Laparoscopic Roux-en-Y Gastric Bypass: One Surgeon’s Technique George S. Ferzli MD, FACS New York, NY
Dr. John Linner 1954 Jejuno-ileal bypass THE BEGINNING
COMPLICATIONS OF JEJUNOILEAL BYPASS <ul><li>Electrolyte disturbances </li></ul><ul><li>Osteoporosis/osteomalacia </li></ul...
Dr. Edward Mason University of Iowa 1967 Gastric Bypass with  loop gastroenterostomy
GASTRIC BYPASS WITH ROUX-en-Y LIMB Roux-en-Y Gastric Bypass 50 mL POUCH WITH A ROUX LIMB TO MINIMIZE BILE REFLUX  COMBINED...
GASTRIC BYPASS WITH ROUX-en-Y LIMB Roux-en-Y Gastric Bypass SUBSEQUENTLY MODIFIED 50 mL POUCH WITH A ROUX LIMB TO MINIMIZE...
ROUX-en-Y GASTRIC BYPASS <ul><li>GOAL: To restrict the </li></ul><ul><li>gastric reservoir </li></ul><ul><li>ADVANTAGES </...
 
Roux-en-Y Gastric Bypass: Operative Options <ul><li>Retro-colic/Retro-gastric gastrojejunostomy </li></ul><ul><li>Ante-col...
Roux-en-Y Gastric Bypass: Our Technique <ul><li>Identify LOT </li></ul><ul><li>Divide jejunum </li></ul><ul><li>Measure Ro...
Roux-en-Y Gastric Bypass: Port Positioning <ul><li>Approximate position for ports marked with abdomen insufflated </li></ul>
Roux-en-Y Gastric Bypass: Identify LOT <ul><li>Retract omentum and transverse colon cephalad </li></ul><ul><li>LOT exposed...
Roux-en-Y Gastric Bypass: Distance to Jejunal division <ul><li>Approx. 50-60cm from LOT </li></ul><ul><li>Assure that this...
Roux-en-Y Gastric Bypass: Jejunal Division <ul><li>Mark proximal jejunum </li></ul><ul><li>Minimal division of mesentery <...
Roux-en-Y Gastric Bypass: Distance to jejuno-jejunostomy <ul><li>Approx 100-110cm </li></ul>
Roux-en-Y Gastric Bypass: Stapled jejuno-jejunostomy <ul><li>Creates large common channel </li></ul>
Roux-en-Y Gastric Bypass: Jejuno-jejunostomy stitch <ul><li>Hand-sewn single-layer anastamosis </li></ul>
Roux-en-Y Gastric Bypass: Finished jejuno-jejunostomy <ul><li>Final view of jejuno-jejunostomy </li></ul>
Roux-en-Y Gastric Bypass: Closure of mesentery <ul><li>Interrupted peritoneal sutures  </li></ul><ul><li>Prevents internal...
Roux-en-Y Gastric Bypass: First Gastric division <ul><li>Along lesser curve, at first gastric vein </li></ul><ul><li>May u...
Roux-en-Y Gastric Bypass: Creation of gastric pouch <ul><li>Calibration tube in  place </li></ul><ul><li>Target is angle o...
Roux-en-Y Gastric Bypass: Final gastric division <ul><li>Full division to angle of His </li></ul>
Roux-en-Y Gastric Bypass: First G-J stitch <ul><li>Find Roux limb </li></ul><ul><li>Proper orientation of Roux limb </li><...
Roux-en-Y Gastric Bypass: Posterior sutures completed <ul><li>Sufficient sutures to allow for proper anastamosis </li></ul>
Roux-en-Y Gastric Bypass: Creating enterotomies <ul><li>Approx 1cm anastamosis </li></ul>
Roux-en-Y Gastric Bypass: Anterior G-J suture <ul><li>Begin with lateral corner </li></ul><ul><li>Sero-muscular stitches <...
