Mgb Review Corp 10 (2)

The MGB
Technique and Physiology
Tips and Tricks
MGB: Done Well is a Simple Operation
But: Need to Understand
Anatomy & Physiology =>
Mechanism of Action => Technique

Need for Safety
• Beware of Brave Surgeons
• Need to Understand
1. How to Avoid Trouble
2. How to Get Out of Trouble

MGB Technique
Following Slides...
Just Some of the
Rules of the MGB

MGB Part 1: Creation of the Gastric Pouch
• Creation of the Gastric Pouch (Band/Sleeve/RNY)
• Bougie of size 28 to 36 F can be used to fashion the pouch
• Understanding MGB Anatomy & Physiology
• MGB NOT Obstructive
• No Tight Pouch (The MGB is not a Sleeve)
• Pouch Diameter and Length are Not Critical
• MGB Pouch Size:
• Pouch Diameter = Esophagus;
• Pouch Length = Allow GJ at the greater curve of the stomach
• Start the Gastric Pouch (Long Pouch) at or beyond Crow’s Foot (junction of body and antrum of the stomach.
• Beware a Twist in the Pouch)
• Avoid Bleeding Along Staple Line; (Very Slow Application of Stapler, use compression)
• Management of EG junction; MGB vs Sleeve (DO NOT go near the EG junction)
• Management of the gastric fundus; (Leaving some fundus is acceptable)
• Never dissect the EG junction
• Never attempt to visualize the diaphragmatic cura
• Always stay lateral to the EG junction
• Leaving some of the fundus behind in the MGB is always acceptable
• Reminder: The MGB is NOT a Sleeve, The MGB is NOT a RNY
• Complete division of the stomach in NOT critical in the MGB

Management of Hiatal Hernia in
Patients WITH or WITHOUT GERD
• Do Nothing!!
• Do Not Dissect the Hiatus,
• Do Not Repair the Crua.
•Reminder the MGB is not a sleeve.
•In cases of a large hiatal hernia
•Reduce the stomach into the abdomen and
•Complete the usual MGB pouch.
•MGB leads to greater than 85% resolution of GERD (Rutledge),
•further treatment is rarely needed
•Additional procedure can be performed in 12-18 months when the
patient is healthier and smaller if necessary (RareNever needed).

Bilio-Pancreatic Bypass
•Never Divide the omentum;
•Retract the omentum medially
•Run the small bowel hand over hand with atraumatic bowel clamps
•Estimate distance of each hand to hand movement
•Estimate Measure the length of the bowel;
•Understand that accurately measuring the bowel length is a “FOOL’S ERRAND”
•Understand that bowel length varies moment to moment, hour to hour and day to day.
•Understand that any and ALL bowel length measurements are inherently imprecise
and thus weight loss is as unpredictable with MGB as with Band, Sleeve and RNY.
•Because of lack of precision always be conservative in creating the bilio-pancreatic
limb.
•Warning the MGB can be the most powerful form of Bariatric Surgery
•Measure the length of the grasper tip (usually between 1.5 and 3 cm)
•Run the bowel length approximately 60 steps of 3 cm (1.2 inches) =>
•Creating Bilio-pancreatic limb length of 180 cm

Bilio-Pancreatic Limb
Length
•Recognize risk of long Bilio-Pancreatic Limb Length and Excess Weight
Loss/Malnutrition
•Understand management of Excess Weight Loss (Rapid 30-60 min Revision)
•Recommendations to MGB Surgeons with
•MGB Experience of Less Than 250 Cases
•MI 30-60 180 cm (count 60 3 cm/1.2 inch steps)
•BMI 60-80 200-250 cm (65-80 3 cm/1.2 inch steps)
•Elderly (Age > 60) Decrease limb length by 20%
•Vegetarians Decrease limb length by 20%
•Frail/Fragile patient Decrease limb length by 20%
•First 200 MGB’s (New MGB surgeon) Decrease limb length by 20%

