused via a side hole by an automatic, gauged insufflation device to a pressure of 15  mm Hg. An alternative approach to the peritoneal cavity is the Hasson technique, which is an open approach via a 1- to 1.5 cm incision at the umbilicus. A blunt obturator cannula is then placed into the abdominal cavity and, in general, anchored in place by fascial sutures. s Alternate site to umbilical or periumbilical site for blind insertion of the insufflation Veress needle. ◆

Chapter 12  •  Gastric and Vagal Pacing   237

Figure 12-1 

Insufflator

Figure 12-2 

238   Section V  •  Other and Investigative Procedures

Figure  12-3: Once pneumoperitoneum is achieved, the access trocars are placed under direct vision. A 5-mm optical viewing trocar is initially used. Once a camera port site is established, placement of the remaining trocars is performed under laparoscopic visualization. The trocars should be placed perpendicular to the abdominal wall. ◆ Figure 12-4: In general, the primary surgeon stands on the right side of the patient, the first assistant faces the surgeon on the patient's left, and the second assistant/camera operator and the scrub nurse are positioned toward the foot of the bed. Placing the patient's arms out on arm boards facilitates access. An alternative configuration of the operating team has the surgeon standing between the abducted legs of the patient. (For further review of the technique for laparoscopic abdominal access, see Section I, Chapter 2.) s Having the patient in the reverse Trendelenburg position is preferred for visualization of the attic of the abdomen. ◆

Chapter 12  •  Gastric and Vagal Pacing   239

Trocar

Figure 12-3 

Anesthetist

Monitor Light Camera Insufflator

Monitor

1st assistant

Surgeon

2nd assistant

Instruments Nurse

Figure 12-4 

240   Section V  •  Other and Investigative Procedures

Figure 12-5: The liver is retracted superiorly and to the right with a liver retractor. The entry point for the retractor is usually made with a 5-mm port just below the xyphoid process; the port is subsequently removed. Adequate liver retraction is essential to expose the esophagogastric angle and spleen to allow safe dissection at the angle of His. ◆ Figure  12-6: Schematic showing a hypothetical lesser curvature lead implantation site; depending on the product, leads may be inserted in the fundus and in the antrum. ◆ Figure 12-7: Electrocautery is used superficially to mark the entry and exit points for the lead. ◆

Chapter 12  •  Gastric and Vagal Pacing   241

Figure 12-5 

Lead implant location Crow’s foot

Figure 12-6 

Figure 12-7 

242   Section V  •  Other and Investigative Procedures

Figure 12-8: With use of a laparoscopic grasper, a needle attached to the foremost portion of the electrode lead is inserted into a muscular tunnel from the entrance to the exit points previously marked by electrocautery. Endoscopic gastroscopy is performed throughout the procedure to verify lead placement. If the lead has perforated the mucosa of the stomach, it is removed and reinserted, with the position checked by gastroscopy. s Proper location of the lead is shown in the muscularis portion of the gastric wall. ◆ Figure 12-9: Once the lead is satisfactorily inserted, it is sutured in place with a nonabsorbable suture, either fastened around the lead or via a proprietary lead element. The suturing procedure may be repeated at the distal end of the lead. s The lead insertion needle is removed. ◆

Chapter 12  •  Gastric and Vagal Pacing   243 Serosa

Implant lead

Muscularis

Mucosa

Figure 12-8 

Figure 12-9 

244   Section V  •  Other and Investigative Procedures

Figure 12-10: The generator pocket is constructed, as a rule, in the anterior abdominal wall on top of the anterior rectus fascia and below the subcutaneous fat. The body of the lead is left gently curved within the abdominal cavity and brought into the generator pocket space through a separate stab wound. The lead is inserted into the generator in accordance with the prescribed protocol. The pocket is closed. s The stimulator, or pacer, may be snugly placed into the subcutaneous pocket without anchoring sutures or may be anchored to the underlying fascia with nonabsorbable sutures via tabs on the stimulator. ◆ Figure 12-11: Schematic illustrating the electrode lead implanted in the gastric wall and the stimulator in the subcutaneous pocket. s Closure of the laparoscopic port sites and the incision for the insertion of the stimulator. ◆

Chapter 12  •  Gastric and Vagal Pacing   245

Figure 12-10 

Figure 12-11 

246   Section V  •  Other and Investigative Procedures

Alternative Open Electrode Placement Technique and Caveats

Figure 12-12: Needle insertion for lead implantation can be guided by tactile sensation and by hand stabilization of the stomach. ◆ Figure 12-13: The subcutaneous stimulator pocket can be dissected out from the primary incision, creating the advantage of a single, small incision, rather than the five to six port site incisions, plus an incision for the stimulator pocket necessitated by the laparoscopic technique. ◆

Laparoscopic vagal pacing technique Technique

◆

Figure 12-14: Schematic of anterior vagus nerve. s Schematic of posterior vagus nerve.

Chapter 12  •  Gastric and Vagal Pacing   247

Figure 12-12 

Figure 12-13 

Figure 12-14 

248   Section V  •  Other and Investigative Procedures

Figure 12-15: Careful dissection of the tissues around the esophagogastric junction is carried out, exposing the trunks of the anterior and posterior vagus nerves. ◆ Figure  12-16: The proprietary circular electrodes are placed around the trunks of the vagus nerves, superiorly for the anterior vagus nerve and inferiorly for the posterior vagus nerve. ◆

Chapter 12  •  Gastric and Vagal Pacing   249

Figure 12-15 

Figure 12-16 

250   Section V  •  Other and Investigative Procedures

Figure 12-17: The stimulator (generator) is tacked into place in the independently created subcutaneous pocket. ◆ Figure 12-18: Schematic showing the vagal blocking mechanism in place with the stimulator in a subcutaneous pocket. ◆

Chapter 12  •  Gastric and Vagal Pacing   251

Figure 12-17 

Figure 12-18 

252   Section V  •  Other and Investigative Procedures

Alternative Open Vagal Pacing Technique and Caveats

In a similar fashion to placement of gastric electrodes, the electrodes for vagal stimulation can be guided by tactile sensation and by hand stabilization of the esophagogastric junction. Again, the subcutaneous stimulator pocket can be dissected out from the primary incision, avoiding the creation of a separate incision in addition to the laparoscopic port incisions.

Chapter

13

Endoluminal Sleeve The inadequacy of classifying metabolic/bariatric procedures as malabsorptive, restrictive/ malabsorptive, and restrictive has been discussed earlier in this text, along with the complementary classification of mechanisms of action based on neurohormonal pathways. Further refinements of the neurohormonal concept are the foregut theory and the hindgut theory espoused by Rubino et al.1 The foregut theory postulates that glycemic control, and thereby body weight and type 2 diabetes, are under the influence of a hormone (possibly gastric inhibitory polypeptide) or another agent released by food in contact with the duodenum. The hindgut theory postulates that certain gut hormones, primary ­glucagon-like peptide 1, elaborated by the contact of food with the ileum, influence glucose metabolism and thereby body weight and type 2 diabetes. The endoluminal sleeve primarily tests the foregut theory because the sleeve prevents the contact of food with the duodenum and proximal jejunum. However, the sleeve probably also increases proximal intestinal transit time and accelerates food stimulation of the ileum, thereby invoking the hindgut theory of causation. The first preclinical report of testing of the endoluminal sleeve in a pig was published in 2006,2 followed by clinical reports in 2007,3 2008,4 2009,5 and 2010.6 Several proprietary devices will most likely enter the market. The step-by-step description of this technique is as generic as possible.

References

1. Rubino F, Forgione A, Cummings DE, et al: The mechanism of diabetes control after gastrointestinal bypass surgery reveals a role of the proximal small intestine in the pathophysiology of type 2 diabetes, Ann Surg 244:741–749, 2006. 2. Milone L, Gagner M, Ueda K, et al: Effect of a polyethylene endoluminal duodeno-jejunal tube (EDJT) on weight gain: a feasibility study in a porcine model, Obes Surg 16:620–626, 2006. 3. Gersin KS, Keller JE, Stefanidis D, et al: Duodenal-jejunal bypass sleeve: a totally endoscopic device for the treatment of morbid obesity, Surg Innov 14:275–278, 2007. 4. Rodriguez-Grunert L, Neto MP, Alamo M, et al: First human experience with endoscopically delivered and retrieved ­duodenal-jejunal bypass sleeve, Surg Obes Relat Dis 4:55–59, 2008. 5. Tarnoff M, Rodríguez L, Escalona A, et al: Open label, prospective, randomized controlled trial of an endoscopic duodenal-jejunal bypass sleeve versus low calorie diet for pre-operative weight loss in bariatric surgery, Surg Endosc 23:650–656, 2009. 6. Escalona A, Yáñez R, Pimentel F, et al: Initial human experience with restrictive duodenal-jejunal bypass liner for treatment of morbid obesity, Surg Obes Relat Dis 6:126–131, 2010.

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254   Section V  •  Other and Investigative Procedures

Placement technique

Figure 13-1: Impermeable polyethylene endoluminal duodenojejunal tube in vitro illustrating the proximal anchoring mechanism and the fluidity of the device. s Alternate version of the device with a proximal 4-mm orifice fluoropolymer flow restrictor to delay gastric emptying. u Figure 13-2: Device placement requires fluoroscopy and endoscopy. With the patient typically under general anesthesia, standard endoscopy is performed to rule out abnormalities of the stomach, followed by endoscopic insertion of a flexible guidewire into the duodenum. The endoscope is then removed. u

Chapter 13  •  Endoluminal Sleeve   255

Figure 13-1 

Figure 13-2 

256   Section V  •  Other and Investigative Procedures

Figure 13-3: With the use of dynamic fluoroscopy, the endoluminal sleeve contained in a capsule is advanced over the guidewire into the duodenum. u Figure 13-4: Once the capsule reaches the duodenum, an inner catheter device with an atraumatic ball at its end is used to pull the attached sleeve out of the capsule and advance it into the jejunum. u

Chapter 13  •  Endoluminal Sleeve   257

Figure 13-3 

Figure 13-4 

258   Section V  •  Other and Investigative Procedures

Figure 13-5: The anchor is deployed using the device's proprietary mechanism to sit in the duodenal bulb. The anchor is self-expanding and ends in barbs that grasp the duodenal wall to seal off the duodenal wall from the flow of food. Bile and pancreatic juice are allowed to flow freely between the duodenal wall and the sleeve. The sleeve and ball are detached from the catheter. The catheter is removed; the ball is retrieved or allowed to pass by peristalsis. Contrast is flushed through the sleeve to test for patency. u Figure 13-6: Completed placement of the duodenojejunal endoluminal sleeve. u

Chapter 13  •  Endoluminal Sleeve   259

Figure 13-5 

Figure 13-6 

Chapter

14

Ileal Transposition A direct consequence of the hindgut theory of satiety in type 2 diabetes control is the concept of transposing a segment of the terminal ileum upstream in the intestinal tract. Several variations of this ­procedure have been developed that encompass different sites for the ileal transposition and different concurrent operations—for example, sleeve gastrectomy. This atlas does not provide a chronologic exposition of these procedures or attempt an evaluation but does portray the methodology for the basic surgical approach of intestinal segment transposition into the proximal jejunum. Because this investigative procedure is the only metabolic/bariatric operation in this atlas that does not use a common access approach for the open and the laparoscopic techniques (which have been ­provided for each chapter when appropriate), specific open incision or laparoscopic port ­placement ­recommendations are not provided. Access to the mid-abdominal cavity obviously needs to be obtained.