Roux-en-Y Gastric Bypass: Last anterior G-J suture <ul><li>Anterior row of stitching completed  </li></ul>
Roux-en-Y Gastric Bypass: Final view G-J <ul><li>Methylene blue has been injected </li></ul>
Roux-en-Y Gastric Bypass: Leak Testing <ul><li>Occlude Roux limb during  dye and air insufflation under fluid </li></ul>
Roux-en-Y Gastric Bypass: Summary <ul><li>Jejuno-jejunostomy created  </li></ul><ul><ul><li>Correctly identify LOT, proxim...
Roux-en-Y Gastric Bypass: Summary <ul><li>Ante-Colic/Ante-Gastric gastro-jejunostomy </li></ul><ul><ul><li>Properly orient...
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Laparoscopic Roux En-Y-Gastric Bypass: One Surgeon's Technique

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Laparoscopic Roux En-Y-Gastric Bypass: One Surgeon's Technique

  1. 1. Laparoscopic Roux-en-Y Gastric Bypass: One Surgeon’s Technique George S. Ferzli MD, FACS New York, NY
  2. 2. Dr. John Linner 1954 Jejuno-ileal bypass THE BEGINNING
  3. 3. COMPLICATIONS OF JEJUNOILEAL BYPASS <ul><li>Electrolyte disturbances </li></ul><ul><li>Osteoporosis/osteomalacia </li></ul><ul><li>Protein malnutrition </li></ul><ul><li>Cholelithiasis </li></ul><ul><li>Diarrhea </li></ul><ul><li>Hair loss </li></ul><ul><li>Arthritis </li></ul><ul><li>Liver failure </li></ul><ul><li>Steatosis </li></ul><ul><li>Renal calculi </li></ul><ul><li>Neuropathy </li></ul><ul><li>Anemia </li></ul>
  4. 4. Dr. Edward Mason University of Iowa 1967 Gastric Bypass with loop gastroenterostomy
  5. 5. GASTRIC BYPASS WITH ROUX-en-Y LIMB Roux-en-Y Gastric Bypass 50 mL POUCH WITH A ROUX LIMB TO MINIMIZE BILE REFLUX COMBINED RESTRICTIVE AND MALABSORPTIVE
  6. 6. GASTRIC BYPASS WITH ROUX-en-Y LIMB Roux-en-Y Gastric Bypass SUBSEQUENTLY MODIFIED 50 mL POUCH WITH A ROUX LIMB TO MINIMIZE BILE REFLUX ROUX LIMB WAS LENGTHENED TO INCREASE MALABSORPTION AND IMPROVE WEIGHT LOSS COMBINED RESTRICTIVE AND MALABSORPTIVE
  7. 7. ROUX-en-Y GASTRIC BYPASS <ul><li>GOAL: To restrict the </li></ul><ul><li>gastric reservoir </li></ul><ul><li>ADVANTAGES </li></ul><ul><li>Controls food intake </li></ul><ul><li>Dumping reduces intake of sweets </li></ul><ul><li>Reversible if indicated </li></ul>Roux-en-Y Gastric Bypass
  8. 9. Roux-en-Y Gastric Bypass: Operative Options <ul><li>Retro-colic/Retro-gastric gastrojejunostomy </li></ul><ul><li>Ante-colic/Ante-gastric gastrojejunostomy </li></ul><ul><li>Stapled gastrojejunostomy </li></ul><ul><li>Hand-sewn gastrojejunostomy </li></ul>
  9. 10. Roux-en-Y Gastric Bypass: Our Technique <ul><li>Identify LOT </li></ul><ul><li>Divide jejunum </li></ul><ul><li>Measure Roux limb </li></ul><ul><li>Complete jejuno-jejunostomy, close mesentery </li></ul><ul><li>Create gastric pouch </li></ul><ul><li>Ante-colic/Ante-gastric gastrojejunostomy </li></ul><ul><li>Leak test </li></ul>
  10. 11. Roux-en-Y Gastric Bypass: Port Positioning <ul><li>Approximate position for ports marked with abdomen insufflated </li></ul>
  11. 12. Roux-en-Y Gastric Bypass: Identify LOT <ul><li>Retract omentum and transverse colon cephalad </li></ul><ul><li>LOT exposed </li></ul>