Gastro-Jejunostomy
• Possibly the most IMPORTANT step in MGB
• After Identifying the Site for the GJ Move Loop to left upper quadrant
• Confirm at least 1-2 meters more distal bowel
• (It is unnecessary to run the entire small bowel)
• Carefully expose tip of gastric pouch; Make sure it is not twisted
• Create gastrotomy ANTERIOR to the staple line 1 cm from first staples at the start of the pouch
• Create jejunotomy on anti-mesenteric border at 180 cm Bilio-pancreatic limb
• Dilate the jejunotomy with the Anvil of the 60-mm blue staple cartridge
• then remove the anvil and place the staple cartridge into the bowel
• Thread the bowel all the way onto the cartridge
• Grasp the gastric pouch at the gastrotomy and advance the anvil into the gastrotomy
• Now stop
• The surgery is almost over; Take your time
• Critical Factors in Gastro-Jejunostomy
• Several features in positioning the staple cartridge, the gastric pouch and the bowel must be exactly
aligned for a successful surgery. Simply proceeding slowly and carefully will result in a good
outcome.

Gastro-Jejunostomy
• Critical Factors:
• Both the gastric pouch and the bowel edges must meet at exactly the junction of the cartridge and the anvil of the staple gun
• No twist in either the bowel or the gastric pouch
• Large visible area of bowel anteriorly (should not be too close to the bowel mesentary)
• Gastric pouch staple line should NOT cross the staple cartridge/anvil longitudinally (keep the gastric pouch staple line out of the jaws
of the stapler and several millimeters away from the anastomosis)
• There should be visible space on the posterior gastric wall between the lateral gastric staple line and the staple cartridge and anvil
(avoid ischemic island)
• Take time No tension on the bowel
• Gastric mesentary not in the staple line
• Carefully and slowly evaluate the placement of the gastric pouch, the bowel and the staple gun
• Do not proceed until each is perfectly placed
• Then close the stapler and begin a very very slow firing of the staple gun, use compression to avoid bleeding.
• Using extra time Slowly is the watchword
• This staple line MUST NOT BLEED
• This achieved simply by the surgeon’s patience and direct pressure
• The stapled GJ is completed and the stapler removed
• Now the GJ should lie perfectly with the sweep of the bowel from the patient’s left to right and the GJ located at the level of the greater
curvature of the stomach or the transverse colon.
• If it is not perfect do not proceed but stop and consider dividing the GJ and performing another GJ 10-15 cm distal to the failed
anastomosis.
• Do not leave an imperfect GJ.

Gastro-Jejunostomy
Closeure
•All that is left is a minor closure of a 1-2 cm defect of the GJ.
•The Diameter of the Gastro-Jejunostomy in the MGB (Large)
•A few comments stapled or hand sewn closure is acceptable but do not forget 100
years of GI and general surgery science and experience.
•One or two layers NEVER MORE.
•The anastomosis heals by diffusion of oxygen blood cells into the spaces between the
sutures. This means there must me 1-3 mm between sutures and the suture should
NOT strangulate the tissue.
•Leak Testing
•For the first 150 cases test the anastomosis with air and methylene blue for
demonstration of technical errors. After the first 150 cases if the surgeons still finds
leaks with air or methylene blue he/she should consider retraining for laparoscopic
surgey with another more experienced surgeon.
•End of Operation
•Do not inject Marcaine in the Port Sites (It does not help post op pain)
•Inspect the Gastro-jejunostomy, the gastric pouch and the EG junction
•No Drains

And More...
•Post Op
•Post Op Orders
•Discharge Instructions
•MGB Diet
•Supplements
•Follow Up
•Follow Up Blood Tests
•Dx Leak Protocol
•Rx Leak Protocol

https://mgbguidelines.wordpress.com/gastric-pouch-creation/
Mini-Gastric Bypass
Done Right!
Dr. Rutledge
(702) 483-7133
Email DrR@clos.net

Mini-Gastric Bypass
(Note: This Not
Single Anastomosis Bypass,
the “Omega Loop” or the SAGB or the
SADI
or the Old Mason Loop Gastric Bypass!)
Dr. Rutledge
702-714-0011
Email DrR@clos.net

Mini-Gastric Bypass
Tragic/Deadly in the
Wrong Hands

Mini-Gastric Bypass
Tragic/Deadly in the
Wrong Hands
The MGB
Done WRONG!