261

262   Section V  •  Other and Investigative Procedures

Open technique

Figure 14-1: No standard sites or landmarks have been established for harvesting a length of ileum, nor has a standard length been prescribed. The ileum 30 cm proximal to the ileocecal valve is readily delivered into the field. The mesentery is divided perpendicular to the bowel for a distance of approximately 6 cm with a stapler, oscillating tissue divider, cautery, or a scalpel or scissors, with ligation of vessels if necessary. The bowel is divided with the linear intestinal stapler and 3.5-mm staples (blue load). u Figure 14-2: The required length of harvested ileum has been estimated to be longer than 100 cm and up to 200 cm. The elevated length of bowel is measured along the mesenteric border with an umbilical tape previously calibrated with a ruler. u

Chapter 14  •  Ileal Transposition   263

30 cm

Figure 14-1 

100-200 cm

Figure 14-2 

264   Section V  •  Other and Investigative Procedures

Figure 14-3: At the designated upper end of the ileal segment, the bowel is again divided with the linear intestinal stapler and 3.5-mm staples (blue load), and the mesentery is divided perpendicular to the bowel for a distance of approximately 6 cm with a stapler, oscillating tissue divider, cautery, or a scalpel or scissors, with ligation of vessels if necessary. s The isoperistaltic orientation of the ileal segment is marked by a circumferential marking suture at the proximal end. u Figure 14-4: All four stapled, divided ends of bowel are oversewn with interrupted, 5/0, nonabsorbable sutures, taken in the Lembert fashion, inverting the staple lines of the divided bowel. u

Chapter 14  •  Ileal Transposition   265

Figure 14-3 

Figure 14-4 

266   Section V  •  Other and Investigative Procedures

Figure 14-5: Ileal continuity is restored by a side-to-side, functionally end-to-end, ileoileostomy. The ends of the bowel are aligned, 5/0 nonabsorbable tacking sutures are placed, and enterotomies 1 cm in length are made with the cautery instrument. u Figure 14-6: The enterotomies are lengthened by a spreading motion with a clamp. u Figure 14-7: The ileoileostomy is created with the intestinal linear stapler and 3.5-mm staples (blue load), set at an anastomotic orifice length of 2.5 to 3.5 cm. u Figure 14-8: The enterotomies and the entire anterior staple line are oversewn, closing the anastomosis with interrupted, 5/0, nonabsorbable sutures, taken in the Lembert fashion. u Figure 14-9: The anastomosis is turned over and the entire posterior staple line is oversewn in ­similar fashion with interrupted, 5/0, nonabsorbable sutures, taken in the Lembert fashion. This maneuver, although often omitted, is a valuable safeguard against an anastomotic leak. u

Chapter 14  •  Ileal Transposition   267

Figure 14-6 

Figure 14-5 

Figure 14-7 

Figure 14-8 

Figure 14-9 

268   Section V  •  Other and Investigative Procedures

Figure 14-10: The bowel is returned to its original position and the mesenteric intestinal defect is closed with a running, 3/0, absorbable suture. u Figure 14-11: Attention is next turned to the upper jejunum, where a segment approximately 30 cm distal to the ligament of Treitz is brought into the operative field. At that site, the mesentery is divided perpendicular to the bowel for a distance of approximately 6 cm with a stapler, oscillating tissue divider, cautery, or a knife or scissors, with ligation of vessels if indicated. The bowel is divided with the linear intestinal stapler and 3.5-mm staples (blue load). s Oversewing the ends of jejunum. u

Chapter 14  •  Ileal Transposition   269

Figure 14-10 

Figure 14-11 

270   Section V  •  Other and Investigative Procedures

Figure 14-12: After the ends of the divided jejunum have been oversewn, the ileal segment is transposed into the jejunal position by anastomosis of its upper end (identified by the marking suture) to the proximal end of jejunum and anastomosis of its distal end to the distal end of jejunum. The side-to-side, functional end-to-end technique for these anastomoses has been described (see Section II, Chapter 4, Figures 4-9 to 4-12). u Figure 14-13: The cut ileal mesenteries are sewed to their jejunal mesenteric counterparts with 3/0 running, absorbable suture. u Figure 14-14: Completed ileal transposition. u

Chapter 14  •  Ileal Transposition   271

Figure 14-12 

Figure 14-13 

Figure 14-14 

272   Section V  •  Other and Investigative Procedures

Laparoscopic technique

In essence, performing an ileal transposition laparoscopically is not materially different from the open approach except for the instrumentation used.

Chapter

15

Duodenal-Jejunal Exclusion Another surgical procedure primarily used to test the foregut theory for type 2 diabetes control is the ­duodenal-jejunal exclusion operation, first described in Gato-Kakizaki rats by Rubino and Marescaux1 in 2004. These investigators obtained excellent glucose control in this nonobese type 2 diabetes rat model without significant weight change. In addition to the basic insights obtained from their study, it opened the way for the exploration of a clinical procedure to control type 2 diabetes in nonobese patients.2,3

References

1. Rubino F, Marescaux J: Effect of duodenal-jejunal exclusion in a non-obese animal model of type 2 diabetes: a new perspective for an old disease, Ann Surg 239:1–11, 2004. 2. Rodriguez-Grunert L, Galvao Neto MP, Alamo M, et al: First human experience with endoscopically delivered and retrieved duodenal-­jejunal bypass sleeve, Surg Obes Relat Dis 4:55–59, 2008. 3. Ramos AC, Galvão Neto MP, de Souza YM, et al: Laparoscopic duodenal-jejunal exclusion in the treatment of type 2 diabetes ­mellitus in patients with BMI <30 kg/m2 (LBMI), Obes Surg 19:307–312, 2009.

273

274   Section V  •  Other and Investigative Procedures

Laparoscopic technique

Figure 15-1: Placement of port sites varies with the procedure to be performed and the preference of the surgeon. Most bariatric procedures require five to six port sites. The camera port is generally a 12-mm port placed in the midline. The location of the other ports varies but, as a rule, they are placed on both sides of the upper abdominal wall; they are mostly 5-mm port sites but may include a 10- or a 15-mm port site. ◆ Figure 15-2: Insufflation of the abdominal cavity with carbon dioxide gas can be established via a spring-loaded, tension-sensing Veress needle inserted blindly. The 2-mm needle has a blunt inner cannula that automatically extends beyond the needle point upon entering the abdominal cavity. The carbon dioxide gas is infused via a side hole by an automatic, gauged insufflation device to a pressure of 15  mm Hg. An alternative approach to the peritoneal cavity is the Hasson technique, which is an open approach via a 1- to 1.5-cm incision at the umbilicus. A blunt obturator cannula is then placed into the abdominal cavity and, in general, anchored in place by fascial sutures. s Alternate site to umbilical or periumbilical site for blind insertion of the insufflation Veress needle. ◆

Chapter 15  •  Duodenal-Jejunal Exclusion   275

Camera port

Figure 15-1 

Insufflator

Figure 15-2 

276   Section V  •  Other and Investigative Procedures

Figure 15-3: Once pneumoperitoneum is achieved, the access trocars are placed under direct visualization. A 5-mm optical viewing trocar is initially used. Once a camera port site is established, ­placement of the remaining trocars is performed under laparoscopic visualization. The trocars should be placed perpendicular to the abdominal wall. ◆ Figure 15-4: In general, the primary surgeon stands on the right side of the patient, the first assistant faces the surgeon on the patient's left, and the second assistant/camera operator and the scrub nurse are positioned toward the foot of the bed. Placing the patient's arms out on arm boards facilitates access to the abdomen. An alternative configuration of the operating team has the surgeon ­standing between the abducted legs of the patient. (For further review of the technique for laparoscopic abdominal access, see Section I, Chapter 2.) s Having the patient in the reverse Trendelenburg position is preferred for visualization of the attic of the abdomen. ◆

Chapter 15  •  Duodenal-Jejunal Exclusion   277

Trocar

Figure 15-3 

Anesthetist

Monitor Light Camera Insufflator

Monitor

1st assistant

Surgeon

2nd assistant

Instruments Nurse

Figure 15-4 

278   Section V  •  Other and Investigative Procedures

Figure 15-5: With the patient in the reverse Trendelenburg position, access to the terminal stomach, pylorus, and first portion of the duodenum is obtained. The duodenum is mobilized from above and below until a clear passage beneath the duodenum is established. The vasculature of the ­tissue plane above the duodenum is extra rich and requires use of a powered tissue divider or ­individual ­clamping and ligation of the vessels. Care must be taken to not injure the common bile duct or other portal structures. The mesentery below the duodenum is also quite vascular and requires careful dissection and hemostasis. Once an instrument can comfortably be inserted underneath the ­duodenum, 2 to 4  cm from the pylorus, the duodenum is ready for division. s Instrument inserted beneath duodenum. ◆ Figure 15-6: When the first portion of the duodenum is cleared, it is divided with the laparoscopic ­linear stapler and the duodenal stump can be inverted and oversewn, using nonabsorbable sutures. s Duodenal stump staple line inverted and oversewn. ◆

Chapter 15  •  Duodenal-Jejunal Exclusion   279

Figure 15-5 

Figure 15-6 

280   Section V  •  Other and Investigative Procedures

Figure 15-7: A loop of jejunum about 50 to 100  cm beyond the ligament of Treitz is elevated to the level of the postpyloric duodenal stump and anastomosed to the duodenum in an end-to-side ­fashion. This anastomosis can be hand (instrument) sewn, without stapling, with a running suture or ­interrupted sutures. ◆ Figure 15-8: The jejunal loop distal to the duodenojejunostomy is anastomosed side to side to the ­proximal segment of the jejunum between the ligament of Treitz and the duodenojejunostomy approximately 30  cm distal to the ligament of Treitz. ◆ Figure 15-9: The bowel is divided with the endostapler between the duodenojejunostomy and the jejunojejunostomy. ◆ Figure 15-10: Completed duodenal-jejunal exclusion. ◆

Chapter 15  •  Duodenal-Jejunal Exclusion   281

Figure 15-7 

Figure 15-9 

Figure 15-8 

Figure 15-10 

282   Section V  •  Other and Investigative Procedures

Alternative Laparoscopic Technique

In essence, the proximal duodenal-jejunal anastomosis can be performed in the same manner as the laparoscopic biliopancreatic diversion/duodenal switch.

Alternative Open Technique

The open technique procedure is essentially identical to the laparoscopic approach except for the access, the use of open instruments, and manual manipulation.

Chapter

16

Endoluminal Procedures

The endoluminal metabolic/bariatric procedure may offer a safe and less costly alternative to open and laparoscopic surgery. Furthermore, endoluminal surgery can allow ambulatory metabolic/bariatric ­surgery to become a reality. Gastric endoluminal surgery started with various suturing devices designed to mimic a Nissen ­fundoplication for the treatment of gastroesophageal reflux disease. This field readily transitioned to metabolic/bariatric surgery with the propagation of proprietary devices by different instrument ­manufacturing companies. These endoscopic devices are designed to suture, staple, clamp, and T-tag gastric tissue to provide intraluminal constricting plications; their effect may be supplemented by ­sclerotherapy and the use of fibrin glue. Although the goal of endoluminal surgery is to develop primary and lasting endoluminal weight loss procedures, real efficacy may only be achieved for predefinitive surgical weight loss or for ­postsurgical revision to restore weight loss. Even if these procedures do not have the longevity of established ­metabolic/bariatric operations, they may be able to be repeated.

