Mini-Gastric Bypass Done Right: A Description of the Surgical Technique

The MGB
Technique and Physiology

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
Wrong Hands
The MGB
Done WRONG!

Mini-Gastric Bypass
Wrong Hands
The MGB
Done RIGHT!

• Anyone can do a “single
anastomosis gastric bypass”
• That Does Not mean they
can/are doing the true
“Mini-Gastric Bypass” (MGB)
• See the Following Example...

Recent Publications
Poor Understanding of the
MGB => Bad Outcomes

Int J Surg Case Rep. 2017; Severe hypoalbuminemia and
steatohepatitis leading to death in a young vegetarian
female, 8 months after mini gastric bypass
29 years old female was admitted 8 month
after Laparoscopic Mini Gastric Bypass
Hypoalbuminemia, anemia, elevated liver
enzymes and direct bilirubinemia,
metabolic acidosis and Steatohepatitis
Patient did not respond to medical care
and died.

JPEN J Parenter Enteral Nutr. 2017
Response to
"Nutrition Deficiencies in Mini Gastric
Bypass Patients: Where Do We Stand
Today?"
Bétry C, Disse E, Chambrier C, Laville M,
Robert M.
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
one anastomosis gastric
bypass/mini gastric bypass to
Roux-en-Y gastric bypass for
bile reflux gastritis after failed
Braun jejunojejunostomy.
Nimeri A

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. One pulmonary
embolism, one postoperative bleeding, one leak
from biliary limb and one complete obstruction at
the gastro-ileal anastomosis.
6 months postoperative, one patient was diagnosed
with marginal ulcer,
12 months after surgery, another patient (2%) was
re-operated for fear of more excessive weight loss.

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

This NOT
Mini-
Gastric
Bypass

•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

The Mini-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

• Revision of
OAGB/MGB
• 2 months Post OP
• SEVERE Bile Reflux
Esophagitis
• Surgery 2 inch
Pouch!!
• No mention in text
Short
Pouch

•The Mini-Gastric Bypass
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

Gastro-
Jejunostomy
Level
of EG
Junctio
n

•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
Junctio
n
Gastro-
Jejunostomy

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

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

• Understand Anatomy
• Esophagus
• Body
• Antrum
• Antrectomy + Billroth II
= Routine General
Surgery

Level
of EG
Junctio
n
Gastro-
Jejunostomy

•Total/Subtotal Gastrectomy
Level
of EG
Junctio
n
Gastro-
Jejunostomy

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

• 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 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
w 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

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

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

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

•Critical Success Factors
Creation of the MGB
Gastric Pouch

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

The MGB
•The Gastric Pouch

• 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:
• Pouch Diameter = Esophagus;

• “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 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

•MGB: Gastric Pouch
• 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.

•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)
• Never dissect the EG junction

•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
• Thread the bowel all the way onto the
cartridge

•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 not
be too close to the bowel mesentary)

•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
• This staple line MUST NOT BLEED

• 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

• 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

Mini-Gastric Bypass Done Right: A Description of the Surgical Technique

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