Table 9.1. Potential advantages of hand assistance

• Already need a 7 to 8 cm incision to repair an umbilical or ventral hernia that is common in this population.

• May use to salvage a total laparoscopic case that needs extra-assistance that a hand can provide.

• If a skilled assistant for a total laparoscopic approach is not available.

• The possible use in higher BMI patients.

• Inexperienced surgeon may use technique as a bridge while acquiring the skills to do the total laparoscopic approach.

ligament of Treitz. A penrose drain is sewn to the end of the Roux limb. A vascular EndoGIA II® with a 45 mm cartridge and 2.0mm staples is used to divide the mesentery. A jejuno-jejunostomy is performed approximately 60 cm distal to where the jejunum was divided. Enterotomy holes are made in the eviscerated segments of jejunum for a side to side anastomosis using an EndoGIA II® with a 60 mm cartridge carrying 2.5 mm staples. The enterotomy hole is then closed using a suture or staple technique with care to avoid narrowing of the lumen. The jejuno-jejunos-tomy may also be performed intracorporeally using hand assistance. We have found in most instances the jejunum can be eviscerated enough into the hand incision to perform the anastomosis using the endoscopic stapler which will ultimately save operative time.

Division of the Gastric Pouch

The Pneumo Sleeve® device is placed over the left hand, which is then inserted into the abdomen, and pneumoperitoneum is reestablished (Fig. 9.1). We have found the 45°-angled viewing laparoscope most helpful for the dissection. The left lateral segment of the liver is retracted using a Nathanson retractor through a subxiphoid 5 mm puncture made by a trocar which is removed to allow insertion of the retractor which is then held in position with a commercially available metallic arm attached to the OR table (Thompson Surgical Instruments, Inc., Traverse City, MI 49684). A 12 mm Versaport® is then placed in a subxiphoid position. A 5 mm trocar is place in the right and left lateral positions. The phrenoesophageal ligament is taken down using the 5 mm UltraShears® (US Surgical Corporation, Norwalk, CT) to identify the angle of His. The lesser omental peritoneum is taken down with the UltraShears®. Palpation of an aberrant left hepatic artery is easily done since a hand is inside. A space is created separating the lesser curve of the stomach from the neurovascular bundle near the third branch off the left gastric artery. A finger on the posterior side is used to speed this dissection and can also control bleeding (Fig. 9.2). Caution should be used to not use surgical clips where the stapler will be placed since it will not work across a clip. An EndoGIA II® with a 60 mm cartridge carrying 3.5 mm staples is fired multiple times from the lesser curve side to the angle of His to make a 15 cc to 30 cc proximal gastric pouch. The laparoscope, which has been changed to 45° scope, is switched between the two ports for optimal visualization. A finger is used throughout this stapling to aid in the dissection and to orient the stapler toward the angle of His. It is important not to staple horizontal and make too large a pouch. A vertical pouch has thicker, less distensable gastric tissue.

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