283

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Schematics

Figure 16-1: Intragastric plication with a T-tag. Figure 16-2: Intragastric inversion with clamping and/or stapling. ◆ Figure 16-3: Intragastric partitioning. ◆ ◆

Chapter 16  •  Endoluminal Procedures   285

Figure 16-1 

Figure 16-2 

Figure 16-3 

Chapter

17

External Gastric Plication Vertical gastric plication by open or laparoscopic surgery may be another metabolic/bariatric ­surgery approach to weight reduction. This procedure is performed without banding, partitioning, or ­transaction of the gastrointestinal tract. Instead, the reconfigured stomach is stabilized with sutures or other ­fastening devices in multiple longitudinal rows. The goal of these operations is to establish serosa-to-serosa healing and a permanent gastric volume–reducing plication. Four preclinical reports have been published on plication.1-4 The enfolding of the gastric wall can be performed on the anterior surface or the greater curvature. Intestinal abrasion of the opposed sites has no demonstrable effect on tissue bonding.4 Several early clinical reports are available demonstrating short-term success.5-8

References

1. Fusco PEB, Poggetti RS, Younes RN, et al: Evaluation of gastric greater curvature invagination for weight loss in rats, Obes Surg 16:171–177, 2006. 2. Fusco PEB, Poggetti RS, Younes RN, et al: Comparison of anterior gastric wall and greater gastric curvature invaginations for weight loss in rats, Obes Surg 17:1340–1345, 2007. 3. Johnson AC, Tyler KR, Harris JL, et al: A novel gastric invagination procedure produces weight loss in rats, presented at Digestive Disease Week, Chicago, 2009. 4. Menchaca H, Harris JL, Thompson SE, et al: Gastric plication: a preclinical study of the durability of serosa-to-serosa apposition, Surg Obes Relat Dis 7:8–14, 2011. 5. Talebpour M, Amoli BS: Laparoscopic total gastric vertical plication in morbid obesity, J Laparoendosc Adv Surg Tech A 17:793–798, 2007. 6. Sales Puccini CE: Surset gástrico de Sales: una alternativa para cirugía bariátrica restrictiva, Rev Colomb Cir 23:131–135, 2008. 7. Ramos AC, Galvao M, Behrens E, et al: Tubular sleeve gastroplasty (TSG) as a new approach to bariatric treatment, presented at the 14th World Congress of the International Federation for the Surgery of Obesity, Paris, 2009. 8. Brethauer SA, Harris JL, Kroh M, et al: Laparoscopic gastric plication for the treatment of severe obesity, Surg Obes Relat Dis 7:15–22, 2011.

287

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Schematics

Abdominal cavity access can be obtained by standard open technique, laparoscopy, or a microorifice incision (see Section V, Chapter 20). The manner in which the plication is achieved varies according to the fastening technique used (e.g., sutures, T-tags, staples). ◆

Figure 17-1: Schematic of anterior surface plication procedure completed with two rows of fasteners. The amount of gastric capacity that can be reduced by this approach is limited by the size of the anterior gastric wall. LC, lesser curvature; GC, greater curvature; a, initial or interior row of ­fasteners for maintaining apposition; b, final load-bearing row of fasteners.

Chapter 17  •  External Gastric Plication   289

b

a

a

b

LC

GC

b a

Figure 17-1 

b a

290   Section V  •  Other and Investigative Procedures

Figure 17-2: Schematic of greater curvature plication procedure completed with two rows of ­fasteners. Through this approach, gastric capacity may be maximally reduced. LC, lesser curvature; GC, greater curvature; a, initial or interior row of fasteners for maintaining apposition; b, final load-bearing row of fasteners. ◆ Figure 17-3: Schematic of suture plication. A gastric wall suture is started on one side of the area to be imbricated, the maneuver is repeated on the other side, the intervening tissue is enfolded, and the suture is tied. ◆

Chapter 17  •  External Gastric Plication   291

b

a

LC

GC

b

a

a b b a

Figure 17-2 

Figure 17-3 

Chapter

18

Transgastric Procedures

Transgastric procedures are a form of natural orifice transluminal endoscopic surgery designed to achieve no external scars. This perceived advantage has many potential limitations, primarily those of patient safety. These operations currently include the transvaginal laparoscopic approach for ­cholecystectomy as well as the transvaginal approach plus two ports (in contrast to four or six laparoscopic ports), sleeve gastrectomy, and band placement. To achieve these feats, advocates of transgastric procedures violate and scar a structure that is naturally contaminated with bacteria. In addition, they need to use ­instruments that are long or extra long and expensive, sacrificing operative time, especially if they need to convert to a standard laparoscopic or open approach. Within this perspective, transgastric ­gastrojejunostomy and gastric bypass operations are being considered.1,2

References

1. Kantsevoy S, Jagannath S, Niiyama H, et al: Endoscopic gastrojejunostomy with survival in a porcine model, Gastrointest Endosc 62:287–292, 2005. 2. Park A, Adrales G, McKinlay R, et al: A novel anastomotic device in a porcine model, Am Surg 70:767–773, 2004.

293

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Possible transgastric gastrojejunostomy technique

Figure 18-1: With endoscopic cautery, an opening is made through the stomach into the peritoneal cavity. ◆ Figure 18-2: With a grasping and/or hooked instrument and endoscopic visualization, a loop of ­jejunum is delivered into the gastric lumen. ◆

Chapter 18  •  Transgastric Procedures   295

Figure 18-1 

Figure 18-2 

296   Section V  •  Other and Investigative Procedures

Figure 18-3: The jejunal loop is sutured in place. Figure 18-4: Endoscopic cautery is used to make an enterotomy in the jejunal loop. ◆ Figure 18-5: The gastrojejunostomy is completed with interrupted sutures to create the anastomosis and provide a seal to prevent leakage. ◆ ◆

Chapter 18  •  Transgastric Procedures   297

Figure 18-3 

Figure 18-4 

Figure 18-5 

Chapter

19

Robotics

In 1999, Cadiere et al.1 reported the first bariatric surgery procedure performed by robotics. They implanted a laparoscopic adjustable gastric band with the robot and the surgeon at a considerable distance from the operative field. Soon, robotically assisted metabolic/bariatric surgery procedures, including banding, Roux-en-Y gastric bypass, and duodenal switch, were being successfully performed on hundreds of patients.2-4 Robotic surgery provides visual amplification, precision of movement, and freedom from tremors and uses the same eye-hand coordination movements as those used in open surgery. The three-dimensional visualization is more natural than the two-dimensional orientation of standard laparoscopic surgery. This technology promises that difficult procedures can be performed with greater accuracy and safety and with better outcomes. However, the robotic approach is costly and therefore limited in its application.

References

1. Cadiere GB, Himpens J, Vertruyen M, et al: The world's first obesity surgery performed by a surgeon at a distance, Obes Surg 9:206–209, 1999. 2. Moser F, Horgan S: Robotically assisted bariatric surgery, Am J Surg 188:38S–44S, 2004. 3. Parini U, Fabozzi M: Brachet Contul R, et al: Laparoscopic gastric bypass performed with the Da Vinci Intuitive Robotic System: preliminary experience, Surg Endosc 20:1851–1857, 2006. 4. Buchwald H, Kellogg TA, Leslie DB, et al: Duodenal switch operative mortality and morbidity are not impacted by BMI, Ann Surg 248:541–548, 2008.

299

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Schematics

◆

Figure 19-1: General operating room configuration for robot-assisted or completely robotic surgery.

Chapter 19  •  Robotics   301

Surgeon

Console

Anesthesia cart

Anesthesiologist

Robot

Monitor

Monitor

Assisting surgeon

Back table Scrub nurse

Control tower

Figure 19-1 

302   Section V  •  Other and Investigative Procedures

Figure  19-2: Schema for port placement for robotic-assisted surgery showing the camera port, the ports for the left and right robotic arms, the left and right assistant's ports, and the liver retractor port. ◆ Figure 19-3: Robotic needle holder and grasper. ◆

Chapter 19  •  Robotics   303

X 12 mm Left robot arm 12 mm Assistant port

5 mm Liver retractor 8 mm Right robot arm 12 mm Assistant port 12 mm Camera port

Figure 19-2 

Figure 19-3 

Chapter

20

Micro-orifice Surgery As the volume and scope of metabolic/bariatric surgery increase, a definite trend toward the development and use of simpler and safer procedures is occurring. The laparoscopic approach has certain disadvantages that can be avoided with a technique for abdominal access via a micro-orifice incision, which is performed with the patient under intravenous propofol sedation/local anesthesia. This technique does not require general anesthesia, abdominal insufflation, or tracheal intubation. At present, this technical innovation for abdominal exposure and closure has been successfully used in the animal laboratory for metabolic/bariatric procedures1 and is in the process of translation to the clinical setting. For procedures that require the subcutaneous placement of a device (e.g., a pacer for gastric electrode stimulation or a filling port for adjustable gastric banding), this method of access allows the construction of a subcutaneous pocket lateral to the primary abdominal opening without any additional skin incision. Not only can difficult metabolic/bariatric procedures be carried out with this approach, but it also offers a physical and psychological appeal for the patient, who does not have to undergo general anesthesia and yet still has freedom from pain during surgery and amnesia regarding the procedure, as well as a cosmetic, single, small incision rather than five to six port-site scars.

Reference

1. Buchwald H, Menchaca HJ, Michalek VN, et al: Micro-orifice metabolic/bariatric surgery under IV sedation/local anesthesia, Obes Surg 20:500–505, 2010.

305

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Open exposure and closure technique

Figure 20-1: A subxiphoid midline incision 6 to 7 cm in length is made. Figure 20-2: The incision is carried into the subcutaneous fat with a scalpel. Small subcuticular bleeders are cauterized for hemostasis. ◆ Figure 20-3: The remainder of the fat down to the linea alba is incised with the cautery. ◆ Figure 20-4: Using the cautery at a fairly low current (25 amps), the linea alba is incised along its length down to the preperitoneal fat, and the preperitoneal fat and the peritoneal lining are incised with the cautery or with scissors. ◆ ◆

Chapter 20  •  Micro-orifice Surgery   307

6-7 cm

Figure 20-1 

Figure 20-3 

Figure 20-2 

Figure 20-4 

308   Section V  •  Other and Investigative Procedures

Figure 20-5: This minimal length, midline incision can be closed with a running, 0 or 1/0, absorbable suture. ◆ Figure 20-6: The subcutaneous tissues are closed with a running, 3/0, absorbable suture. A superfascial drain is not necessary for this minimal incision. ◆ Figure 20-7: A cosmetic subcuticular closure with a running, 4/0, absorbable suture completes the procedure. ◆

Chapter 20  •  Micro-orifice Surgery   309

Figure 20-5 

Figure 20-6 

Figure 20-7 

Section

VI

Revisional Surgery There is no perfect operation; all metabolic/bariatric surgery procedures can fail. Revisional metabolic/bariatric surgery should be within the work scope of advanced metabolic/bariatric surgeons but should not be attempted by all metabolic/bariatric surgeons or by non-metabolic/bariatric surgeons. Outside the management of acute or semiacute general surgical emergencies occurring in the bariatric patient (e.g., bowel obstruction), there are four basic categories for which revisional surgery may be considered: 1. Anatomic failure of the operation (e.g., band erosion, pouch prolapse, pouch dilation, outlet dilation or constriction, anastomotic stricture, staple-line failure) 2. Operative side effects or complications that have not responded to nonoperative therapy (e.g., nonanatomic vomiting, unremitting diarrhea, protein deficiency and liver failure, nephrolithiasis) 3. Inadequate weight loss in a compliant patient (e.g., average or subaverage weight loss after laparoscopic adjustable gastric banding in a super-obese patient) 4. Patient failure to conform to behavioral requirements (e.g., a patient consistently eats too much after an anatomically competent operation) Patients in the first two categories—anatomic failure of the operation or operative side effects or complications—should be offered revisional surgery when (1) no cardiovascular, pulmonary, or other physical or psychological contraindications to revisional surgery exist, and (2) the patient, after full disclosure of potential operative and postoperative problems, actively seeks remedial surgery. For the most part, revisional surgery also should be offered to persons in the third category. The fourth ­category—patients who do not conform to behavioral requirements—poses a difficult problem for the surgeon. In these cases, careful reflection is required, and the rejection rate for revisional surgery will be significant. Before revisional surgery can be contemplated, a thorough patient evaluation is mandatory. At minimum, a battery of electrolyte and metabolic laboratory tests is required, along with a 311

312   Section VI  •  Revisional Surgery detailed assessment of vitamin and mineral plasma levels. Surgical anatomy needs to be ascertained by contrast radiography and endoscopy. Cardiac, pulmonary, and other organ systems work-ups and consultations should be obtained when indicated. Once a patient is cleared for surgery, he or she needs to undergo conditioning to be as fit for surgery as possible on a nutritional, metabolic, and cardiovascular level. At times, this need for conditioning will delay the revisional surgery and may even necessitate several weeks of preoperative total parenteral nutrition. Revisional metabolic/bariatric surgery can be carried out through either open or laparoscopic access, as dictated by the surgeon's preference. Because advanced metabolic/bariatric surgeons are thoroughly familiar with the open and laparoscopic approaches for abdominal access and closure, these aspects of a revisional operative procedure are not reviewed in this section. Surgeons performing revisional procedures also universally encounter extensive adhesions and must be prepared to spend the time necessary for lysis of adhesions, which can be a factor when scheduling revisional surgery. In this section we consider the reasonable operative revisions available for failed jejunoileal bypass, laparoscopic adjustable gastric banding, vertical Silastic ring or banded gastroplasty, Roux-en-Y gastric bypass, biliopancreatic diversion/duodenal switch, and sleeve gastrectomy procedures. Revision of the investigative procedures described in this atlas, such as gastric partitioning, the Magenstrasse and Mill procedure, pacing, ileal transposition, duodenal­jejunal exclusion, and plication, are not discussed or illustrated.

