Today we will focus on explaining the steps to follow when it comes to performing the jejuno – jejunal anastomosis. This is a very important step in the operation and as regards the results of the surgery.
The surgical procedure is carried out laparoscopically. To perform the gastric dissection the patient is placed in the supine position with open legs.
A total of 6 trocars are used. A 12 mm trocar is placed in a supraumbilical position for a 30° scope, three 12-mm serve as working channels for the leading surgeon at the epigastrium and on each flank, a 5-mm trocar is placed in a more lateral position on the left flank, and the last 12-mm trocar at the umbilicus is used during the inframesocolic phase of the by-pass.
At the beginning of surgery the surgeon stands between the legs with one assistant on each side of the patient.
When creating the jejuno-jejunal anastomosis the first thing to do is to change the patient’s position, placing the patient in the Trendelenburg position and left lateral decubitus. The lead surgeon stands on the right side of the patient with the first assistant to his right. The second assistant is located between the patient’s legs.
The scope is located on the right-flank 12 mm trocar. The surgeon works with his right hand on the 12 mm trocar located in the umbilical position and his left hand on the 12 mm trocar located at the epigastrium. The assistant works from the left flank and through the supraumbilical 12 mm trocars.
Once correctly positioned, the next thing to do is measure the distance that to perform the anastomosis. 180 cm of the Roux-limb were distally measured in the bowel from the gastrojejunal anastomosis. We use a 50-cm strip as a reference to measure the bowel.
After locating the anastomosis site, the lead surgeon brings together the two bowel loops. Then the surgeon performs a small enterotomy with the hook at the antimesenteric surface of the alimentary limb. The assistant holds the jejunum through the 12 mm supraumbilical port. A similar enterotomy is performed at the biliopancreatic limb.
To create the intracorporeal anastomosis we use a 60mm Beige EndoGIA™ TriStaple™ that is introduced through the 12mm epigastric port. The alimentary limb is rectified by the simultaneous tension from the leading surgeon and his assistant. This makes it possible to introduce the mechanical suture in the small enterotomy. The assistant surgeon keeps the bowel inside the mechanical suture.
Now the leading surgeon brings together the other branch of the mechanical suture and the biliopancreatic limb enterotomy. The small bowel is grabbed and pulled against the mechanical suture. This maneuver makes it possible to introduce the EndoGIA™ in the intestinal lumen. We always check the orientation of the loop before we fire the mechanical suture.
Then we close the enterotomy to complete the anastomosis. To do this, we use a 3/0 Vicryl running suture. In some cases a 3/0 vicryl stitch may be placed at the other end to improve traction and exposure. The surgeon starts the running suture at the antimesenteric side of the bowel defect.
The running suture is completed towards the inferior angle of the enterotomy. At this stage the assistant grasps the suture with a holder while the surgeon passes the needle through the tissues to maintain the tension and improve exposure while working. This support is provided through the 12-mm trocar placed on the left flank.
Finally the suture is completed by knotting the vicryl suture at the other end.
We recommend always following the same steps and creating a systematic work methodology that yields good results.