Mini-Gastric Bypass Technical Errors, Tips & Pointers The Mistake of the Twisted PouchAnterior Gastro-Jejunostomy (No it is Not A Good Idea!)

1. Mini-Gastric Bypass
Technical Errors, Tips & Pointers
The Mistake of the
Twisted Pouch
Anterior Gastro-Jejunostomy
(No it is Not A Good Idea!)

2. Twisted Pouch
Common Error in “New” Inexperienced MGB Surgeons
Common in RNY surgeons
Low Port sites => Twisted pouch because of poor positioning of First
Staple Firing => Beginning Twist
2nd Common Error is short posterior pouch wall vs long anterior wall
These two errors => Twist so that anterior pouch surface twists 180
degrees
=> Makes an Anterior GJ seem like a good idea; Wrong!

3. Dr Rutledge Advice:
Never Do Anterior GJ
Anterior GJ only “Looks Good” in the twisted MGB gastric Pouch
When the anterior surface “Appears” to be a good location for the GJ
==> Means you have created a twisted Gastric Pouch
Results:
Post Op N&V Short and Long Term Dyspepsia
Stomach Pouch => Untwists => Twisted Bowel Loop

4. Errors in Creating the Gastric Pouch
Correct Pouch
How the MGB Gastric Pouch
Should Lie:
Like a Normal Stomach
Medial = Lesser Curvature
180 Degrees
Lateral = Neo-Greater Curvature

5. Errors in Creating the Gastric Pouch
“TWISTED” Pouch
How the MGB Gastric Pouch ...
Should NOT Lie: WRONG
NOT Like a Normal Stomach
Medial = Lesser Curvature
180 Deg Twist
9 O'clock to 3 o'clock
Lateral = Neo-Greater Curvature
Twist

6. Errors in Creating the Gastric Pouch
“TWISTED” Pouch
How the MGB Gastric Pouch
Should NOT Lie: WRONG
NOT Like a Normal Stomach
Medial = Lesser Curvature
180 Deg Twist
9 O'clock to 3 o'clock
Lateral = Neo-Greater Curvature
Twist

7. Twisted Pouch
Lesser Curvature
Twisted
Now Lies Lateral
Greater Curvature
Twisted
Now lies Medial!

8. Twisted Pouch
Lesser Curvature
Twisted
Now Lies Lateral
Greater Curvature
Twisted
Now lies Medial!
Anterior Anastomosis => Twist
Post Op => Stomach Uncoils
=> Twisted Bowel

9. Clockwise Intra-Op Twist =>
Counter Clockwise Post Op Twist
Stomach Lesser Curve
Medial (Correct = UNTwisted)
Small Bowel Twisted
Medial “Clockwise”
(INCorrect = Twisted)
NOT This way
at the time of surgery

10. Errors in Creating the Gastric Pouch
“TWISTED” Pouch
How the MGB Gastric Pouch
Should NOT Lie: WRONG
NOT Like a Normal Stomach
Medial = Lesser Curvature
180 Deg Twist
9 O'clock to 3 o'clock
Lateral = Neo-Greater Curvature
Twist

11. Doing the MGB Wrong
The Twisted Gastric Pouch
The Neo-Gastric Pouch Should not be twisted
That should be obvious
The lesser curve should lie at 9 o'clock, medially
The Neo-Greater curvature should lie at 3 o'clock, laterally
Twisted (Wrong) pouch makes the anterior GJ “look” like a good
choice

12. The Twisted Gastric Pouch
Often Leads to Post Op Complications
Twisted Gastric Pouch Syndrome:
Post op
Nausea and vomiting
CT-Scana, Endoscopy all negative
“INVISIBLE ILLNESS”
Rx: Revision
Prevention: Simple, Do Not Twist the Pouch &
Never Anterior Anastomosis