Chapter

21

Jejunoileal Bypass Revision Metabolic/bariatric surgery began to be performed in the early 1950s. The jejunoileal bypass and variants of this operation were the dominant metabolic/bariatric procedures performed until the late 1970s—a considerable span of approximately 25 years.1 The weight loss engendered by the ­jejunoileal bypass was outstanding. Unfortunately, the adverse effects and complications of this operation were multiple, severe, and often life threatening: gas-bloat syndrome, steatorrhea, electrolyte imbalance, ­nephrolithiasis, hepatic fatty metamorphosis and liver failure, cutaneous eruptions, febrile states, and impaired mentation.2 Some of these complications were presumed to be caused by stasis in the bypassed ­intestinal segment, resulting in an overgrowth of anaerobic bacteria and subsequent ­formation of ­bacterial toxins and alcohols. The modern biliopancreatic diversion/duodenal switch operations were designed to prevent intestinal stasis by continuous transit of food in the enteric (Roux) limb and bile and pancreatic juice in the biliopancreatic limb. When Roux-en-Y gastric bypass was introduced, the jejunoileal bypass became obsolete and s­ ubsequently was rarely performed. Most patients who had undergone a jejunoileal bypass underwent jejunoileal bypass take-down, with or without the construction of more acceptable metabolic/bariatric procedures. Some of these patients, however, had an excellent weight loss result and minimal ­complications and maintain their jejunoileal bypass to this day. Out of these ranks, because of new or advancing problems, come today's jejunoileal bypass patients who are in need of operative revision. The first part of a jejunoileal bypass revision is take-down of the jejunoileostomy, usually followed by construction of, or conversion to, a modern metabolic/bariatric procedure. Two standard jejunoileostomies were performed as part of the jejunoileal bypass: (1) end-to-side, hand-sewn anastomosis of the proximal 14 inches of jejunum beyond the ligament of Treitz to the distal most 4 inches of ileum, and (2) end-to-end, hand-sewn anastomosis of the proximal 40  cm of jejunum distal to the ligament of Treitz to the distal most 4  cm of ileum, with separate anastomosis of the bypassed bowel, end to side, hand sewn, into the cecum. Reasonable replacement metabolic/bariatric operations are adjustable gastric banding, vertical ring or banded gastroplasty, sleeve gastrectomy, and Roux-en-Y gastric bypass. It is not advisable to substitute a biliopancreatic diversion/duodenal switch, which is primarily a malabsorptive procedure, for a failed primarily malabsorptive procedure. Some patients who need a jejunoileal bypass take-down are in such poor condition, even after metabolic and nutritional rescue interventions, that it is safer and more reasonable not to perform a concurrent new metabolic/bariatric operation but only to perform a jejunoileal bypass take-down rapidly, without any problems. If these patients do well, further 313

314   Section VI  •  Revisional Surgery metabolic/bariatric surgery can be considered in the future. Some patients who need and request jejunoileal bypass take-down and are in a relatively good state of health refuse a second metabolic/bariatric operation, stating that they have now learned how to eat properly and will be able to maintain their jejunoileal bypass weight response. Unfortunately, but invariably, they are wrong and will regain most, if not all, their pre-jejunoileal bypass weight and return for further metabolic/bariatric surgery in the future.

References

1. Buchwald H, Buchwald JN: Evolution of operative procedures for the management of morbid obesity 1950–2000, Obes Surg 12:705–717, 2002. 2. Buchwald H, Rucker RD Jr.: Rise and fall of jejunoileal bypass. In Nelson RL, Nyhus LM, editors: Surgery of the small intestine, Norwalk, CT, 1987, Appleton & Lange, pp 529–541.

Take-down end-to-side jejunoileostomy technique

Figure 21-1: After adhesions are cleared, the end-to-side, hand-sewn jejunoileostomy is mobilized into the field. The anastomosis is 4 inches proximal to the ileocecal valve and the proximal jejunum is 14 inches from the ligament of Treitz. The bypassed jejunoileal segment is traced back to its proximal closed end, and the proximal jejunal segment is traced back to the ligament of Treitz. ◆ Figure 21-2: With a stapling instrument and 3.5-mm staples (blue load), the ileal portion of the ­end-to-side jejunoileostomy is divided proximally and distally, and the jejunal portion of the ­anastomosis is divided proximal to the anastomosis. The mesenteries of the segment to be resected are hemostatically divided, and the resected specimen is removed from the field. ◆ Figure 21-3: Ileal bowel continuity is restored via a side-to-side, functionally end-to-end anastomosis. The proximal and distal ends of ileum are placed adjacent to each other, stay sutures are secured, and entries are made into both limbs of the bowel with a cautery instrument. ◆ Figure 21-4: The enterotomy openings are spread with a clamp in the plane of the cautery incisions. ◆ Figure  21-5: The ileoileostomy is created with the intestinal linear stapler and 3.5-mm staples (blue load). The length for this orifice is set between 2.5 and 3.5  cm on the ruled stapler markings. ◆ Figure  21-6: The anastomosis is oversewn circumferentially with interrupted, 5/0, nonabsorbable sutures—that is, not only are the orifices of the anastomosis oversewn, but the entire staple line is reinforced with sutures. The ends of the ileal segment also have been oversewn with interrupted, 5/0, nonabsorbable sutures. Oversewing of the anterior aspect of the anastomosis is illustrated. ◆

Chapter 21  •  Jejunoileal Bypass Revision   315

Figure 21-1  Figure 21-2 

Figure 21-3 

Figure 21-5 

Figure 21-4 

Figure 21-6 

316   Section VI  •  Revisional Surgery

Figure 21-7: The anastomosis is turned over and the posterior staple line is oversewn with interrupted, 5/0, nonabsorbable sutures. An area approximately 2  cm in length is always present where the staples partially protrude because a linear stapler cannot make a curved anastomotic corner. We believe it is essential in oversewing the posterior staple line to make certain that this stapled area is covered. ◆ Figure 21-8: The mesenteric defect is closed with either interrupted, 5/0, nonabsorbable sutures or a running, 3/0, absorbable suture. ◆ Figure 21-9: Next, total bowel continuity is restored by a comparable side-to-side, functional end-to-end upper jejunal anastomosis (see Figures  21-3 to 21-10). The proximal jejunal-end staple line is oversewn; the distal jejunal end was closed because it was the upper end of the bypassed segment. This anastomosis must be performed carefully because the distal jejunal segment is extremely narrow and thin after years of disuse. ◆ Figure 21-10: Placement of a Foley catheter jejunostomy drain proximal to this anastomosis, using the Witzel technique, is advised because several weeks may pass before bowel transit is restored. In the interval, the patient can be fed full liquids, or even purees, with the jejunostomy tube left to drain by gravity. In essence, with this mechanism in place, during the interval before full bowel functional continuity is restored, the nutritional conduit of the patient will be comparable with its pre-revision state. ◆

Chapter 21  •  Jejunoileal Bypass Revision   317

Figure 21-7 

Figure 21-9 

Figure 21-8 

Figure 21-10 

318   Section VI  •  Revisional Surgery

Take-down end-to-end jejunoileostomy technique

Figure 21-11: After adhesions are cleared, the end-to-end, hand-sewn jejunoileostomy is mobilized into the field. The anastomosis is 4  cm proximal to the ileocecal valve and the proximal jejunum is 40  cm from the ligament of Treitz. The bypassed jejunoileal segment was anastomosed to the cecum in an end-to-side fashion and the proximal, closed end was attached to the anterior taenia of the cecum to prevent intussusception. The entire bypassed jejunoileal segment is freed of adhesions and traced back to its proximal closed end, and the proximal jejunal segment is traced back from the jejunoileal anastomosis to the ligament of Treitz. ◆ Figure  21-12: Using a stapling instrument and 3.5-mm staples (blue load), the terminal ileum is divided distal to the end-to-end jejunoileal anastomosis, and the proximal jejunum is similarly divided ­proximal to the end-to-end anastomosis. The mesenteries of the original end-to-end anastomosis are hemostatically divided, and the resected jejunoileostomy specimen is removed from the field. ◆

Chapter 21  •  Jejunoileal Bypass Revision   319

Figure 21-11 

Figure 21-12 

320   Section VI  •  Revisional Surgery

Figure 21-13: The stapled terminal ileal stump, now less than 4  cm in length, is oversewn with 5/0 interrupted, nonabsorbable sutures, in the Lembert manner. ◆ Figure 21-14: The proximal end of the originally bypassed segment is cleared of adhesions and anastomosed to the proximal jejunal segment by a side-to-side, functionally end-toend anastomosis. This maneuver must be carried out carefully because of the size discrepancy between the previously bypassed jejunal segment and the dilated proximal jejunum. The proximal and distal ends of jejunum are placed adjacent to each other, stay sutures are secured, and entries are made into both limbs of the bowel with a cautery instrument. ◆ Figure 21-15: The enterotomy openings are spread with a clamp in the plane of the cautery incisions. ◆ Figure 21-16: The jejunojunostomy is created with the intestinal linear stapler and 3.5-mm staples (blue load). The length for this orifice is set between 2.5 and 3.5  cm on the ruled stapler markings. ◆ Figure 21-17: The anastomosis is oversewn circumferentially with 5/0 interrupted, nonabsorbable sutures—that is, not only the orifices of the anastomosis are oversewn but the entire staple line is reinforced with sutures. The end of the proximal jejunal segment also has been oversewn with interrupted, 5/0, nonabsorbable sutures. Oversewing of the anterior aspect of the anastomosis is illustrated. ◆

Chapter 21  •  Jejunoileal Bypass Revision   321

Figure 21-14  Figure 21-13 

Figure 21-16  Figure 21-15 

Figure 21-17 

322   Section VI  •  Revisional Surgery

Figure 21-18: The anastomosis is turned over and the posterior staple line is oversewn with 5/0 interrupted, nonabsorbable sutures. An area approximately 2  cm in length is always present where the staples partially protrude because a linear stapler cannot make a curved anastomotic corner. We believe is essential when oversewing the posterior staple line to make certain that this stapled area is covered. ◆ Figure 21-19: The mesenteric defect is closed with either interrupted, 5/0, nonabsorbable sutures or a running, 3/0, absorbable suture. ◆ Figure 21-20: Placement of a Foley catheter jejunostomy drain proximal to this anastomosis, using the Witzel technique, is advised because several weeks may pass before bowel transit is restored. In the interval, the patient can be fed full liquids, or even purees, with the jejunostomy tube left to drain by gravity. In essence, with this mechanism in place, during the interval before full bowel functional continuity is restored, the nutritional conduit of the patient will be comparable with its pre-revision state. ◆

Chapter 21  •  Jejunoileal Bypass Revision   323

Figure 21-18 

Figure 21-19 

Figure 21-20 

324   Section VI  •  Revisional Surgery

Concurrent or Subsequent Revisions

1. Revision to laparoscopic adjustable gastric band: see Section IV, Chapter 1. 2. Revision to vertical Silastic ring or banded gastroplasty: see Section IV, Chapter 3. 3. Revision to sleeve gastrectomy: see Section IV, Chapter 4. 4. Revision to Roux-en-Y gastric bypass: see Section III.

