1. The document describes the mini-gastric bypass (MGB) procedure performed by Dr. Rutledge. 2. The MGB involves creating a gastric pouch through antrectomy and gastrojejunostomy, similar to standard general surgery procedures. A Collis gastroplasty is also performed to create a non-obstructive gastric tube. 3. Dr. Rutledge's results from over 6,000 MGB patients over 20 years show very low complication rates, short operative and hospital times, and durable weight loss and diabetes resolution for over 15 years. The MGB can be tailored for different patients and is reversible.

1. A Few of the
Fine Points and Tips
Mini-Gastric Bypass
Dr Rutledge
Email: DrR@clos.net

2. Mini-Gastric Bypass
Operative Procedure
1. “Standard Gen Surgery”
Antrectomy & Gastro-jejunostomy
2. Collis Gastroplasty
Non Obstructive Restriction
3. Antecolic Billroth II Loop
Gastro jejunostomy
Tailor Bypass to Patient

3. Mini-Gastric Bypass
• Simple
• Elegant
• Effective
• Durable > 15 yrs
• Powerful
• Tailored to Patient
• Reversible
• Revisable

4. Lets Do MGB
Easy 30 minute Case

5. Dissection Lesser Curve
at or just below Crow's Foot

6. Staple Perpendicular to the
Lesser Curve

7. Perpendicular to Lesser
Curve, Base of the Pouch

8. NOT a Sleeve Pouch
Wide Base

10. 1. Avoid EG Junction
2. Cobra Head Distal Tip

11. NO
YES
Anterior Gastrotomy

13. Avoid EG Junction
Tips Re: Gastro-Jejunostomy

14. Stapled Anastomosis

15. Staple vs Suture (1-2 layer)
Everted Anastomosis

16. Mini-Gastric Bypass
• Simple
• Elegant
• Effective
• Durable > 15 yrs
• Powerful
• Tailored to Patient
• Reversible
• Revisable

17. DrR MGB Presentation
Part 1: Introduction, History of MGB;
Slides 2-11
Part 2: Confusion;
MGB = Standard General Surgery,
Slides 12-30
Part 3: Confusion;
Mechanism of Action
Slides 31-42
Part 4: MGB Surgical Technique
Slides 43-76

18. Part 1: Introduction,
History of MGB

19. History of MGB & Dr Rutledge
• Dr Rutledge Trauma Surgeon Professor of
Surgery 20 years Univ of North Carolina
• 1997 Patient: Illegal Drug Dealer
• Gun Shot Wounds X 6 to Abdomen
• 9 pm Thurs Night Sept 1997 Emergency
Surgery
• Injury to Stomach, Tail of Pancreas and
Multiple Loops of Small Bowel

20. History of MGB
Patient w Gun Shot Wounds 1997
• Injury to
Stomach, Pancreas
and Multiple Loops of
Small Bowel
• Rx
Distal Gastrectomy
• Distal Pancreatectomy
• Splenectomy

21. History of MGB
RX: Antrectomy, Distal Pancreatectomy Splenectomy

22. History of MGB
Reconstruction Ante-Colic Billroth II

23. 1997 Next Morning Planned Lap RNY
MGB = Standard General Surgery
(MGB => Antrectomy & Billroth II)

24. For 20 years American Surgeons Cannot
Understand This Simple Fact
MGB = Standard General Surgery
(MGB => Antrectomy & Billroth II)

25. 20 Years Later
Surgeons Still Misunderstand
the MGB
• The MGB is NOT a RNY
with One Less Anastomosis

26. MGB = Billroth II,
Billroth II is GOOD
General Surgeons Know How to
Use the Billroth II
Many Bariatric Surgeons are
Uninformed and Fear the Billroth II

27. 20 Years FEAR of MGB?
Mason Loop *NOT* MGB
Billroth II Loop Gastro-Jejunostomy
WRONG RIGHT

28. History of MGB
Mason Loop VIOLATED Rule General Surgery
Billroth II Loop: Antrum: YES, EGJx: NO,
NEVER

29. The Billroth II is a Good Operation
When Used Wisely!
• Well Informed
General
Surgeons
=>
Routinely Use
the Billroth II
• Uninformed
Bariatric
Surgeons
=>
Fear the
Billroth II

30. MGB: Easy / Not Easy
Restriction via Post Gastrectomy Syndrome
• Basic General Surgery
• 1. Collis Gastroplasty
NON-Obstructive Gastric Tube
NOT Sleeve, Not Roux type Pouch
• 2. Antrectomy & Billroth II
NON-Obstructive Gastro-Jejunostomy
MODERATE Bypass
• Should be Simple
But...