Mini-Gastric Bypass
Simple, Safe, Effective
Tailored, Reversable
The MGB
Done RIGHT!

•
Mini-Gastric Bypass
• Anyone can do a
“single anastomosis bypass”
• That Does Not make it a true
“Mini-Gastric Bypass”
• See the Following Examples...

Recent Publications
Unequivocally Demonstrate:
Poor Understanding of the MGB
=> Bad Outcomes

Misunderstanding of the MGB Surgery
Death and Complications to MGB patients
MGB Center/Surgeon of Excellence Program
Why, What is the Need:
=> 20 Years of Documented MGB Excellence
And
=> 20 Years of Documented
Misunderstanding of the MGB
including Death and Complications to MGB
patients
in the Hands of “Non-Expert” MGB Surgeons

Int J Surg. 2016 Sep
Sleeve gastrectomy vs Mini gastric bypass
Misunderstanding & Complications:
CONCLUSION:
“MGB seems to have better weight loss at one year
compared to LSG with
“ MGB higher gastric complications. (??)”
(No other study has reported stricture at the GJ
anastomosis of such high rates)

Tragic Report of "Omega-Loop" Bypass with
100% Excess Weight Loss Resulting in Liver
Failure and Death...

A Tragic Report of "Omega-Loop" Bypass with 100% Excess
Weight Loss Resulting in Liver Failure and Death...
Need for Standardization, Education and Recognition prevent
more harm
CONCLUSION:
“MGB seems to have better weight loss at one year
compared to LSG with
“ MGB higher gastric complications. (??)”
(No other study has reported stricture at the GJ
anastomosis of such high rates)

Int J Surg. 2016 Sep
Sleeve gastrectomy vs Mini gastric bypass
At one year MGB >> Sleeve,
%TWL 38 ± 8 vs. 34 ± 8 (P < 0.0001)
BMI Decrease: -17 ± 5 vs. -15 ± 4 (P = 0.005)
But
** Rate of stenosis higher for MGB group,
** 16.9% vs.
** 0% in Sleeve Patients (P < 0.0001).

The Mini-Gastric Bypass:
Standardization, Education & Recognition
Why, What is the Need:
=> 20 Years of Documented MGB Excellence
And
=> 20 Years of Documented
Misunderstanding of the MGB
including Death and Complications to MGB
patients
in the Hands of “Non-Expert” MGB Surgeons

The MGB Certificates of Excellence:
Recognition
=> Certified MGB Certificates Recognized
Facebook
Web page
Twitter
Youtube
Dr Rutleddge and
Members of the MGB Board of Governors
OVER 100,00 Followers
 JOIN US

The MGB Certificates of Excellence:
Standardization
=> Expert Group => MGB Guidelines
Education
=> Teaching and Certification
 Knowledge: Bronze Certificate
 Technical Skill: Silver Certificate
 Outcomes: Gold Certificate
 Teacher: Platinum Certificate

Death: 8 months after MGB
Diagnosis & Management?
29 y.o. female 8 months after MGB
Hypoalbuminemia, anemia, elevated liver
enzymes and direct bilirubinemia,
metabolic acidosis and Steatohepatitis
What to Do!
Patient did not respond to Medical Rx and
DEATH.
Do you know what to do?
Int J Surg Case Rep. 2017

Malnutrition: Death 8 months after MGB
29yr F, 8 months after MGB:
=> Low albumin & Hgb,
High LFTs & Bilirubin,
Acidosis & Steatohepatitis
=> Diagnosis? Simple:
Bypass is Too LONG
Liver Failure,
Malnutrition/Deficiency(s)

