Laparoscopic gastric bypass

After starting the operation (Creating the pneumoperitoneum, working trocar placement, exploring the abdominal cavity) expose the angle of His.

Then begin fashioning the gastric pouch at the lesser curvature 2 cm inferior to the gastroesophageal junction. In order to avoid bleeding complications and assure blood flow to the pouch, spare the left gastric artery which will supply the gastric pouch. Begin dividing the stomach in a horizontal direction with a linear stapler (staple height 3.5 mm).

Continue the dissection in triangular fashion toward the left crus of diaphragm. It serves as an anatomical landmark.

Transect the entire gastric fundus to bypass the production site of the enterohormone ghrelin from the intestinal transit and prevent subsequent dilation.

Finally, ensure adequate ultrasound hemostasis at the staple line.

After completely dividing the stomach, expose the ligament of Treitz. Divide the greater omentum if very fat.  About 50 cm distad to the ligament of Treitz, bring the jejunal limb antecolically to the gastric pouch. When measuring it is helpful to always keep the efferent limb on the right on the monitor screen with the instrument of the right hand to avoid misidentification of the limbs. The use of measuring tools is helpful.

Alternative routes to the gastric pouch for the efferent limb.

Tip: To avoid fashioning a limb that is too short, first check that the efferent limb is long enough to reach the pouch. If the limb proves to be too short nevertheless, it is recommended to fashion a primary gastric sleeve-like pouch and/or skeletonize the efferent limb or bring the limb up via a retrocolic retrogastric route.

Anchor the jejunal limb tension-free on the gastric pouch with two sutures.

Note: If the limb is anchored too far craniad, this will result create a distal pouch reservoir with overflow phenomenon; if the limb is anchored too far caudad, this will increase the risk of a dumping syndrome. The limb should therefore be placed at the second staple line and tailored to the shape and size of the pouch.

Tip: To avoid a twisted limb (“blue limb” syndrome), bring up the limb under direct vision (with the mesentery pointing to the left). Correct and eliminate any limb rotation.

Limb misidentification must be ruled out at all cost and this requires consistent identification of the ligament of Treitz. Any misidentification of the limbs must be corrected immediately since otherwise the overstretched stomach (distension) carries the risk of cardiac arrest.

Create the gastroenterostomy by opening both the gastric pouch and efferent limb in parallel with the ultrasound dissector. Open the gastric pouch on its posterior wall.

This can be done with electrocautery hook electrodes/shears, ultrasound or Ligasure.

Close the posterior wall of the anastomosis with a linear stapler (blue cartridge) and leave the anterior wall open.

Tip: Avoid posterior perforation by carefully keeping the anchor suture under tension when making the incision, and oversew if necessary.
If intestinal continuity was severed already prior to the gastroenterostomy and the distance from the end of the efferent limb is too long, resect the ear of the small intestine.

Before closing the gastric and intestinal openings, insert a sizer into the efferent jejunal limb.

Then close the anastomosis with a running suture and secure it with interrupted sutures.

Alternatively, fashion the gastroenterostomy with an EEA stapler or suture all of it by hand.

Tip: Avoid postoperative anastomotic stricture by advancing an 8 mm probe across the anastomosis to prevent posterior wall entrapment when closing the anterior wall.