CLINICAL INDICATIONS:
This is a __-year-old patient who underwent a complete
investigation at the University of California, San Francisco, Bariatric Surgery Center and
fulfilled the Bariatric Surgery Center criteria and the National Institutes of Health criteria
to undergo surgery for morbid obesity. The patient was offered the laparoscopic versus
open Roux- en-Y gastric bypass. The preoperative investigation can be found in the
UCSF Bariatric Surgery chart. The patient was informed in detail about the medical and
surgical alternatives for the treatment, and the morbidity and the mortality associated
with the procedure. The patient understood and signed informed consent and was
brought to the operating room in stable condition.
FINDINGS:
Morbid obesity, body mass index (BMI) of __.
PROCEDURE:
The patient was prepped and draped in the usual sterile fashion
and administered general anesthesia with endotracheal intubation. A Foley catheter
was inserted. An arterial line, two large-bore peripheral intravenous lines and an
orogastric tube were placed by the Anesthesia Team. Subcutaneous heparin and
antibiotics IV were administered. The patient had all extremities padded and protected,
and was safely secured to the operative table.
A first trocar was inserted in a supraumbilical 10 mm incision into the peritoneal cavity
under direct visualization. Pneumoperitoneum was then obtained at 15 mmHg. Reinsertion of the camera was then accomplished, and visualization and inspection of the
whole abdominal cavity did not demonstrate any abnormalities. Two additional 10- 12
mm trocars were inserted under direct vision, one in the right side of the abdomen
approximately 7 cm lateral to the supraumbilical trocar in the lateral aspect of the rectus
muscle sheath and the other 10-12 mm trocar was inserted under direct vision in the left
side of the abdomen, also in a paramedian position about 10 cm above the umbilical
trocar. Two 5 mm trocars were then inserted under direct vision, one in the left
subcostal area at the level with the anterior axillary line and the other in a right
paramedian position. An additional 5 mm trocar was inserted in the subxiphoid area
under direct vision, and through that trocar was inserted a grasper which was attached
to the left crus of the diaphragm to accomplish the retraction of the left lobe of the liver.
The patient was placed in Trendelenburg position. The greater omentum was then
retracted superiorly toward the supramesocolic aspect of the abdomen. The Treitz angle
was identified and located. The first loop of jejunum was then run for about 30 cm from
the Treitz angle and divided with an Endo GIA white load of 45 mm. The mesentery of
that proximal jejunal loop was then divided with another firing of a gray load of a 45 mm
Endo GIA. Hemostasis was reviewed and obtained. The distal portion of the jejunal
loop was run for 150 cm and was apposed with the proximal jejunal loop to create a
lateral-lateral jejunojejunostomy. This was accomplished by opening a hole in the
antimesenteric portion of the proximal and the distal jejunum using the Harmonic
Scalpel. Then, a 60 mm white load Endo GIA stapler was inserted in each opening,
approximated and fired, creating a jejunojejunostomy. The stapler was then removed,
and the entrance site of the stapler was closed by using a 60 mm white load Endo GIA
stapler. Two additional seromuscular stitches were placed at the crotch and as an antikinking stitch proximally using 2-0 Ti-Cron. A running suture of 0 Ti- Cron was placed in
the mesenteric defect to approximate the mesenteric defect that was created, closing it
properly.
Then, attention was directed to divide the greater omentum. This was accomplished by
using the Harmonic Scalpel to a point close to the transverse colon. Then, patient was
placed in reverse Trendelenburg and the stomach was displaced and inspected. A small
window just at the level of first gastric vein about 5 cm from the gastroesophageal
junction was created to access the lesser sac by using the Harmonic Scalpel. Then, an
Endo GIA 45 mm blue load was inserted in the lesser curvature window, and the
stomach was transected approximately 5 cm from the gastroesophageal junction
horizontally. Then, two loads of a 60 mm stapler blue load Endo GIA were inserted to
create a small gastric pouch and divide the stomach vertically. Complete division of the
His angle was inspected and was accomplished by firing an additional 45 mm blue load
Endo GIA stapler. Hemostasis was reviewed and obtained. The anvil of the circular 25
mm stapler was inserted using the device called Oroanvil, inserted by the
anesthesiologist through the patient's mouth. After the distal portion of the device
appeared just above the horizontal staple line of the stomach, we created a small
opening with the Harmonic scalpel, removing the tube that connected to the anvil
proximally. We then pulled the tube through left lower quadrant trocar to exteriorize the
anvil. We then divided the holding suture and disconnected the anvil from the tube that
was removed and discarded. The anvil was in good position in the gastric pouch. We
dilated the RLQ incision to insert a wound protector device and introduced the EEA
stapler through it. We then brought the Roux loop in an antecolic fashion through the
greater omentum window created previously and introduced the EEA stapler through an
opening in the stapled portion of the Roux loop. The stapler introducer was then
advanced and exteriorized through the antimesenteric portion of the bowel and
connected to the anvil in the gastric pouch. The gastric pouch and the Roux loop were
then approximated with care to apposition it properly and fired to create the
gastrojejunostomy. The EEA stapler was then removed and the open portion of the Roux
loop was closed by firing a 60 mm Endo GIA white load. The wound protective device
was removed and a trocar re-inserted. The extra intestine stapled off when closing the
Roux loop was removed from the abdomen. Three sutures between the anterior aspect
of the Roux loop in the seromuscular and the gastric pouch in an interrupted fashion
were placed to create a second row for the gastrojejunostomy. An orogastric tube was
passed through by the anesthesiologist through the gastrojejunostomy.
We clamped the jejunum just distal to the gastrojejunostomy and inflated the gastric
pouch and the gastrojejunostomy with 60 cc of methylene blue in increments of 10 cc
using the orogastric tube. No leaks or extravasation was noted after careful inspection
of all aspects of the anastomosis and gastric pouch. The anesthesiologist then
suctioned out the methylene blue solution and removed the orogastric tube. We then
placed 5 cc of fibrin glue in the posterior and anterior aspects of the gastrojejunal
anastomosis and gastric pouch staple line.
We then inserted a #19 Blake drain in the superior portion of the abdomen, exteriorizing
it through the left upper quadrant. All the trocars were then removed under direct vision.
The pneumoperitoneum was deflated. The skin was closed using staples. A dressing
was applied. The drain was sutured to the abdominal wall with a 2-0 nylon suture. At the
end of the procedure, the sponge, instrument and needle counts were correct.
The patient was then extubated, awakened from anesthesia, and transported to the
recovery room in stable condition.