Malnutrition: Death 8 months after MGB
29yr F, 8 months after MGB:
=> Diagnosis? Simple: Bypass is Too LONG
Liver Failure, Malnutrition/Deficiency(s)
=> What to Do?
Preop Education/Planning
Resuscitation,
Nutritional Support,
Early, Simple 30-60 min Revision

JPEN J Parenter Enteral Nutr. 2017
"Nutrition Deficiencies in Mini Gastric Bypass
Patients: Where Do We Stand Today?"
Bétry C, Disse E, Chambrier C, Laville M, Robert M.
Do You Know What to Do?
JPEN J Parenter Enteral Nutr. 2017
Nutrition Deficiencies in Mini Gastric Bypass Patients.
Athanasiou A, Markakis C, Spartalis E.

Surg Obes Relat Dis. 2016
Conversion of
OAGB/MGB to Roux-en-Y for
Bile reflux gastritis after failed
Braun jejunojejunostomy.
Nimeri A
Do You Know What to Do?

A Comparison of SADI Patients
Single anastomosis sleeve ileal (SASI) bypass
Int J Surg. 2016 Efficacy of single anastomosis
sleeve ileal (SASI) bypass for type-2 diabetic
morbid obese patients, Mahdy T1
10% postoperative complications. Pulmonary
embolism, Postoperative bleeding, Leak & one
complete obstruction at the gastro-ileal
anastomosis.
6 months postoperative, Marginal ulcer,
12 months after surgery, another patient (2%) was
re-operated for excessive weight loss.

•
No No No
This is NOT an Mini-Gastric
Bypass
Available from Bariatric Surgery Website !?!!

•
Edward E. Mason, MD, PhD
NOT a Mini-Gastric Bypass
This NOT
Mini-Gastric
Bypass

Dr Rutledge's Advice
MGB Technique
• If You Do Not Understand the Basic
General Surgery Principles
• My advice will not appear justified
• Expertise from Band, Sleeve, RNY
& BPD/Sadi
• Often do not apply to the Anatomy
& Physiology of the MGB
• Reminders of Basic GI Surgery the
MGB

The Mini-Gastric Bypass
• Of course anyone is entitled to
perform any surgery they see fit
• But some surgeons have performed
an operation that they claim is a
“Mini-Gastric Bypass”
• Do not understand the
Anatomy & Physiology of the
• Basic GI Surgery the MGB and
Failed Mason Loop Gastric Bypass

Do Not Understand Appropriate use Billroth II
• Some surgeons Do not understand Basic
General Surgical Principles
• Appropriate use Billroth II
• Yes => Antrectomy & Billroth II
• No => Total/Subtotal Gastrectomy & Billroth II
• Need to Understand Why
• Anatomy & Physiology of proper use of Billroth
II
• i.e. Failed Mason Loop Gastric Bypass

Confusion
by Surgeons, Authors,
Reviewers and Editors
An Example of
Misunderstanding the MGB

•
Recent Case Report
Obes Surg Feb 2016
• Revision of
OAGB/MGB
• 2 months Post OP
• SEVERE Bile Reflux
Esophagitis
• Surgery 2 inch Pouch!!
• No mention in text Short
Pouch

•
Do Not Understand Failed Mason Loop vs
MGB
• Critics of MGB as well as certain
surgeons performing what they call
“MGB?”
• Do not understand the
Anatomy & Physiology of the MGB
• Difference between MGB and the
Failed Mason Loop Gastric Bypass
• Have not learned the lessons of General
surgery and when and to use Billroth II

•
Surgeons Must Differentiate
Old Mason Loop vs MGB?
Gastro-
Jejunostomy
Level
of EG
Junction

•
MGB Gastro-Jejunostomy
at the Level of the Transverse
Colon
Bowel Loop
Gastro-
Jejunostomy
Gastric Pouch
Level of the Transverse
Colon

•
Error Example:
Bird's Beak Defect
Short Pouch
Bird's Beak Defect
Level
of EG
Junction
Gastro-
Jejunostomy

•
Wrong
This is Not an MGB!
Short Pouch
Old Mason Loop Bypass Error!

