Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Laparoscopic Roux En-Y-Gastric Bypass: One Surgeon's Technique

3,424 views

Published on

Published in: Health & Medicine
  • Be the first to comment

Laparoscopic Roux En-Y-Gastric Bypass: One Surgeon's Technique

  1. 1. Laparoscopic Roux-en-Y Gastric Bypass: One Surgeon’s Technique George S. Ferzli MD, FACS New York, NY
  2. 2. Dr. John Linner 1954 Jejuno-ileal bypass THE BEGINNING
  3. 3. COMPLICATIONS OF JEJUNOILEAL BYPASS <ul><li>Electrolyte disturbances </li></ul><ul><li>Osteoporosis/osteomalacia </li></ul><ul><li>Protein malnutrition </li></ul><ul><li>Cholelithiasis </li></ul><ul><li>Diarrhea </li></ul><ul><li>Hair loss </li></ul><ul><li>Arthritis </li></ul><ul><li>Liver failure </li></ul><ul><li>Steatosis </li></ul><ul><li>Renal calculi </li></ul><ul><li>Neuropathy </li></ul><ul><li>Anemia </li></ul>
  4. 4. Dr. Edward Mason University of Iowa 1967 Gastric Bypass with loop gastroenterostomy
  5. 5. GASTRIC BYPASS WITH ROUX-en-Y LIMB Roux-en-Y Gastric Bypass 50 mL POUCH WITH A ROUX LIMB TO MINIMIZE BILE REFLUX COMBINED RESTRICTIVE AND MALABSORPTIVE
  6. 6. GASTRIC BYPASS WITH ROUX-en-Y LIMB Roux-en-Y Gastric Bypass SUBSEQUENTLY MODIFIED 50 mL POUCH WITH A ROUX LIMB TO MINIMIZE BILE REFLUX ROUX LIMB WAS LENGTHENED TO INCREASE MALABSORPTION AND IMPROVE WEIGHT LOSS COMBINED RESTRICTIVE AND MALABSORPTIVE
  7. 7. ROUX-en-Y GASTRIC BYPASS <ul><li>GOAL: To restrict the </li></ul><ul><li>gastric reservoir </li></ul><ul><li>ADVANTAGES </li></ul><ul><li>Controls food intake </li></ul><ul><li>Dumping reduces intake of sweets </li></ul><ul><li>Reversible if indicated </li></ul>Roux-en-Y Gastric Bypass
  8. 9. Roux-en-Y Gastric Bypass: Operative Options <ul><li>Retro-colic/Retro-gastric gastrojejunostomy </li></ul><ul><li>Ante-colic/Ante-gastric gastrojejunostomy </li></ul><ul><li>Stapled gastrojejunostomy </li></ul><ul><li>Hand-sewn gastrojejunostomy </li></ul>
  9. 10. Roux-en-Y Gastric Bypass: Our Technique <ul><li>Identify LOT </li></ul><ul><li>Divide jejunum </li></ul><ul><li>Measure Roux limb </li></ul><ul><li>Complete jejuno-jejunostomy, close mesentery </li></ul><ul><li>Create gastric pouch </li></ul><ul><li>Ante-colic/Ante-gastric gastrojejunostomy </li></ul><ul><li>Leak test </li></ul>
  10. 11. Roux-en-Y Gastric Bypass: Port Positioning <ul><li>Approximate position for ports marked with abdomen insufflated </li></ul>
  11. 12. Roux-en-Y Gastric Bypass: Identify LOT <ul><li>Retract omentum and transverse colon cephalad </li></ul><ul><li>LOT exposed </li></ul>
  12. 13. Roux-en-Y Gastric Bypass: Distance to Jejunal division <ul><li>Approx. 50-60cm from LOT </li></ul><ul><li>Assure that this </li></ul><ul><li>reaches liver edge </li></ul>
  13. 14. Roux-en-Y Gastric Bypass: Jejunal Division <ul><li>Mark proximal jejunum </li></ul><ul><li>Minimal division of mesentery </li></ul>
  14. 15. Roux-en-Y Gastric Bypass: Distance to jejuno-jejunostomy <ul><li>Approx 100-110cm </li></ul>
  15. 16. Roux-en-Y Gastric Bypass: Stapled jejuno-jejunostomy <ul><li>Creates large common channel </li></ul>
  16. 17. Roux-en-Y Gastric Bypass: Jejuno-jejunostomy stitch <ul><li>Hand-sewn single-layer anastamosis </li></ul>
  17. 18. Roux-en-Y Gastric Bypass: Finished jejuno-jejunostomy <ul><li>Final view of jejuno-jejunostomy </li></ul>
  18. 19. Roux-en-Y Gastric Bypass: Closure of mesentery <ul><li>Interrupted peritoneal sutures </li></ul><ul><li>Prevents internal hernia </li></ul>
  19. 20. Roux-en-Y Gastric Bypass: First Gastric division <ul><li>Along lesser curve, at first gastric vein </li></ul><ul><li>May use ultrasonic device/cautery </li></ul><ul><li>Assure entry by visualizing posterior wall </li></ul>
  20. 21. Roux-en-Y Gastric Bypass: Creation of gastric pouch <ul><li>Calibration tube in place </li></ul><ul><li>Target is angle of His </li></ul>
  21. 22. Roux-en-Y Gastric Bypass: Final gastric division <ul><li>Full division to angle of His </li></ul>
  22. 23. Roux-en-Y Gastric Bypass: First G-J stitch <ul><li>Find Roux limb </li></ul><ul><li>Proper orientation of Roux limb </li></ul><ul><li>Begin with posterior layer </li></ul>
  23. 24. Roux-en-Y Gastric Bypass: Posterior sutures completed <ul><li>Sufficient sutures to allow for proper anastamosis </li></ul>
  24. 25. Roux-en-Y Gastric Bypass: Creating enterotomies <ul><li>Approx 1cm anastamosis </li></ul>
  25. 26. Roux-en-Y Gastric Bypass: Anterior G-J suture <ul><li>Begin with lateral corner </li></ul><ul><li>Sero-muscular stitches </li></ul>
  26. 27. Roux-en-Y Gastric Bypass: Last anterior G-J suture <ul><li>Anterior row of stitching completed </li></ul>
  27. 28. Roux-en-Y Gastric Bypass: Final view G-J <ul><li>Methylene blue has been injected </li></ul>
  28. 29. Roux-en-Y Gastric Bypass: Leak Testing <ul><li>Occlude Roux limb during dye and air insufflation under fluid </li></ul>
  29. 30. Roux-en-Y Gastric Bypass: Summary <ul><li>Jejuno-jejunostomy created </li></ul><ul><ul><li>Correctly identify LOT, proximal and distal limbs </li></ul></ul><ul><ul><li>Minimal division of mesentery </li></ul></ul><ul><li>Gastric pouch created </li></ul><ul><ul><li>Assure appropriate pouch size </li></ul></ul><ul><ul><li>Use calibrating tube if necessary </li></ul></ul>
  30. 31. Roux-en-Y Gastric Bypass: Summary <ul><li>Ante-Colic/Ante-Gastric gastro-jejunostomy </li></ul><ul><ul><li>Properly orient Roux limb, with minimal tension </li></ul></ul><ul><ul><li>Split omentum if necessary </li></ul></ul><ul><li>Stapling device used primarily for divisions </li></ul><ul><ul><li>Hand-sewn anastamosis whenever possible </li></ul></ul><ul><li>Always perform leak test </li></ul><ul><ul><li>Best opportunity to fix/reinforce anastamosis </li></ul></ul>

×