The patient is a 54-year-old lady who has been obese since childhood. She has a BMI of 54 Kg/m2. She has consulted with obesity specialists and dietitians and has tried various forms of therapy to lose weight, to no avail.
Her medical record is: Impaired glucose tolerance, severe OSA, HBP, dyslipidemia, Gastroesophageal reflux disease and Barrett’s esophagitis, NASH, lower back pain due to spinal stenosis, for which she may need surgery. Her mobility is very limited, and she’s dependent on crutches. Osteoarthritis involving both knees.
The patient is in the supine position with the leading surgeon to the left, the patient and the camera and the assistant surgeon to the right. Five trocars were used, four of which were 12-mm ports. The reason for this is that the stapling device will be used through all four of the 12-mm ports. A 3D camera with a flexible tip was used. Its port is a 10-mm trocar. The first port is placed in a vision just beneath Palmer’s point on the left, 20 cm from the xiphisternum, in the mid-clavicular line.
The second port is placed high up, just below the xiphisternum, directing downwards, towards the patient’s left-hand side, in order to facilitate the construction of the enteroenterostomy later on. This port will be used mainly for the retraction of the liver on a pneumatic stabilising arm.
The third trocar is then placed in the mid-clavicular line, 20 cm from the xiphisternum, on the patient’s right-hand side. The fifth port is then placed on the left lateral position below the ribcage.
The operation starts with the surgeon’s left hand grasping the fundus of the stomach. By gently pulling it downwards, the fibrous adhesions between the fundus, the diaphragm, and the left crus are exposed. By using the electric cautery, these adhesions are freed until the left crus is identified. This is to facilitate the stapling of the fundus. Care must be taken not to work too closely to the esophagus.
Once this has been performed, the assistant surgeon uses a babcock through the right lateral port, and grasps the stomach between the second and third vascular arcade, which can be seen clearly. He then lifts and elevates the stomach, so that the surgeon can gain entry to the retrogastric space by using a cautery device. Once a small opening has been created, the assistant then grasps the exposed part of the stomach, so that he everts the stomach to expose the posterior wall. With blunt dissection, and by gently spreading with the soft bowel grasper, the retrogastric space is entered.
The assistant surgeon places the articulated 45 mm yellow TriStaplerTM that will be used throughout the procedure. Make sure that the posterior blade enters the retrogastric space with ease, ensuring no surrounding tissues are present. The stapler is then rotated to the right, ensuring a nice, horizontal staple line and to avoid tapering the pouch. The staple line is inspected by lifting it with the suction tip.
The anesthetist is then asked to advance the gastroscope with the surgeon’s help and guidance until a line can be seen at the staple line. The surgeon then uses a 60-mm stapler through the left clavicular port and gently maneuvers it towards the EG junction. Care must be taken that the posterior blade slides in easily. Stapling too close to the esophagus can result in an hourglass-shaped pouch, and also be associated with a high incidence of leakage. A small piece of untransected fundus still remains. A suction or any suitable instrument is used in the surgeon’s right hand to gain access to the retrogastric space and to create a tunnel. The stapler is then introduced through the left lateral port.
With the pouch now completed, attention is focused on the small bowel. The surgeon lifts the transverse colon and omentum, identifies the ligament of Treitz, then rotates the small bowel, so that the biliary loop is towards the patient’s left-hand side, and the future alimentary loop is on the patient’s right-hand side. A sufficient length of small bowel is moved into the upper epigastrium. Now that we are handling the small bowel, the bowel is grasped completely by the soft bowel grasper to minimise potential damage to the bowel wall. The length of this loop is typically between 30 and 40 cm.
The surgical nurse introduces the babcock through the more lateral left port and grabs the biliary loop. An enterotomy is created closer to the mesenteric side of the alimentary loop. Care must be taken to make sure that the mucosa is open, and the soft bowel grasper is used to maintain the exposure of the enterotomy .
The surgical assistant the pulls the stomach downwards with the babcock while the surgeon creates the gastrostomy. In this case, it is done anterior to the distal staple line, but it can be easily done posteriorly as well. Care must be taken to adequately visualise the mucosal layer of the stomach ensuring that it’s open effectively to avoid creating a false tract.
Next, the surgeon introduces a 45-mm stapler through the midclavicular point with his right hand. The blades are open, the enterotomy entered, and the blades are then closed. The babcock holding the biliary loop is then removed, and the surgeon gently moves the bowel upwards towards the gastric pouch. The reason for the close blades is to minimise small bowel injury. After the blades are closed and fired, the staple line is carefully inspected. The assistant surgeon lifts the pouch so that the posterior staple line can also be visualised.
The enterotomy is closed with a V-lock 2.0. The assistant lifts the gastric pouch to expose the posterior staple line, and the first suture is placed 1 cm under the staple line. The enterotomy is closed in a two-line fashion using standard techniques. The internal layer is completed with a suture 1 cm above the staple line. The needle holder is opened and pushed down onto the bowel, ensuring the correct tension is applied
The alimentary loop is then moved to the patient’s right-hand side. The biliary and alimentary loops are lying in a nice crescent shape, and no twisting or acute angles are created. The endoscope is passed through the anastomosis and down the alimentary loop to ensure that the anastomosis is nice and wide open. The endoscope is then retracted and passed down the biliary loop and left inside to avoid the creation of an O loop.
The patient is now rolled over to her right-hand side the bowel falls away and will not interfere when creating the enteroenterostomy. Once a desired length of the alimentary loop is reached, in this case 220 cm, the assistant surgeon uses a babcock through the right lateral port and grasps the alimentary loop. This grasper crosses right over the small bowel and grasps the mesenterium to avoid injuries of the small bowel.
The assistant surgeon then moves the proximal part of the alimentary loop next to the biliary loop, which is clearly identified by the light of the endoscope inside. The surgeon then creates two enterotomies with the hook cautery, this time at the anti-mesenteric border of both bowel loops. The surgeon now uses his right hand through the left lateral port and introduces the mechanical suture, directing it upwards through both loops of small bowel. The babcock holding the alimentary loop is now removed and the surgeon pulls the small bowel over the blade, and inspects that everything is nicely in position before closing and firing.
A 90-mm enteroenterostomy is now created, and the stapler is opened and retracted. The surgeon grasps the enterotomy from staple line to staple line, lifts it up, and the iDriveⓇ loaded with the 60-mm vascular medium yellow stapler is introduced by the assistant surgeon through the right lateral port. The enterotomy is stapled closed.
The opening at the mesenterium of the biliary loop is created by hook cautery. Traction of the small bowel is accomplished by the surgeon’s right hand. The 60-mm stapler is introduced by the surgeon’s left hand through the left midclavicular port. Once the posterior blade is visible and the staple line is close enough to the stomach remnant the mechanical suture is fired.
The Roux-en-Y gastric bypass is now completed, and all that remains now is to close the mesenteric gap. This is performed by a 2.0 prolene. A knot is tied and the suture is cut al 15mm.
With the surgeon now unscrubbed to perform the gastroscopic evaluation of the gastroenterostomy, at the same time, the assistant surgeon inspects the anastomosis from outside. The purpose of the gastroscopic evaluation is to detect any staple line bleeding and to ensure that there is no leakage.