31. MGB
Knowledge = Technique
1. If You Do Not Understand the
Mechanism of Action and the Anatomy
(Knowledge)
2. Then
You Will NOT Know How to Do the
Surgery (Technique)

32. Confusion Re: MGB
• MGB is NOT
Old Mason Loop
Violates Basic General
Surgery
• MGB is NOT
Like RNY or Sleeve
Obstruction From
Small or Narrow Pouch

33. Confusion Re: MGB
• MGB is NOT Primarily Malabsorptive
Forgetting Basic General Surgery (2 m bypass)
• MGB NOT Like Jejuno-ileal Bypass, BPD, SADI
Massive Gut Bypass
• Misunderstanding Mechanism of Action
MGB *IS*
=> Restriction WITHOUT Obstruction
=> Post Gastrectomy Syndrome
=> Good Dumping / Bad Dumping
=> ** Not ** Band / Sleeve / RNY

34. MGB:
Easy:
ifYou Know What You are Doing
Disaster in the
Wrong Hands

35. All the Details for Doing a
Good MGB...
1. If You Do Not Understand the
Mechanism of Action and the
Anatomy (Knowledge)
2. Then
You Will NOT Know How to Do the
Surgery (Technique)

36. MGB
Surgical Technique
in Brief

37. 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

38. 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).

39. Part 2: 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

40. 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%

41. 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.

42. 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.

43. Gastro-Jejunostomy Closure
• 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 surgery 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

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

45. Obviously
I Cannot Teach All of
These Things in One
Lecture

46. Objectives
1. History of DrRutledge & MGB
(It's Just General Surgery)
2. MGB = Billroth II, Billroth II is GOOD
3. MGB = General Surgery, How to
4. The Future of Bariatric (Metabolic) Surgery
5. Diabetes Epidemic
6. The Mini-Gastric Bypass can be Tailored;
Useful for all types of patients
Especially * thin * Diabetics

47. FIRST
Dr Rutledge's
Remarkable
MGB Results

48. Dr Rutledge's Results
Mini-Gastric Bypass
• In 6,000+ patients
• Over almost 20 years
• < 5% complications
• Mean 36 minute op time
• Median 1 day hospital stay
• 10-15 year follow up
(Talk to 10+ Year MGB Patients on Facebook)
• Controlled prospective trials
(** 2X better than Sleeve **)
• Reversible and Revisable < 30 minutes

49. Dr Rutledge's Results
Confirmed in Every Published Series
• MGB: Tailored to Fit the Patient & Surgeon
• Very High levels of patient satisfaction
• General Surgery Data & Controlled Trial:
MGB Twice as effective as Sleeve
Rx Diabetes
• Resolution Diabetes 85%-90%+
• Decreased Hunger, Chol, BP, cRP,
Enforced Mediterranean Diet
• Easily Reversible Revisable ...

50. Mini-Gastric Bypass
Operative Procedure
1. “Standard Gen Surgery”
Antrectomy & Gastro-jejunostomy
2. Collis Gastroplasty
Non Obstructive Restriction
3. Antecolic Billroth II Loop
Gastro jejunostomy
Tailor Bypass to Patient

51. Mini-Gastric Bypass
• Simple
• Elegant
• Effective
• Durable > 15 yrs
• Powerful
• Tailored to Patient
• Reversible
• Revisable

52. Lets Do MGB
Easy 30 minute Case

53. Dissection Lesser Curve
at or just below Crow's Foot

54. Staple Perpendicular to the
Lesser Curve

55. Perpendicular to Lesser
Curve, Base of the Pouch

56. NOT a Sleeve Pouch
Wide Base

58. 1. Avoid EG Junction
2. Cobra Head Distal Tip

59. NO
YES
Anterior Gastrotomy

61. Avoid EG Junction
Tips Re: Gastro-Jejunostomy

62. Stapled Anastomosis

63. Staple vs Suture (1-2 layer)
Everted Anastomosis

64. Mini-Gastric Bypass
• Simple
• Elegant
• Effective
• Durable > 15 yrs
• Powerful
• Tailored to Patient
• Reversible
• Revisable

65. Ideal Candidates for MGB
EVERYONE? ;-)
•MGB Can Be Tailored to Meet All Needs
•Usual Bariatric Patient (+/- Diabetes)
•Super Obese
•GERD Patient
•“Difficult” Patient
•Borderline Patient
•FUTURE PATIENTS? Non-obese
Diabetics

66. The End
Finito