Chapter

22

Laparoscopic Adjustable Gastric Banding Revision The incidence of laparoscopic adjustable gastric banding revisions is rising, and the relative ­prevalence of laparoscopic adjustable gastric banding selection is plateauing or declining. Laparoscopic ­adjustable gastric banding revisions are performed for band complications (e.g., prolapse and erosions), ­inadequate weight loss, and patient dissatisfaction. Regarding complications, the primary concern is ­remedying the situation as indicated as well as removing the offending band. Many metabolic/­bariatric surgeons replace a malfunctioning band with a new one. In cases of inadequate weight loss or patient ­dissatisfaction, band replacement usually is not an option. These patients are best served with ­conversion to a ­Roux-en-Y gastric bypass, sleeve gastrectomy, or biliopancreatic diversion/duodenal switch. Of course, some patients insist on take-down with no new metabolic/bariatric procedure. The first step in revising a laparoscopic adjustable gastric banding procedure is to restore functional anatomy by removing the band. As a rule, this step is readily accomplished, but rarely is it as simple as often stated. Adhesions and distorted anatomy at the esophagogastric junction can impede access and prolong band take-down.

325

326   Section VI  •  Revisional Surgery

Take-down technique

Figure 22-1: After exposure has been obtained by lysis of adhesions and liver retraction upward and to the right, the band is cut, as is the connecting tubing. The band usually slips out easily from the ­gastrogastric tunnel and the encasing pseudomembrane. It is then removed from the field. ◆ Figure 22-2: The infusion port is removed through an incision in the old port site scar after detaching the fastening device or sutures previously used. ◆

Chapter 22  •  Laparoscopic Adjustable Gastric Banding Revision   327

Figure 22-1 

Figure 22-2 

328   Section VI  •  Revisional Surgery

Revision Procedures

1. Revision to new laparoscopic adjustable gastric band: see Section IV, Chapter 1. 2. Revision to Roux-en-Y gastric bypass: see Section III, Chapter 2. 3. Revision to sleeve gastrectomy: see Section IV, Chapter 4. 4. Revision to biliopancreatic diversion/duodenal switch: see Section II, Chapter 2.

Chapter

23

Vertical Silastic Ring and Banded Gastroplasty Revision Revisions of vertical Silastic ring or banded gastroplasties are performed in cases of anatomic ­complications (e.g., dilated pouch, too patulous or too narrow an outlet, or a broken staple line ­partition with a ­gastrogastric fistula) and weight gain and when anatomy is sound after a vertical banded ­gastroplasty but either inadequate weight loss has occurred or weight has been regained. Weight gain can occur in a person with a narrowed, obstructing outlet if he or she resorts to a ­comfort, high-calorie, semiliquid diet. Postoperative vomiting can be expected after a nonadjustable restrictive procedure. However, the persistence of vomiting warrants urgent investigation and perhaps immediate surgery. We have also seen a late complication of vertical banded gastroplasty surgery diagnosable by experience—namely, ­late-onset outlet obstruction without diagnostic confirmation. These patients have good results and do well for years but then return with obstructive outlet symptoms. Endoscopy and upper gastrointestinal contrast radiographs may show normal post–vertical banded gastroplasty anatomy. However, adhesive ­attachments of the vertical banded gastroplasty ring or band, usually to the overlying liver, may have developed, obstructing the passage of food through the outlet, but with an open outlet on ­insufflation during endoscopy and normal flow of contrast material. These persons warrant ­consideration for ­operative revision. Before agreeing to perform vertical banded gastroplasty revision, the surgeon must investigate the vertical banded gastroplasty anatomy by both endoscopy and upper gastrointestinal radiography, ­thoroughly evaluate the patient's general health and nutritional status, and adequately prepare the patient for elective surgery. Criteria for patient selection must be based on the surgeon's analysis of need and the patient's request for revision after a full discussion of the potential risks and gains. Unfortunately, the deciding factor is often the discretion of the payor organization, which bases its ­decision on its own economic perceptions. A vertical banded gastroplasty can be revised to essential natural gastric physiology, but this a­ lternative invariably is followed by weight gain. An anatomically impaired vertical banded ­gastroplasty can be revised to a functioning vertical banded gastroplasty. More often, an anatomically or ­functionally impaired vertical banded gastroplasty is revised to another metabolic/bariatric operation, most ­frequently a Roux-en-Y gastric bypass, and less commonly to a biliopancreatic diversion/duodenal switch or sleeve gastrectomy. Adding or substituting an adjustable gastric band for a failed vertical banded gastroplasty does not seem to be reasonable. 329

330   Section VI  •  Revisional Surgery

Take-down vertical silastic ring or banded gastroplasty and vertical banded gastroplasty restoration technique

Figure 23-1 (take-down of Silastic ring): After exposure has been obtained by lysis of adhesions and liver retraction upward and to the right, a scalpel is used to incise the tissue on the anterior surface of the visible and palpable Silastic ring. ◆ Figure 23-2 (take-down of Silastic ring): The Silastic ring is cut and removed in two parts. The fixating nonabsorbable suture is removed as well. If the ends of the ring are brown instead of white, the ring's edge has penetrated into the gastric lumen. This phenomenon is rare, but when it occurs suture ­closure of the gastric groove that contained the Silastic ring is required. ◆ Figure 23-3 (take-down of mesh collar): After exposure has been obtained by lysis of adhesions and liver retraction upward and to the right, scissors are used to divide the anterior surface of the ­polypropylene mesh collar. ◆ Figure 23-4 (take-down of mesh collar): The mesh collar is carefully and sharply resected from its ­adhesions to the anterior gastric conduit and cut at both anterior margins, and the pieces are removed. No attempt is made to remove the posterior part of the polypropylene mesh collar because it is firmly imbedded into the gastric wall and is unable to be clearly visualized. ◆ Figure 23-5 (dilation of the vertical banded gastroplasty outlet): After the Silastic ring is removed or the polypropylene mesh is partially removed, if the operation is intended to restore physiologic gastric function, the vertical banded gastroplasty outlet can be dilated with successive passage per ora of dilating bougies up to #55 Fr in diameter. ◆ Figure 23-6 (staple-line restoration): If the surgeon intends to restore the integrity of the vertical banded gastroplasty gastric pouch to manage a broken staple line or an enlarged pouch, the vertical staple line must be reapplied. This objective can be accomplished with a notched, noncutting, four-row, 90-mm stapler and 3.5-mm staples (blue load), even if the original vertical banded gastroplasty was of the Mason banded type with a through-andthrough gastric opening. As a rule, if a Silastic ring vertical banded gastroplasty is redone, the old ring is removed and a new one is placed after ­re-creation of the upper gastric pouch (see Section IV, Chapter 3). If the old vertical staple line has opened, placement of the new staple line can be guided solely to achieve a small upper pouch because a third gastric pocket, between the gastric pouch and the gastric remnant, will be drained via the break in the old staple line into the gastric remnant. If the old vertical staple line is intact, however, the new staple line must be placed immediately over the old one or superior to the original gastric pouch orifice to provide distal drainage of any third gastric pocket that is created. ◆

Chapter 23  • Vertical Silastic Ring and Banded Gastroplasty Revision   331

Figure 23-1  Figure 23-2 

Figure 23-3 

Figure 23-5 

Figure 23-4 

Figure 23-6 

332   Section VI  •  Revisional Surgery

Revision vertical banded gastroplasty to roux-en-y gastric bypass technique

Figure 23-7: As the first stage of the procedure or after construction of a Roux limb, the old ­vertical banded gastroplasty pouch is stapled closed with a noncutting, four-row, 90-mm stapler with ­3.5-mm staples (blue load). If the initial procedure used a Silastic ring, it can be left in place or, preferably, removed; the posterior surface of the old polypropylene band is usually left in place. Figures 23-7 to 23-13 demonstrate the revision of a previously banded vertical banded gastroplasty, starting with the ­separation of the upper gastric pouch from the gastric remnant. ◆ Figure  23-8: The proximal end of the Roux limb is brought up, retrocolic or antecolic, and anastomosed to the inferior portion of the stapled-off upper pouch. The Roux limb is oriented vertically onto the upper pouch and secured by two nonabsorbable, 5/0, stay sutures. ◆ Figure 23-9: Small enterotomies are made into the Roux limb and the gastric pouch and spread with a clamp. ◆ Figure 23-10: The gastrojejunostomy is performed with the linear stapler and 3.5-mm staples (blue load). The orifice size on the ruled side of the stapler is set at 1  cm, which will create an orifice between 8 and 12  mm, as a function of gastric and intestinal wall thickness and subsequent suture placement. As a rule, at this stage of the operation, we may pass a soft nasogastric tube with holes placed in the gastric pouch and into the Roux limb. ◆

Chapter 23  • Vertical Silastic Ring and Banded Gastroplasty Revision   333

Figure 23-7 

Figure 23-9 

Figure 23-8 

Figure 23-10 

334   Section VI  •  Revisional Surgery

Figure 23-11: The entire anterior surface of the anastomosis, the enterotomy sites, and the adjacent ­staple line are oversewn with interrupted, 5/0, nonabsorbable sutures, taken in the Lembert fashion. ◆ Figure 23-12: The gastrojejunostomy is turned over and the entire posterior staple line is oversewn with interrupted, 5/0, nonabsorbable sutures, in the Lembert manner. Placement of the posterior suture line may require that this surface be approached from both the inferior and posterior positions. ◆ Figure 23-13: The completed Roux-en-Y gastric bypass consisting of a small upper gastric pouch with bowel continuity restored by an 8- to 12-mm gastrojejunostomy, a 75-cm Roux limb, and a distal jejunojejunostomy. ◆

Chapter 23  • Vertical Silastic Ring and Banded Gastroplasty Revision   335

Figure 23-11 

Figure 23-12 

Figure 23-13 

336   Section VI  •  Revisional Surgery

Revision vertical banded gastroplasty to biliopancreatic diversion or duodenal switch and sleeve gastrectomy technique

Figure 23-14: If the vertical banded gastroplasty revision is being performed because of inadequate weight loss or regaining of weight and not because of a mechanical problem or vomiting, a ­modified biliopancreatic diversion or duodenal switch can be created. For a biliopancreatic diversion, the ­procedure would consist of a subtotal distal gastrectomy and closure of the distal duodenal stump with construction of a 50- to 100-cm distal common channel. Step-by-step narration and illustration for this operation is provided in Section II, Chapter 3. ◆ Figure 23-15: If the vertical banded gastroplasty revision is to a duodenal switch, a sleeve ­gastrectomy is necessary before the aforementioned construction is feasible. This sleeve gastrectomy is ­performed in a manner similar to that narrated and illustrated in Section IV, Chapter 10. Under these ­circumstances, it is necessary to be careful to place the gastric resection staple line on top of the vertical banded ­gastroplasty staple line. s If the vertical banded gastroplasty pouch has enlarged, it may be feasible to place a gastric resection staple line within the vertical banded gastroplasty pouch toward the lesser curvature. ◆ Figure 23-16: If the vertical banded gastroplasty revision is to a sleeve gastrectomy only, the aforementioned steps should be followed for the construction of the sleeve gastrectomy. For both revision to a duodenal switch or a simple sleeve gastrectomy, we recommend oversewing the staple line to prevent postoperative leaks. ◆