•
Mini-Gastric Bypass
Done Right
LONG Gastric Pouch

•
Surgeons Need to Understand
Basics of Gastric General Surgery
• Misunderstanding Basics
of Gastric General Surgery
• Proper vs Improper use of
Billroth II
• Difference between
Total/Subtotal Gastrectomy
Vs.
Distal Gastrectomy/Antrectomy

•
Gastric Anatomy
Distal Gastrectomy/Antrectomy
• Understand Anatomy
• Esophagus
• Body
• Antrum
• Antrectomy + Billroth
II = Routine General
Surgery

•
Distal Gastrectomy + Billroth II
= Routine General Surgery
Level
of EG
Junction
Gastro-
Jejunostomy

•
MGB = Antrectomy w Billroth II
Routine General Surgery!

•
Level
of EG
Junction
Gastro-
Jejunostomy

•
Basic General Surgery:
Never Reconstruct with Loop Billroth II
Only RNY

•
Mason Loop
Violation of Basic General Surgery
• Basic General Surgery
• Total/Subtotal
Gastrectomy NEVER
Reconstruct w Loop!
• Mason Loop Bypass
Reconstruct w Loop
• Thus Mason Loop =>
Failure
• Violation of Basic
General Surgical
Principles

•
Mason Loop
Violation of Basic General Surgery
• Mason Loop Bypass
Reconstruct w Loop
• Thus Mason Loop
=> Failure
• Violation of Basic
General Surgical
Principles

•
•Basic General Surgery
•NEVER Reconstruct
w Billroth II
w Billroth II
w Billroth II

•
Understanding of
Proper Use of Billroth II
• Billroth II
• NEVER use BII after
Total/Subtotal
Gastrectomy
• Distal Gastrectomy or
Antrectomy
= Proper use of
Billroth II

•
MGB Gastric Pouch
• Mini-Gastric Bypass:
Shown to be an excellent operation
• But Many Critics/New Surgeons Do
Not Understand MGB or Proper use
of Billroth II
• One Critical Success Factor:
• LONG Gastric Pouch

•
MGB Gastric Pouch
• General Surgery:
• Acceptable:
Antrectomy/Distal
Gastrectomy
+ Billroth II Loop
• Never Acceptable:
+ Billroth II Loop

•
MGB Gastric Pouch
• Acceptable:
Antrectomy/Distal
Gastrectomy
+ Billroth II Loop
• Not Acceptable
Total/Subtotal
Gastrectomy
+ Billroth II Loop

•
Another Tragedy of A
“Claimed” MGB of Vienna
IBC
• Patient Presentation
• “Leak after MGB”
• 2 inch GASTRIC POUCH!
• Not an MGB!
• Single Anastomosis = Yes
• Omega Loop = Yes

•
MGB Pouch
• EG Junction
• Pouch from
EGJ to Antrum
• Crow's Foot
• Antrum

•
Critical Success Factors
Creation of the MGB
Gastric Pouch
https://mgbguidelines.wordpress.com/gastric-pouch-
creation/

•
End
•But there are a few
more....
•Tips, Tricks
•and
•Traps

The MGB
The Gastric Pouch

MGB Gastric Pouch Length
Pouch Volume
• How Long is the MGB
Pouch?
• Wrong Question
Not in Centimeters
• Answer: From
EG Junction to Beyond the
Crow's Foot into the
Antrum
• The MGB Gastro-
Jejunostomy should lie at
the level of the Transverse
Colon

•
Creation of the MGB Pouch
• Creation of the Gastric Pouch
(Band/Sleeve/RNY)
• Bougie of size 28 to 36 F can be used to
fashion the pouch
• Understanding MGB Anatomy & Physiology
• MGB NOT Obstructive
• No Tight Pouch (The MGB is not a Sleeve)
• Pouch Diameter and Length are Not Critical
• MGB Pouch Size:

