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The Roux-en-Y gastric bypass (RYGP) is considered to be gold standard in the United States for the surgical treatment of morbid obesity. The anastomosis of the gastric pouch to the jejunum can be done manually,1 with a linear stapler,2 with a circular stapler with the collocation of an anvil, transgastric, or with the circular stapler passing the anvil through the mouth.3,4 The latter method of anastomosis has been our preference.

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The laparoscopic RYGP was first performed by Wittgrove and Clark, 1994. The gastric-jejunal anastomosis was first performed via retrocolic passage, but nowadays almost all of the surgeons perform this via ante-colic passage. The proximal gastric pouch is narrowed by a silicone ring as suggested by Fobi and Capella.5,6 However, most surgeons today make a calibrated anastomosis, about 1.2 cm, thereby avoiding the use of foreign material.

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To make the jejunal stretch to the gastric pouch, surgeons section the greater omentum, gaining extra centimeters.7 We use a 10–12-cm devascularization of the jejunum, which is taken to the gastrojejunal anastomosis. The anastomosis with the gastric pouch being completed, the segment of the devascularized jejunum is resected.

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It is necessary to use an adequate anesthetic considering relaxation and depth, intubations with the patient awake, and the induction of a general anesthesia. The patient walks to the operating room, and at the end of the intervention the patient is already awake and returns to the room on his or her own. After staying in the postanesthetic recovery room for 2 hours, the patient walks to his or her room, without the need to visit intensive care unit (ICU).

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Pneumatic calf sequential compression is used for the prevention of thromboembolism. With the patient in supine position, without bending the inferior members, a reduced surgical time (60–90 minutes), the use of pneumatic leggings, being able to walk the same day of surgery, and the application of intense physical therapy, we feel justified in the selective use of prophylactic anticoagulants.

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The patient is placed adequately on the surgical table appropriate for the obese patient, which permits reverse and lateral movement without there being dislocation during the surgical procedure. No gastric tube is left in place and the bladder catheter is removed within 24 hours. A balanced diet is begun on the first postoperative day.

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The surgeon and the camera are positioned on the right and the assistants on the left of the patient for better use of the circular stapler. Seven trocars, longer ones preferred, are used: One 10/11 mm for optics, three 12 mm for work, and three 5 mm to retract the liver, the stomach and for aspiration (Figure 20–1).

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Figure 20–1.
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Positioning of the trocars. Seven trocars are used, longer ones preferred. One 10-mm long for ...

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