• Trocar sites are identified, and trocars, such as ENDOPATH EXCEL™ trocars, inserted to gain access to the abdominal cavity and stomach. Generally, 5 trocars are used and is a mix of 5 and 12mm trocars. 
  • Initial Access to the abdomen is generally obtained by either:

ROUX LIMB/ JEJU-JEJUNOSTOMY CREATION

  • Identify the Ligament of Treitz.
  • Measure the small intestine from the ligament to create the bilio-pancreatic (BP) limb). This is typically 50-100cm in length. The small bowel and mesentery are divided with stapler, such as ECHELON™ 3000 stapler.
     
  • Making sure to correctly identify the limbs, the small bowel distal to this division is measured to create the roux limb, 80-150cm in length.  
  • Enterotomies are made in the distal point of the BP limb and the distal point of the roux limb with an advanced energy device, such as HARMONIC™ 1100.
  • The jejunosomty is created in varying fashions. This can be hand sewn but typically this is created with a stapler to create an end-to-side anastomosis. The jaws of the stapler are inserted into enterotomies, closed and lined up evenly, then fired. 
  • The enterotomy is then closed with an absorbable suture or stapled closed. This should be inspected to make sure the anastomosis is patent and the outlet to the common channel is not constricted.
  • The mesenteric defect is generally closed with a non-absorbable suture to reduce the incidence of internal hernia.  

POUCH CREATION

  • Typically, after a liver retractor is placed, a small amount of dissection is done above the cardia of the stomach to allow for easier creation of gastric pouch.
  • The esophago-gastric junction is identified and approximately 5cm is measured distally.
  • Dissection is done along the lesser curvature. This is often an area with vessels and increased risks of bleeding. Very careful dissection must be done in this area.  
  • A window is created into the lesser sac.
  • Make certain all items are removed from the stomach.
  • Using an endoscopic stapler, such as ECHELON™ 3000 stapler, the stomach is divided to create a 30-60cc gastric pouch.
  • Cartridge selection with different stapling heights to adequately staple the tissue while remaining perfused without oozing can vary based on clinical judgement of stomach thickness.
  • Other options including staple line reinforcement (buttress), such as ECHELON ENDOPATH™ Staple Line Reinforcement and oversewing may be utilized depending on surgeon preference.
  • Hemostasis along staple line and surgical site can be controlled in many ways if needed. Suturing, clips, or adjunct hemostatic agents such as Vistaseal™ Fibrin Sealant (Human), are all options to control small areas of oozing. 

GASTRO-JEJUNOSTOMY 

  • The roux limb is brought into the upper abdomen, which can be done before or after the pouch creation.
  • The roux limb can be brought up in a retro-colic/retro-gastric or ante-colic/ante-gastric fashion. 

Creation of gastro-jeunostomy can be accomplished with a variety of techniques:

  • Circular Stapler Technique
    • This is a common technique to complete the gastrojejunostomy. The anvil of the circular stapler device, such as ECHELON™ Circular Powered Stapler is placed in the stomach pouch in various ways.  Often this is done prior to finally creating the pouch. The gastric stapling is completed around the anvil to complete the pouch. The stapler is introduced through an enlarged trocar sight, most commonly in the lower upper quadrant. The roux limb is opened on the distal end and the stapler inserted. The stapler and anvil are connected, and stapler fired to complete the anastomosis. The stapler is removed through the roux limb and the open tip of the roux limb is then stapled closed with a linear stapler. 
  • Linear Stapler Technique
    • This can be performed in a one- or two-layer technique.  
      The roux limb is placed proximally near the gastric pouch. Taking care to make sure there is no kinking or tension on the limb. For a single layer, enterotomies are made in the gastric pouch and the roux limb with an advanced energy device, such as HARMONIC™ 1100.  Each stapler jaw is placed into these enterotomies. The Echelon™ 3000 stapler is marked to allow insertion to the appropriate depth (typically 30-40mm) and then closed. The stapler is closed and fired following compression of the tissue. This creates the gastrojejunostomy. The defect is typically sutured closed.  

      The gastrojejunostomy can also be completed in a 2-layer fashion as well. A back row of sutures can be placed posteriorly connecting the pouch and roux-limb. This may reduce tension and align the tissue for stapling. Once the anastomosis is completed, the staple line is oversewn to complete the second layer. It is generally recommended to place a bougie or another device through the anastomosis to prevent narrowing as the second layer is completed. 

  • A provocative leak test is often performed. Leak test can be performed in variety of ways including endoscopy, methylene blue pressure test, air-leak test, etc. 
  • Closure of mesenteric defects:
    • antecolic/gastric-pseudo-Peterson’s space.
    • retro colic/gastric-closure of mesocolic defects.

Hiatal Hernia

A hiatal hernia is a common finding during bariatric surgery. One of the long-term potential complications of a sleeve gastrectomy is GERD. Surgeons are generally prepared for the identification and repair of a hiatal hernia during bariatric procedures.  

The intra-abdominal pressure is reduced, and trocar sites observed upon removal to check for bleeding.

The wounds are closed using synthetic absorbable monofilament, such as Monocryl™ Plus Antibacterial suture, and a topical skin adhesive such as DERMABOND™ PRINEO™ Skin Closure System or any appropriate dressing. 
 

Potential complications include but are not limited to:

  • Surgical bleeding
  • Staple line Leak
  • Stricture
  • DVT/ Pulmonary Embolism
  • Surgical site infection (deep or superficial).
  • Internal hernia/obstruction
  • Anastomotic leak

 

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