Buchwald’s Atlas of Metabolic & Bariatric Surgical Techniques and Procedures
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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.
Acquisitions Editor: Judith Fletcher Developmental Editor: Rachel Miller Publishing Services Manager: Patricia Tannian Project Manager: Carrie Stetz Design Direction: Steve Stave
Printed in China Last digit is the print number: 9 8 7 6 5 4 3 2 1
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.
15
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
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1st assistant
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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.
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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
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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.
253
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