Chapter 22
Laparoscopic Gastric Bypass: Trans-Gastric Circular Stapler

Numerous techniques have been published for performing laparoscopic Roux-en-Y gastric bypass. Some of the most widely adopted of these techniques are described in other chapters of this book, and each of these techniques has been shown to produce successful outcomes when performed by experienced surgeons.

This chapter describes the authors’ preferred technique: antecolic, antegastric, circular-stapled gastrojejunostomy with transgastric anvil placement. We favor a circular-stapled anastomosis because of its efficiency and reproducibility. Transgastric delivery of the anvil has several advantages: It allows precise anvil placement by the operating surgeon, requires no special equipment, and can be performed without the assistance of the anesthesiologist. Furthermore, it eliminates the risk of hypopharyngeal and esophageal trauma, which has been described when the transoral route is used for anvil placement.1,2

The choice of the antecolic route for the roux limb is based on the consideration of internal hernias. Two reviews of internal hernias after laparoscopic gastric bypass found that the retrocolic window was the most common site of symptomatic herniation.3,4 Antecolic placement of the Roux limb avoids creation of a retrocolic defect. Only on rare occasion, such as when a Roux limb has poor mobility and would create anastomotic tension at the gastrojejunostomy, do we prefer the retrocolic route for the Roux limb to reach the gastric pouch.

### Perioperative Preparation

Preoperatively, the patient is given 5,000 U of heparin subcutaneously, sequential compression devices are placed on the patient's legs, and prophylactic antibiotics are administered. Following induction, a Foley catheter is introduced. A soft, 16 F balloon tipped orogastric tube is placed by the anesthesiologist. The patient lies supine with the arms abducted and secured on arm boards. Because steep reverse Trendelenburg positioning will be required, the patient is secured to the operating room table with a hip belt and footplate.

### Trocar Placement

When the draping is complete, the surgeon and camera operator take position on the patient's right side, while the assistant and scrub tech are on the opposite side. To initiate the operation, the xiphoid is identified by palpation, and 15 cm caudad to this and 3 cm to the left of the midline a 1-cm transverse skin incision is made. An optical, bladeless 10-mm trocar (trocar #1) is advanced under vision with a zero degree laparoscope into the abdomen. After insufflation, a 10-mm 45° scope is used, instead of the straight laparoscope, for the operation. Working ports are introduced, as shown in Figures 22–1 and 22–2. A 12-mm trocar (trocar #2) is placed in the left anterior axillary line at the same level as the camera port. A 5-mm port (trocar #3) is then placed at the midpoint of the line between the xiphoid and trocar #2. The surgeon then places the right-sided working ports. ...

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