Chapter 23  • Vertical Silastic Ring and Banded Gastroplasty Revision   337

Figure 23-14 

Figure 23-15 

Figure 23-16 

Chapter

24

Roux-en-Y Gastric Bypass Revision Revisions of Roux-en-Y gastric bypass are performed for demonstrable anatomic failures (e.g., dilated pouch or outlet, narrowed outlet, broken staple line, gastrogastric fistula), nonresponding operative adverse effects or complications (e.g., nonanatomic vomiting, iron deficiency), inadequate weight loss, or weight regain. Once considered the gold standard metabolic/bariatric operation, the Roux-en-Y gastric bypass, although in ascendancy in Europe, is in decline in the United States.1 As newer operations are introduced, the more standard procedures lose some of their attractiveness. Furthermore, as standard operations exhibit longer periods of follow-up, their failure rates increase. The Roux-en-Y gastric bypass has likely been performed on more patients than any other metabolic/bariatric procedure; thus, it is not surprising that failure rates and reasons for revision are increasing. As standard assessment before Roux-en-Y gastric bypass revision, the surgeon must investigate the Roux-en-Y gastric bypass anatomy by both endoscopy and upper gastrointestinal radiography, thoroughly evaluate the patient's general health and nutritional status, and adequately prepare the patient for surgery. True informed consent is mandatory and must include conveying potential short- and long-term risks to the patient. Although a Roux-en-Y gastric bypass functionally can be taken down as the sole revision, this operation is not recommended because it is almost invariably followed by a return of weight to the original preoperative level. However, take-down of the bypass may be a first step in a revision that entails another metabolic/bariatric operation. A Roux-en-Y gastric bypass that has failed anatomically can be repaired. A bypass can be banded. A standard (75-cm) or slightly elongated (100- to 150-cm) bypass can be revised to a true long-limb bypass (75 to 125  cm from the ileocecal valve), which is, in essence, a conversion to a functional biliopancreatic diversion. A Roux-en-Y gastric bypass can be revised to a sleeve gastrectomy or a duodenal switch.

Reference

1. Buchwald H, Oien D: Metabolic/bariatric surgery worldwide 2008, Obes Surg 19:1605–1611, 2009.

339

340   Section VI  •  Revisional Surgery

Take-down undivided Roux-en-Y gastric bypass and restoration gastric continuity technique

Figure 24-1: Anatomy of stapled, undivided Roux-en-Y gastric bypass. This configuration can be taken down and normal anatomy can be functionally restored in a variety of ways: (a) through excision and closure of the gastrojejunostomy with a side-to-side gastrogastrostomy; (b) through take-down of the gastrojejunostomy with anastomosis of the open upper gastric pouch to the distal gastric remnant; (c) through excision and closure of the gastrojejunostomy and gastric staple line excision with a side-to-side gastrogastrostomy; and (d) by connecting the upper and lower gastric pouches with a segment of jejunum. ◆ Figure 24-2 (option a): After lysis of adhesions has been performed and visualization of the attic of the abdomen has been obtained (see Section I, Chapter 1, Figures 1-8 and 1-9), the gastrojejunostomy is divided on the gastric side with the linear stapler and 3.5-mm staples (blue load). We always oversew the gastric staple line wih interrupted, 4/0, nonabsorbable sutures, taken in the Lembert fashion. We use 4/0 sutures to oversew a gastric wall, in contrast to our more common choice of 5/0 suture. s Oversewing the new staple line. ◆

Chapter 24  •  Roux-en-Y Gastric Bypass Revision   341

Figure 24-1 

Figure 24-2 

342   Section VI  •  Revisional Surgery

Figure 24-3 (option a): The upper and lower gastric pouches are now reconnected via a side-to-side gastrogastrostomy performed anterior to the prior gastric cross stapling. This anastomosis can be performed with a stapler or entirely hand sewn in one or two layers. The stapled anastomosis is illustrated. A posterior row of interrupted, 5/0, nonabsorbable sutures is placed, in the Lembert fashion, over a distance of approximately 3  cm. ◆ Figure 24-4 (option a): Entry is gained into the upper and lower pouches, with the cautery applied toward one end of the suture line. ◆ Figure 24-5 (option a): The aforementioned incisions are widened with a spreading instrument, and a linear stapler is used to construct the gastrogastrostomy with 3.5-mm staples (blue load). ◆ Figure 24-6 (option a): The entire anterior aspect of the anastomosis, the enterotomy sites, and the adjacent staple line are oversewn with interrupted, 5/0, nonabsorbable sutures, taken in the Lembert fashion. ◆

Chapter 24  •  Roux-en-Y Gastric Bypass Revision   343

Figure 24-3 

Figure 24-5 

Figure 24-4 

Figure 24-6 

344   Section VI  •  Revisional Surgery

Figure  24-7 (option a): After take-down of adhesions to the now-detached Roux limb and ligation or otherwise sealed division of the mesentery of the Roux limb, the jejunojejunostomy construction of the Roux limb is taken down. This procedure is achieved in the simplest manner by dividing the Roux limb just superior to the original side-to-side jejunojejunostomy with the linear stapler and 3.5-mm staples (blue load). Again, we oversew the retained staple line with interrupted, 5/0, nonabsorbable sutures, taken in the Lembert fashion. The Roux limb is removed from the field. s Oversewing the retained staple line. ◆ Figure 24-8 (option b): After lysis of adhesions has been performed and visualization of the attic of the abdomen has been obtained (see Section I, Chapter 1, Figures 1-8 and 1-9), the gastrojejunostomy is divided on the gastric side, leaving a proximal orifice that can be widened with scissors. ◆

Chapter 24  •  Roux-en-Y Gastric Bypass Revision   345

Figure 24-7 

Figure 24-8 

346   Section VI  •  Revisional Surgery

Figure 24-9 (option b): Gastric continuity is now reestablished by anastomosis of the opening in the upper pouch to the distal gastric pouch (gastric remnant). This procedure is accomplished by first placing a posterior row of interrupted, 5/0, nonabsorbable sutures, taken in the Lembert fashion. ◆ Figure 24-10 (option b): Next, an incision the length of the upper pouch orifice is made in the lower pouch with the cautery. ◆ Figure  24-11 (option b): The anastomosis is completed with an anterior row of interrupted, 5/0, nonabsorbable sutures, taken in the Lembert fashion. Note: This anastomosis also can be performed in two layers with a running, 4/0, absorbable suture for the inner row. The Roux limb is excised (see Figure 24-7). ◆

Chapter 24  •  Roux-en-Y Gastric Bypass Revision   347

Figure 24-9 

Figure 24-10 

Figure 24-11 

348   Section VI  •  Revisional Surgery

Figure 24-12 (option c): After lysis of adhesions has been performed and visualization of the attic of the abdomen has been obtained (see Section I, Chapter 1, Figures 1-8 and 1-9), the gastrojejunostomy is divided on the gastric side and oversewn (see Figure 24-2). The gastric cross-staple line is excised with several applications of the linear stapler and 3.5-mm staples (blue load), above and below the gastric cross-staple line. The undivided upper and lower gastric pouches have now been divided. s Oversewing the staple lines. ◆ Figure 24-13 (option c): The upper and lower gastric pouches are reunited via a side-to-side gastrogastrostomy. A posterior row of interrupted, 5/0, nonabsorbable sutures is placed, in the Lembert fashion, over a distance of approximately 3  cm. This anastomosis is completed as illustrated in Figures 24-3 to 24-5. The Roux limb is excised (see Figure 24-7). ◆

Chapter 24  •  Roux-en-Y Gastric Bypass Revision   349

Figure 24-12 

Figure 24-13 

350   Section VI  •  Revisional Surgery

◆

Figure 24-14 (option d): If the adhesions at the prior gastrogastrostomy are dense and the upper pouch is small, a unique reestablishment of gastric continuity can be performed by dividing the Roux limb some 6  cm from the gastrogastrostomy with the linear stapler and 3.5-mm staples (blue load), oversewing the proximal end of this division and anastomosing the proximal end to the distal gastric pouch in side-to-side fashion. The remainder of the Roux limb is excised (see Figure 24-7).

Take-down divided Roux-en-Y gastric bypass and restoration gastric continuity technique

Figure 24-15: Anatomy of stapled, divided Roux-en-Y gastric bypass. Again, this configuration can be taken down and normal anatomy can be functionally restored in a variety of ways: (a) through excision and closure of the gastrojejunostomy with a side-to-side gastrogastrostomy, (b) through take-down of the gastrojejunostomy with anastomosis of the open upper gastric pouch to the distal gastric pouch, and (c) by connecting the upper and lower gastric pouches with a segment of jejunum. ◆ Figure 24-16 (option a): After lysis of adhesions has been performed and visualization of the attic of the abdomen has been obtained (see Section I, Chapter 1, Figures 1-8 and 1-9), the gastrojejunostomy is divided on the gastric side with the linear stapler and 3.5-mm staples (blue load) or laparoscopically with the appropriate laparoscopic stapler. The new gastric staple line is oversewn. The upper and lower gastric pouches are now reconnected via a side-to-side gastrogastrostomy performed between the two divided gastric pouches. Performance of this anastomosis is similar to the steps outlined in Figures 24-3 to 24-6 of this chapter pertaining to take-down of the undivided Roux-en-Y gastric bypass. This procedure is completed by take-down of the Roux limb as illustrated in Figure 24-7. ◆

Chapter 24  •  Roux-en-Y Gastric Bypass Revision   351

Figure 24-15 

Figure 24-14 

Figure 24-16 

352   Section VI  •  Revisional Surgery

Figure 24-17 (option b): After lysis of adhesions has been performed and visualization of the attic of the abdomen has been obtained (see Section I, Chapter 1, Figures 1-8 and 1-9), the gastrojejunostomy is divided on the gastric side, leaving a proximal orifice that can be widened with scissors. Gastric continuity is reestablished by anastomosis of the opening in the upper pouch to the distal gastric pouch (gastric remnant). Placement of a posterior row of interrupted, 5/0, nonabsorbable sutures, taken in the Lembert fashion, is illustrated. The remainder of option b is completed in the manner demonstrated in the step-by-step technique on the take-down of the undivided Roux-en-Y gastric bypass and restoration of gastric continuity (see Figures 24-10 and 24-11). ◆ Figure 24-18 (option c): If the adhesions at the previous gastrojejunostomy are dense and the upper pouch is small, a unique reestablishment can be performed by dividing the Roux limb some 6  cm from the gastrojejunostomy, oversewing the proximal end of this division, and anastomosing the proximal end to the distal pouch in a side-to-side fashion. The remainder of the Roux limb is excised (see Figure 24-7). ◆

Repair of anatomically failed Roux-en-Y gastric bypass technique

◆

Figure 24-19: A defect in the staple line of an undivided Roux-en-Y gastric bypass can be closed by restapling the stomach, as illustrated, by applying a transgastric staple line with a noncutting, four-row, 90-mm stapler with 3.5-mm staples (blue load). This new staple line is placed superiorly to the original staple line, conceivably decreasing the size of the upper pouch. In this revisional procedure, a middle gastric pouch or pocket may be created, which is of no consequence because it will be drained inferiorly through the gastrogastric fistula into the gastric remnant. Note: The equivalent closure of a gastrogastric fistula in a divided Roux-en-Y gastric bypass involves careful identification of both ends of the fistula, resection of the intervening tract, and oversewing the two fistula sites. Other repairs of anatomic failures involve endoscopy (i.e., dilation of a tight gastrojejunostomy and possible narrowing by proprietary devices of a widened gastrojejunostomy), gastric pouch imbrication, and partial or total reconstruction of the upper pouch and gastrojejunostomy of a Roux-en-Y gastric bypass. Some of these procedures, or aspects thereof, have been described and illustrated in this text.