  12. 13. Roux-en-Y Gastric Bypass: Distance to Jejunal division <ul><li>Approx. 50-60cm from LOT </li></ul><ul><li>Assure that this </li></ul><ul><li>reaches liver edge </li></ul>
  13. 14. Roux-en-Y Gastric Bypass: Jejunal Division <ul><li>Mark proximal jejunum </li></ul><ul><li>Minimal division of mesentery </li></ul>
  14. 15. Roux-en-Y Gastric Bypass: Distance to jejuno-jejunostomy <ul><li>Approx 100-110cm </li></ul>
  15. 16. Roux-en-Y Gastric Bypass: Stapled jejuno-jejunostomy <ul><li>Creates large common channel </li></ul>
  16. 17. Roux-en-Y Gastric Bypass: Jejuno-jejunostomy stitch <ul><li>Hand-sewn single-layer anastamosis </li></ul>
  17. 18. Roux-en-Y Gastric Bypass: Finished jejuno-jejunostomy <ul><li>Final view of jejuno-jejunostomy </li></ul>
  18. 19. Roux-en-Y Gastric Bypass: Closure of mesentery <ul><li>Interrupted peritoneal sutures </li></ul><ul><li>Prevents internal hernia </li></ul>
  19. 20. Roux-en-Y Gastric Bypass: First Gastric division <ul><li>Along lesser curve, at first gastric vein </li></ul><ul><li>May use ultrasonic device/cautery </li></ul><ul><li>Assure entry by visualizing posterior wall </li></ul>
  20. 21. Roux-en-Y Gastric Bypass: Creation of gastric pouch <ul><li>Calibration tube in place </li></ul><ul><li>Target is angle of His </li></ul>
  21. 22. Roux-en-Y Gastric Bypass: Final gastric division <ul><li>Full division to angle of His </li></ul>
  22. 23. Roux-en-Y Gastric Bypass: First G-J stitch <ul><li>Find Roux limb </li></ul><ul><li>Proper orientation of Roux limb </li></ul><ul><li>Begin with posterior layer </li></ul>
  23. 24. Roux-en-Y Gastric Bypass: Posterior sutures completed <ul><li>Sufficient sutures to allow for proper anastamosis </li></ul>
  24. 25. Roux-en-Y Gastric Bypass: Creating enterotomies <ul><li>Approx 1cm anastamosis </li></ul>
  25. 26. Roux-en-Y Gastric Bypass: Anterior G-J suture <ul><li>Begin with lateral corner </li></ul><ul><li>Sero-muscular stitches </li></ul>
  26. 27. Roux-en-Y Gastric Bypass: Last anterior G-J suture <ul><li>Anterior row of stitching completed </li></ul>
  27. 28. Roux-en-Y Gastric Bypass: Final view G-J <ul><li>Methylene blue has been injected </li></ul>
  28. 29. Roux-en-Y Gastric Bypass: Leak Testing <ul><li>Occlude Roux limb during dye and air insufflation under fluid </li></ul>
  29. 30. Roux-en-Y Gastric Bypass: Summary <ul><li>Jejuno-jejunostomy created </li></ul><ul><ul><li>Correctly identify LOT, proximal and distal limbs </li></ul></ul><ul><ul><li>Minimal division of mesentery </li></ul></ul><ul><li>Gastric pouch created </li></ul><ul><ul><li>Assure appropriate pouch size </li></ul></ul><ul><ul><li>Use calibrating tube if necessary </li></ul></ul>
  30. 31. Roux-en-Y Gastric Bypass: Summary <ul><li>Ante-Colic/Ante-Gastric gastro-jejunostomy </li></ul><ul><ul><li>Properly orient Roux limb, with minimal tension </li></ul></ul><ul><ul><li>Split omentum if necessary </li></ul></ul><ul><li>Stapling device used primarily for divisions </li></ul><ul><ul><li>Hand-sewn anastamosis whenever possible </li></ul></ul><ul><li>Always perform leak test </li></ul><ul><ul><li>Best opportunity to fix/reinforce anastamosis </li></ul></ul>

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