•
• “I have often said creation of the
gastric pouch in the MGB is
simple,
but it is surprising how many
ways you can screw it up”
• Dr Rutledge

•
• Creation of the Gastric Pouch
(Band/Sleeve/RNY)
• Creation of the MGB gastric pouch
should be Simple
• but there are several differences
between the MGB pouch and the
• Gastric pouch created in the Sleeve,
RNY and the dissection recommended
for the Lap Band

•
• Never attempt to visualize the diaphragmatic cura
• Always stay lateral to the EG junction
• Leaving some of the fundus behind in the MGB is
always acceptable
• Reminder: The MGB is NOT a Sleeve, The MGB is
NOT a RNY
• Complete division of the stomach in NOT critical in the
MGB

•
MGB: Gastric Pouch
• MGB Pouch Size:
• Pouch Length = Allow GJ at the greater curve
of the stomach
• Start the Gastric Pouch (Long Pouch) at or
beyond Crow’s Foot (junction of body and
antrum of the stomach.

•
MGB: Gastric Pouch
• Beware a Twist in the Pouch
• Avoid Bleeding Along Staple Line; (Very Slow
Application of Stapler, use compression)
• Management of EG junction; MGB vs Sleeve
(DO NOT go near the EG junction)
• Management of the gastric fundus; (Leaving
some fundus is acceptable)

•
Management of Hiatal
Hernia
• Patients WITH or WITHOUT GERD
• In MGB; On finding Hiatal Hernia;
• Do Nothing!!
Do Not Dissect the Hiatus,
Do Not Repair the Crua.
• Reminder the MGB is not a sleeve.
• In cases of a large hiatal hernia...

•
Management of Hiatal
Hernia
• In cases of a large hiatal hernia
• Reduce the stomach into the abdomen and
• Complete the usual MGB pouch.
• MGB leads to greater than 85% resolution of
GERD (Rutledge),
• Further treatment is rarely needed
• Additional procedure can be performed in 12-18
months when the patient is healthier and smaller if
necessary (RareNever needed).

The MGB
•The Biliopancreatic Limb

•
Bilio-Pancreatic Bypass 1
• Never Divide the omentum;
• Retract the omentum medially
• Run the small bowel hand over hand with
atraumatic bowel clamps
• Estimate distance of each hand to hand
movement
• Estimate Measure the length of the bowel;

•
• Understand that accurately measuring the
bowel length is a “FOOL’S ERRAND”
• Understand that bowel length varies moment
to moment, hour to hour and day to day.
• Understand that any and ALL bowel length
measurements are inherently imprecise and
thus weight loss is as unpredictable with MGB
as with Band, Sleeve and RNY.
• Because of lack of precision always be
conservative in creating the bilio-pancreatic
limb.

•
• Warning the MGB can be the most powerful
form of Bariatric Surgery
• Measure the length of the grasper tip (usually
between 1.5 and 3 cm)
• Run the bowel length approximately 60 steps
of 3 cm (1.2 inches) =>
• Creating Bilio-pancreatic limb length of 180
cm

•
Bilio-Pancreatic Limb
Length
• Create gastrotomy ANTERIOR to the staple
line 1 cm from first staples at the start of the
pouch
• Create jejunotomy on anti-mesenteric border
at 180 cm Bilio-pancreatic limb
• Dilate the jejunotomy with the Anvil of the 60-
mm blue staple cartridge
• then remove the anvil and place the staple
cartridge into the bowel
• Thread the bowel all the way onto the
cartridge

The MGB
•The GastroJejunostomy

•
Gastro-Jejunostomy 1
• Gastro-Jejunostomy
• Possibly the most IMPORTANT step in
MGB
• After Identifying the Site for the GJ Move
Loop to left upper quadrant
• Confirm at least 1-2 meters more distal
bowel
• (It is unnecessary to run the entire small
bowel)
• Carefully expose tip of gastric pouch; Make
sure it is not twisted