Banding of a Roux-en-Y gastric bypass technique

◆

Figure 24-20: Inadequate weight loss or weight regain can be treated with placement of an adjustable gastric band around the upper gastric pouch without any additional procedure. As a rule, this procedure would be done laparoscopically, but it can be done via the open technique. Details of band placement can be found in Section IV, Chapter 7, Figures 7-5 to 7-16.

Chapter 24  •  Roux-en-Y Gastric Bypass Revision   353

Figure 24-17 

Figure 24-19 

Figure 24-18 

Figure 24-20 

354   Section VI  •  Revisional Surgery

◆

Figure 24-21: An alternative to placement of an adjustable gastric band is the placement of a nonadjustable Silastic ring or polypropylene mesh band around the upper gastric pouch— in essence, the creation of a Fobi II pouch (see Section III, Chapter 5, Figure 5-33).

Roux-en-Y gastric bypass revision to a long-limb Roux-en-Y gastric bypass technique

◆

Figure 24-22: Because operative revision of the upper gastric pouch and gastrojejunostomy of a Roux-en-Y gastric bypass for inadequate weight loss or weight gain fails at least as often as the original procedure, Roux-en-Y gastric bypass revision by revision of the Roux limb offers a more successful alternative. After adhesions are cleared, the Roux limb jejunojejunostomy is isolated and the alimentary Roux limb, the biliopancreatic limb, and the distal common channel are carefully identified. With a linear stapler and 3.5-mm staples (blue load), the alimentary limb is divided just superior to the jejunojejunostomy. s Oversewing the cut, stapled ends.

Chapter 24  •  Roux-en-Y Gastric Bypass Revision   355

Figure 24-21 

Figure 24-22 

356   Section VI  •  Revisional Surgery

Figure 24-23: With a calibrated umbilical tape along the mesentery border, 75 to 100  cm are measured proximally from the ileocecal valve. Distal (brown) and proximal (blue) circumferential marking sutures are placed. s Common channel, 75 to 100  cm. ◆ Figure 24-24: The distal end of the alimentary Roux limb is brought down to the ileum 75 to 100  cm from the ileocecal valve mark and a side-to-side, functionally end-to-end, anastomosis is performed. For details on the construction of this anastomosis, see Section II, Chapter 4, Figures 4-5 to 4-14. Subsequently, the mesenteric defect is closed. ◆

Chapter 24  •  Roux-en-Y Gastric Bypass Revision   357

75-100 cm

Figure 24-23 

Figure 24-24 

358   Section VI  •  Revisional Surgery

Roux-en-Y gastric bypass revision to sleeve gastrectomy or duodenal switch technique

Figure  24-25: Before a greater curvature sleeve resection can be performed, it is necessary to take down the Roux-en-Y gastric bypass and restore gastrogastric continuity (see the beginning of this chapter). The subsequent sleeve gastrectomy must be done extremely carefully because it usually involves crossing staple lines. More than ever, oversewing the sleeve gastrectomy staple line is advised. For sleeve gastrectomy technique details, see Section IV, Chapter 10, Figures 10-6 to 10-10. s Oversewing the sleeve gastrectomy staple line. ◆ Figure 24-26: Revision of a Roux-en-Y gastric bypass to a duodenal switch first involves a sleeve gastrectomy, followed by duodenal switch completion with construction of the appropriate lengths of alimentary limb, biliopancreatic limb, and common channel. An intestinal revision schematic is illustrated; there are several means of resecting the Roux limb en route to a duodenal switch configuration. For technique details, see Section II, Chapter 4, Figures 4-5 to 4-14 and 4-20 to 4-24. ◆

Chapter 24  •  Roux-en-Y Gastric Bypass Revision   359

Figure 24-25 

Figure 24-26 

Chapter

25

Sleeve Gastrectomy Revision An early or late strictured sleeve gastrectomy usually can be handled by endoscopic dilation. Rarely will a stricture require operative resection and gastrogastrostomy. As a rule, sleeve gastrectomy revisions are performed because of inadequate weight loss or weight regain. Redoing the sleeve gastrectomy with excision of more of the gastric curvature can be attempted but is not advised because it is not likely to be successful. The two recommended revisions are conversion to a Roux-en-Y gastric bypass or ­performing the intestinal surgery portion of a duodenal switch. After all, the sleeve gastrectomy came into existence as a freestanding procedure by the serendipitous finding of significant weight loss after the sleeve gastrectomy portion of a planned two-part duodenal switch.

361

362   Section VI  •  Revisional Surgery

Revision sleeve gastrectomy by re-resection of greater curvature technique

◆

Figure 25-1: After lysis of adhesions has been performed and visualization of the attic of the abdomen has been obtained (see Section I, Chapter 2, Figures 2-8 and 2-9), the greater curvature of the stomach is re-resected and oversewn with an intragastric bougie in places. For technique details of a sleeve gastrectomy, see Section IV, Chapter 10, Figures 10-6 to 10-10.

Chapter 25  •  Sleeve Gastrectomy Revision   363

Figure 25-1 

364   Section VI  •  Revisional Surgery

Revision sleeve gastrectomy to Roux-en-Y gastric bypass technique

Figure 25-2: The Roux limb is constructed. For technique details, see Section III, Chapter 5, Figures 5-5 to 5-15. ◆ Figure 25-3: After lysis of adhesions has been performed and visualization of the attic of the abdomen has been obtained (see Section I, Chapter 2, Figures 2-8 and 2-9), the sleeve gastrectomy is divided with a stapling device, leaving a small upper gastric pouch. The two new staple lines are oversewn. s Oversewing the staple line. ◆ Figure  25-4: The Roux limb is brought up, retrocolic or antecolic, to the upper gastric pouch and the gastrojejunostomy is constructed (see Section III, Chapter 5, Figures 5-18 to 5-32). Note: References to previous chapters for performing revisional surgery usually pertain to the open technique; however, if the laparoscopic technique is used, parallel descriptions are found in the same previous section. ◆

Chapter 25  •  Sleeve Gastrectomy Revision   365

Figure 25-2 

Figure 25-3 

Figure 25-4 

Chapter

26

Biliopancreatic Diversion/ Duodenal Switch Revision Outside structural or other mechanical difficulties, revisions of a biliopancreatic diversion or a ­duodenal switch generally are performed because of (1) unremitting metabolic complications (e.g., unrelieved hypoalbuminia and liver decompensation), with or without excessive weight loss, (2) excessive weight loss in a patient who is in good health and is receiving goodquality nutrition (rare), and (3) ­inadequate weight loss (uncommon). Scopinaro believes the size of the gastric pouch of his ­biliopancreatic ­diversion is unimportant regarding outcomes. We agree and therefore do not recommend revisional surgery for a functioning biliopancreatic diversion gastric pouch. As previously stated, a sleeve gastrectomy can be made smaller with less volume by a re-resection of the greater curvature aspect of the stomach (see Section VI, Chapter 25). Again, We do not recommend this approach. Thus, realistically, revision of ­biliopancreatic diversion/duodenal switch procedures consists of increasing the length of the common channel for metabolic complications, with or without excessive weight loss, and decreasing the length of the common channel for persons with inadequate weight loss.

367

368   Section VI  •  Revisional Surgery

Lengthening the common channel of a biliopancreatic diversion or duodenal switch technique

◆

Figure 26-1: After lysis of adhesions and adequate visualization of the abdominal contents have been obtained, the biliopancreatic limb, the alimentary Roux limb, and the common channel are clearly identified. The Roux limb is divided with a linear stapler and 3.5-mm staples (blue load) immediately above the jejunoileostomy, and the ends of the staple lines are oversewn. By dividing the Roux limb, the mesenteric blood supply to the Roux limb, the biliopancreatic limb, and the common channel are not disturbed. s Site of Roux limb division.

Chapter 26  •  Biliopancreatic Diversion/Duodenal Switch Revision   369

Roux limb divided

Figure 26-1 

370   Section VI  •  Revisional Surgery

◆

Figure  26-2: Preoperatively, the surgeon discusses with the patient and decides on the ­additional length of functioning common channel to be created. As a rule, 75 to 125  cm are added. The agreed-upon distance is measured proximally along the mesenteric border with a calibrated umbilical tape. At the designated site, a side-to-side, functionally end-toend, enteroenterostomy of the detached Roux to the now-lengthened common channel is performed, followed by closure of the mesentery to prevent internal herniations. For technique details, see Section II, Chapter 4, Figures 4-9 to 4-14.

Shortening the common channel of a biliopancreatic diversion or duodenal switch technique

◆

Figure 26-3: The procedure previously outlined is followed, but the detached Roux limb is moved ­distally on the common channel to the designated site for the jejunoileostomy. This anastomosis is performed in a side-to-side, functionally end-to-end, manner, followed by closure of the mesentery to prevent internal herniation.

Chapter 26  •  Biliopancreatic Diversion/Duodenal Switch Revision   371

Figure 26-2 

Figure 26-3 

372   Section VI  •  Revisional Surgery

Figure 26-4: An alternative method to shorten the common channel is to resect a portion of it. The ­designated length for resection is measured distal to the jejunoileostomy, and the bowel is transected with a linear stapler and 3.5-mm staples (blue load) at both ends of the planned resection. The ­specimen is removed from the field. The ends of the staple lines are oversewn. ◆ Figure 26-5: Bowel continuity subsequent to resection is restored by side-to-side, functionally ­end-to-end, anastomosis, with subsequent mesenteric closure. For technique details, see Section II, Chapter 4, Figures 4-9 to 4-14. ◆

Chapter 26  •  Biliopancreatic Diversion/Duodenal Switch Revision   373

Common channel segment removed

Figure 26-4 

Figure 26-5 

Index Note: Page numbers followed by f indicate figures.

A Abdominal access, 1, 3, 15 laparoscopic technique, 16-20 abdominal insufflation, 16, 17f closure of trocar sites, 20, 21f Hasson approach, 16 liver retraction superiorly and to right, 20, 21f operating team placment, 18, 19f port-site placements, 16, 17f small fascial incision closure, 20 trocar placements, 18, 19f open technique, 4-14 attic cavity exposure, 10, 11f bariatric retractor placement, 9f, 11f closure procedure, 10, 11f alternative, 12, 13f left subcostal approach, 14 linea alba incision and preperitoneal fat removal, 6, 7f, 8, 9f midline incision, 4, 5f subcutaneous tissue tear to linea alba, 6, 7f suction drain placement, 12, 13f suturing and closure completion, 12, 13f wound protector placement, 8, 9f Adjustable gastric banding, 145-159 laparoscopic revision, 325-328 revision procedures, 328 take-down technique, 326-328, 327f laparoscopic technique, 146-158 dissection at angle of His, 150, 151f gastric band positioning, 154, 155f gastric band securement, 156, 157f operating team placement, 148, 149f port-site placements, 146, 147f retroperitoneal access, 152, 153f standard features of, 146 trocar placement, 148, 149f tubing connection to port and port fixation, 158, 159f precursors of, 145

B Biliopancreatic diversion, 25-53 current, 25 and duodenal switch, 55-91 original attempts, 25 Scopinaro, 25 laparoscopic technique, 40-52 open technique, 26-40

Biliopancreatic diversion/duodenal switch, 55 laparoscopic technique, 74-90 common channel measurement, 82, 83f completed, 90, 91f duodenal mobilization/division, 80, 81f, 82, 83f duodenojejunostomal anastomosis, 88, 89f gastric vessel division, 78, 79f jejunal measurement and division, 84, 85f jejunoileostomal anastomosis, 84, 85f, 86, 87f, 88, 89f mesenteric defect closure, 88, 89f mesocolic window closure, 90, 91f operating team placement, 78, 79f port-site placement, 74, 75f sleeve gastrectomy, 80, 81f trocar placement, 76, 77f open technique, 56-74 abdominal attic exposure in, 66, 67f common channel measurement, 58, 59f completed, 74, 75f duodenal division/mobilization, 70, 71f, 72, 73f duodenojejunostomal anastomosis, 72, 73f, 74, 75f gastric vessel division, 68, 69f jejunal division and oversewn ends, 60, 61f, 62, 63f jejunoileostomal anastomosis, 62, 63f, 64, 65f jejunojejunostomy site marking, 60, 61f mesenteric defect closure, 66, 67f midline incision, 56, 57f sleeve gastrectomy, 68, 69f, 70, 71f Biliopancreatic diversion/duodenal switch revision, 367 common channel lengthening technique, 368-370, 369f, 371f common channel shortening technique, 370-372, 371f, 373f

