Laparoscopic RouxenY Gastric Bypass Detailed Technical Issues

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Eric J. DeMaria Introduction

Laparoscopic Roux-en-Y gastric bypass is one of the most difficult and challenging laparoscopic procedures routinely performed today. It requires advanced skills and knowledge of both the fields of bariatric surgery and laparoscopy, familiarity with both short and long term follow-up of patients, as well as early postoperative technical and delayed long-term nutritional and metabolic complications. Those issues will be discussed in other chapters. The topic of this chapter is to provide a detailed technical step by step description of the procedure.

Abdominal Access and Creating Pneumoperitoneum

Abdominal access for laparoscopy is a critical issue in the morbidly obese patient. Techniques for abdominal access are wide and varied; however, the most important issue is the careful planning of trocar placement so that the surgeon has the best possible view and can use his surgical instruments optimally to accomplish their objectives. While this principle is very important in all laparoscopic procedures, there is no field in which this is more true than bariatric surgery. Currently we perform laparoscopic Roux-Y gastric bypass (LRYGB) using a 6 access port technique (Fig. 10.1, see all figures at end of chapter). There are critical factors involved in the decision to place each trocar at a given location.

The initial trocar is placed in the left subcostal position. A Veress needle is inserted through an incision large enough to accommodate a 12 mm trocar, just beneath the costal margin. The trocar ideally should be placed in the anterior-axillary line or even a bit more laterally. It may become extremely awkward for the surgical assistant to utilize this trocar if it is placed too medially. After insufflating approximately 4 L of CO2 gas to create an appropriate pneumoperitoneum, the abdomen is entered under direct vision using one of the commercially available access devices through which the laparoscope is inserted (Visiport®, Tyco/US Surgical, Norwalk, CT). This is particularly useful if the patient has had previous abdominal surgery to avoid bowel injury. The pre-insufflation technique through the Veress needle is important because it creates an intraperitoneal buffer of CO2 which allows for easy recognition of the appropriate space. Prior to using this technique, we did inadvertently enter the colon during insertion on one occasion, mandating open surgical repair.

This initial 12 mm port is then utilized to introduce a 45° angled viewing laparoscope for placement of the other trocars under direct vision. A 45° scope is very important for successful completion of the procedure, and we have found it impossible to do the procedure with a 0° scope and difficult with a 30° scope. Because high quality images are essential for obtaining the level of technical information that is required to do the procedure,a high quality three-chip camera system is mandatory. We have also found that approaching the larger patient laparoscopically is aided by having a "bariatric-length" laparoscope. We have used several prototypes of this type of scope of approximately 55 cm in length made for our program. (Stryker Endoscopy, Santa Clara, CA). While the length of the scope is very important, one cannot sacrifice on illumination detail, which may occur with a longer scope.

Placement of the supraumbilical trocar for the laparoscope is usually done four finger breadths above the umbilicus and slightly to the left of midline. One should not go so far laterally as to risk injury to the epigastric vessels. This trocar is placed under direct vision after insufflating the abdomen and inserting a 12 mm trocar in the left upper quadrant. This allows one to position the supraumbilical trocar below the anterior abdominal wall attachment of the falciform ligament of the liver. If the trocar comes through the falciform ligament, it is often a constant source of aggravation during the procedure as the fatty tissue may fog the camera repeatedly. This is particularly true when the scope must be pulled back until it is just barely protruding from the trocar during the small bowel portion of the procedure.

Placement of the port site for liver retraction depends on the type of liver retractor used. We prefer a subxiphoid location and utilize a Nathanson liver retraction device which resembles a metal hook inserted through the trocar puncture site after the trocar is removed. Anchoring this device to a rigid fixation arm (Automated Medical Products Corp, Edison, NJ, Iron Intern®) allows for the liver retraction to be accomplished without an assistant holding the retractor, thus keeping it out of the way of the operating surgeon who stands on the patient's right side. There are a wide variety of appropriate liver retractors on the market and most surgeons utilize a right lateral trocar placement for some type of paddle-style liver retractor. These devices can also be anchored with some type of rigid arm system to obviate the need for an assistant to hold the retractor, which may be unreliable during a long surgical procedure.

One additional 5 mm trocar is placed in the left abdomen to allow the surgical assistant to work in a two-handed manner. It is important to assess the amount of abdominal wall distension that has occurred during insufflation in order to determine optimal placement of trocars. If a great deal of abdominal distension has occurred during insufflation, this may cause the subcostal position of the first trocar to descend lower on the abdominal wall than anticipated. Occasionally an 8 to 10 cm gap is created between this trocar and the left costal margin after insufflation. In these circumstances, we insert a 5 mm trocar superiorly at the level of the costal margin on the left side for the assistant's right hand. The assistant will find that this location provides optimal access to the proximal stomach during the initial dissection and gastrojejunal anastomosis. When the abdominal wall is not particularly compliant and less distension occurs, the left-sided initial 12 mm trocar may be within a few centimeters of the left costal margin after insufflation. In that circumstance, we utilize the initial trocar for the assistant's right hand instrument and insert a 5 mm trocar inferior to this location. This trocar should also remain in the lateral abdomen

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