•
Gastro-Jejunostomy 1b
• Create gastrotomy ANTERIOR to the staple
line 1 cm from first staples at the start of
the pouch
• Create jejunotomy on anti-mesenteric
border at 150-200 cm Bilio-pancreatic limb
• Dilate the jejunotomy with the Anvil of the
60-mm blue staple cartridge
• then remove the anvil and place the staple
cartridge into the bowel
• Thread the bowel all the way onto the
cartridge

•
Gastro-Jejunostomy 2a
• Grasp the gastric pouch at the gastrotomy and
advance the anvil into the gastrotomy
• Now stop
• The surgery is almost over; Take your time
• Critical Factors in Gastro-Jejunostomy
• Several features in positioning the staple
cartridge, the gastric pouch and the bowel
must be exactly aligned for a successful
surgery. Simply proceeding slowly and
carefully will result in a good outcome.

•
Gastro-Jejunostomy 2b
• Critical Factors:
• Both the gastric pouch and the bowel edges
must meet at exactly the junction of the
cartridge and the anvil of the staple gun
• No twist in either the bowel or the gastric
pouch
• Large visible area of bowel anteriorly (should

•
Gastro-Jejunostomy 2c
• Gastric pouch staple line should NOT cross
the staple cartridge/anvil longitudinally (keep
the gastric pouch staple line out of the jaws of
the stapler and several millimeters away from
the anastomosis)
• There should be visible space on the posterior
gastric wall between the lateral gastric staple
line and the staple cartridge and anvil (avoid
ischemic island)
• Take time No tension on the bowel

•
Gastro-Jejunostomy
• Gastric mesentary not in the staple line
• Carefully and slowly evaluate the placement of
the gastric pouch, the bowel and the staple
gun
• Do not proceed until each is perfectly placed
• Then close the stapler and begin a very very
slow firing of the staple gun, use compression
to avoid bleeding.
• Using extra time Slowly is the watchword

•
Gastro-Jejunostomy
• This achieved simply by the surgeon’s
patience and direct pressure
• The stapled GJ is completed and the stapler
removed
• Now the GJ should lie perfectly with the sweep
of the bowel from the patient’s left to right and
the GJ located at the level of the greater
curvature of the stomach or the transverse
colon.

•
Gastro-Jejunostomy
• If it is not perfect
do not proceed but
stop and consider dividing the GJ and
performing another GJ
10-15 cm distal to the failed anastomosis.
• Do not leave an imperfect GJ.

•
Gastro-Jejunostomy
Closeure
• All that is left is a minor closure of a 1-2 cm defect of
the GJ.
• The Diameter of the Gastro-Jejunostomy in the MGB
(Large)
• A few comments stapled or hand sewn closure is
acceptable but do not forget 100 years of GI and
general surgery science and experience.
• One or two layers NEVER MORE.

•
Gastro-Jejunostomy
Closeure
• The anastomosis heals by diffusion of oxygen
blood cells into the spaces between the
sutures.
• This means there must me 1-3 mm between
sutures and the suture should NOT
strangulate the tissue.

•
Gastro-Jejunostomy
Closeure
• Leak Testing
• For the first 150 cases test the anastomosis
with air and methylene blue for demonstration
of technical errors. After the first 150 cases if
the surgeons still finds leaks with air or
methylene blue he/she should consider
retraining for laparoscopic surgey with another
more experienced surgeon.
• End of Operation

•
MGB
Tips and Tricks
• Youtube.com Videos
• http://www.youtube.com
/watch?v=1B45TUAimJE
• Technique of Mini-Gastric
Bypass; Tips and Tricks

•
Conclusions
• Mini-Gastric Bypass
Shown to be an excellent
operation
• But Many New Surgeons Do
Not Know the Critical Factors
to Do the MGB Correctly
• One Critical Success Factor:
• LONG Gastric Pouch

Mgb Review Corp 10 (2)

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