Timothy J. Nolan Introduction
Laparoscopic gastric bypass (LGB) has developed in recent years due to close collaboration between physicians and the technology manufacturers. Close relationships with surgeons have allowed our industry to recognize the emergence of this procedure, and start to develop technologies that help make a LGB a safe, effective option for a challenging patient population.
This chapter will discuss the instruments and technology currently used by many surgeons to perform LGB. The examples presented are from United States Surgical* but many are available from other manufacturing sources. As this writing is about a most advanced and challenging procedure, it is assumed the reader has an understanding of basic laparoscopic equipment. It is important to recognize that although current technology has enabled surgeons to perform LGB safely and effectively, further advances are needed to aid surgeons in their continued efforts to refine this procedure.
Initial access for insufflation can be achieved by the use of an insufflation needle or through open technique. For the bariatric patient, the Surgineedle™ is available in a longer length (150mm) (Fig. 3.1). This single use pneumoperitonium needle is designed to help protect internal viscera from inadvertent injury; it has a blunt stylet that advances over the sharp tip upon entry to the abdominal cavity. For open access, the Blunt Tip Trocar (Fig. 3.2) provides an airtight seal by inflating the distal balloon against the peritoneum and securing a soft foam anchor against the skin. This eliminates the need for fascial sutures (no easy task in the morbidly obese) and is more forgiving to variations in open cut down techniques.
As LGB is a most technically challenging procedure, high quality operative ports are essential for the surgeon to maintain concentration on the task at hand. Versaport™ V2 (Fig. 3.3) allow the surgeon to exchange instruments that are 5mm in diameter up to the trocar's maximum without stopping to place converters on the valve system. Morbidly obese patient often have extremely large livers, and excessive intra-abdominal fat and single use, shielded trocars are most often used. The Versaport™ V2 trocar has a shielded linear blade designed to help the surgeon achieve a controlled safe entry into the abdominal cavity. When trocar anchors, such as Surgigrips™ (Fig. 3.4) are used, it is important to secure them into the fascia to hold securely. This may be challenging in large patients, and surgeons often utilize
Fig. 3.2. Blunt Tip Trocar sutures to additionally secure the ports to the skin. As with all laparoscopic procedures, the facial defect from trocar sites, 10mm and larger, are commonly closed with suture. Suture passing instruments such as the Endo Close are commonly used (Fig. 3.5).
An alternative to traditional trocars, the STEP™ access system (Fig. 3.6) allows the surgeon to create intra peritoneal access without using cutting trocars. Radial dilation technology is used to expand a 14 gauge insufflation needle up to a 12mm
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