C Current investigative procedures, 229 duodenal-jejunal exclusion, 273-282 endoluminal procedures, 283-285 endoluminal sleeve, 253-259 external gastric plication, 287-291 gastric and vagal pacing, 235-252

ileal transposition, 261-272 intragastric balloon, 231-233 micro-orifice surgery, 305-309 robotics, 299-303 transgastric procedures, 293-297

D Duodenal switch, 55 Duodenal-jejunal exclusion, 273 laparoscopic technique, 274-282 alternative, 282 duodenal division and oversewing, 278, 279f duodenal mobilization, 278, 279f duodenojejunostomal anastomosis, 280, 281f jejunojejunostomal anastomosis, 280, 281f operating team placement, 276, 277f port-site placement, 274, 275f trocar placement, 276, 277f open technique, 282

E Endoluminal procedures, 283 intragastric inversion with clamping or stapling, 284, 285f intragastric partitioning, 284, 285f intragastric plication, 284, 285f Endoluminal sleeve, 253, 254, 255f clinical studies of, 253 placement of, 254, 255f placement technique, 254-258 anchor device deployed in duodenal bulb, 258, 259f completed, 258, 259f guidewire advancement into duodenum, 256, 257f guidewire advancement into jejunum, 256, 257f External gastric plication, 287 abdominal access in, 288 anterior surface plication procedure, 288, 289f greater curvature plication procedure, 290, 291f suture curvature plication procedure, 290, 291f

F Fobi II vertical banded Roux-en-Y gastric bypass, 112, 113f

376   Index G

J

Gastic segmentation, 161-169 open technique, 162-168 completed, 168, 169f gastric band introduction and securement, 166, 167f, 168, 169f midline incision, 162, 163f retrogastric tunnel formation, 164, 165f Gastric and vagal pacing. See also Gastric electrode placement; Vagal electrode placement development of, and contributors, 235 Gastric bypass, 24, 93 development of procedures, 94 laparoscopic Roux-en-Y, 114-141 open Roux-en-Y, 96-113 Gastric electrode placement, 236-246 laparoscopic, 236-246 generator pocket construction and pacer insertion, 244, 245f lead implant location and marking, 240, 241f lead placement and securement, 242, 243f operating team placement, 238, 239f port-site placement, 236, 237f retractor placement and abdominal exposure, 240, 241f trocar placement, 238, 239f open, 246, 247f Gastric plication endoluminal procedures, 283-285 external, 287-291

Jejunoileal bypass, 23, 24 Jejunoileal bypass revision, 313 concurrent or subsequent, 324 take-down end-to-end jejunoileostomy, 318-324, 319f, 321f, 323f take-down end-to-side jejunoileostomy, 314-316, 315f, 317f

H Hand-sewn Roux-en-Y gastric bypass, 138-140, 139f, 141f Hasson approach, in laparoscopic abdominal access, 16 Hindgut theory, 253

I Ileal transposition, 261 open, 262-270 completed, 270, 271f harvested ileum, 262, 263f ileal division, 262, 263f, 264, 265f ileoileostomal anastomosis, 266, 267f ileojejunal anastomoses, 270, 271f jejunal division, and oversewing, 268, 269f mesenteric defect closure, 268, 269f oversewing of divided bowel, 264, 265f Intragastric balloon, 231-233 insertion technique, 232, 233f Intragastric inversion with clamping or stapling, 284, 285f Intragastric partitioning, 284, 285f Intragastric plication, 284, 285f

L Linear Roux-en-Y gastric bypass, 134-136, 135f, 137f Long limb Roux-en-Y gastric bypass, 94, 110, 111f

M Magenstrasse and Mill procedure, in sleeve gastrectomy, 220, 221f Malabsorptive procedure(s), 23 biliopancreatic diversion, 25-53 biliopancreatic diversion/duodenal switch, 55-91 current practice, 24 history of, and contributors, 23 Malabsorptive/restrictive procedures, 93 development of, and contributors, 94 laparoscopic Roux-en-Y gastric bypass, 114-141 open Roux-en-Y gastric bypass, 96-113 Micro-orifice surgery, 305 open exposure and closure technique, 306-308, 307f, 309f Mini-laparotomy, 1

R Restrictive procedures, 143 development of, and contributors, 143-144 laparoscopic adjustable gastric banding, 145-159 open gastric segmentation, 161-169 sleeve gastrectomy, 211-227 vertical silastic ring and banded gastroplasty, 171-209 Revisional surgery, 311-312 biliopancreatic diversion/duodenal switch revision, 367-373 jejunoileal bypass revision, 313-324 laparoscopic adjustable gastric banding revision, 325-328 Roux-en-Y gastric bypass revision, 339-359 sleeve gastrectomy revision, 361-365 vertical silastic ring and banded gastroplasty revision, 329-337 Robotics, 299 needle holder and grasper, 302, 303f operating room configuration, 300, 301f port-site placement, 302, 303f Roux-en-Y gastric bypass, 94 Fobi II vertical banded, 112 Roux-en-Y gastric bypass hand-sewn, 138-140, 139f, 141f

laparoscopic, 114-140 abdominal attic exposure, 122, 123f alternative, 134-140 gastric pouch creation, 124, 125f, 126, 127f gastrojejunostomy completion, 132, 133f gastrojejunostomal anastomosis, 128, 129f, 130, 131f initial pouch contruction or Roux limb, 118, 119f jejunojunostomal anastomosis, 120, 121f mesenteric defect closure, 122, 123f operating team placement, 116, 117f port-site placement, 114, 115f retrocolic tunnel creation, 126 Roux limb up to gastric pouch, 126, 127f trocar placement, 116, 117f linear, 134-136, 135f, 137f long limb, 94, 110, 111f open, 96-112 abdominal attic exposure, 104, 105f alternative, 112 completed, 110, 111f gastric Penrose drain placement, 106, 107f gastric pouch construction, 108, 109f gastric vessels division, 106, 107f gastrojejunostomal anastomosis, 106, 107f, 108, 109f jejunojunostomal anastomosis, 102, 103f mesenteric defect closure, 104, 105f midline incision, 96, 97f Roux limb construction, 98, 99f, 100, 101f subcutaneous tear and linea alba incision, 98, 99f vertical, 112 Roux-en-Y gastric bypass revision, 339 banding, 352-354, 353f divided, take-down and restoration options, 350-352, 351f option a, 350, 351f option b, 352, 353f option c, 352, 353f to duodenal switch, 358, 359f to long limb Roux-en-Y gastric bypass, 354-356, 355f, 357f in procedure failure, 55-91, 353f silastic ring placement in, 354, 355f to sleeve gastrectomy, 358, 359f take-down and restoration options, 340-350 option a, 340, 341f, 342, 343f, 344, 345f option b, 344, 345f, 346, 347f option c, 348, 349f option d, 350, 351f

Index   377 S Scopinaro biliopancreatic diversion, 25 laparoscopic technique, 40-52 abdominal attic exposure, 50, 51f common channel measurement, 44, 45f completed, 52, 53f gastric resection, 52, 53f gastrojejunostomy, 52, 53f jejunal division, 46, 47f jejunoileostomal anastomosis, 46, 47f, 48, 49f mesenteric defect closure, 50, 51f operating team placement, 44, 45f port-site placements, 40, 41f trocar placement, 42, 43f open technique, 26-40 abdominal attic exposure, 36, 37f common channel measurement, 28, 29f completed, 40, 41f gastric resection, 38, 39f gastrojejunostomy, 38, 39f jejunal division, 30, 31f jejunal ends oversewn, 32, 33f jejunoileostomal anastomosis, 32, 33f, 34, 35f jenjunojejunostomy site marking, 30, 31f mesenteric defect closure, 36, 37f midline incision, 26, 27f subcutaneous tear down to linea alba, 28, 29f Single-orifice laparoscopic surgery, 1 Sleeve gastrectomy, 211-227 development of, and contributors, 94 laparoscopic, 220-226 completed, 226, 227f gastric vessel dissection and ligation, 224, 225f operating team placement, 224, 225f oversewn sleeve staple line, 226, 227f port-site placement, 220, 221f sleeve gastrectomy creation, 226, 227f trocar placement, 222, 223f Magenstrasse and Mill procedure for, 220, 221f open, 212-218 abdominal attic exposure, 216, 217f completed, 218, 219f gastric sleeve creation, 218, 219f gastric vessel division and ligation, 216, 217f

Sleeve gastrectomy midline incision, 212, 213f oversewing sleeve gastrectomy staple line, 218, 219f subcutaneous tissue tear and linea alba incision, 214, 215f Sleeve gastrectomy revision, 361 by re-resection of greater curvature of stomach, 362, 363f to Roux-en-Y gastric bypass, 364, 365f

T Transgastric gastrojejunostomy technique, 294-296, 295f, 297f Transgastric procedures, 293 gastrojejunostomy technique, 294-296

V Vagal electrode placement laparoscopic, 246-252 electrode placement at vagus nerve trunks, 248, 249f esophagogastric tissue dissection, 248, 249f generator placement in subcutaneous pocket, 250, 251f nerve anatomy in, 246, 247f vagal blocking mechanism schematic, 250, 251f open, 252 Vertical banded gastroplasty laparoscopic (Champion approach), 202-208 band application, 208, 209f completed, 208, 209f liver retraction and gastric area preparation, 206, 207f operating team placement, 204, 205f port-site placement, 202, 203f trocar placement, 204, 205f wedge resection of stomach, 208, 209f laparoscopic (Mason approach), 190-200 completed, 201f, 209f gastric pouch completion, 200, 201f gastric pouch creation, 198, 199f gastric window creation, 196, 197f, 198, 199f liver retraction and preparation of gastric area, 194, 195f operating team placement, 192, 193f port-site placement, 190, 191f trocar placement, 192, 193f

open (Mason procedure), 180-188 completed, 188, 189f gastic pouch completion, 188, 189f gastic pouch creation, 186, 187f gastic window creation, 185f, 186, 187f gastrohepatic preparation for gastric window, 184, 185f midline incision, 180, 181f, 182, 183f subcutaneous tissue tear and linea alba incision, 182, 183f Vertical banded gastroplasty revision, 329 to biliopancreatic diversion, 336, 337f to duodenal switch, 336, 337f ring or band take-down and staple line restoration, 330, 331f to Roux-en-Y bypass, 332-334, 333f, 335f to sleeve gastrectomy, 336, 337f Vertical Roux-en-Y gastric bypass, 112, 113f Vertical silastic ring and banded gastroplasty revision, 329 to biliopancreatic diversion, 336, 337f to duodenal switch, 336, 337f ring or band take-down and staple line restoration, 330, 331f to Roux-en-Y bypass, 332-334, 333f, 335f to sleeve gastrectomy, 336, 337f Vertical silastic ring gastroplasty open technique, 172-178 catheter insertion, 176, 177f completed, 178, 179f gastrohepatic preparation for silastic ring, 174, 175f midline incision, 172, 173f silastic ring placement and securement, 178, 179f subcutaneous tissue tear and linea alba incision, 174, 175f vertical pouch construction, 176, 177f Vertical silastic ring gastroplasty revision, 329 to biliopancreatic diversion, 336, 337f to duodenal switch, 336, 337f ring or band take-down and staple line restoration, 330, 331f to Roux-en-Y bypass, 332-334, 333f, 335f to sleeve gastrectomy, 336, 337f