The laparoscopic Roux-en-Y gastric bypass (LRYGBP) remains the procedure of choice for the treatment of morbid obesity by the majority of bariatric surgeons in the United States. The laparoscopic approach, first described by Wittgrove and Clark,1 is one of the most significant advances in the surgical treatment of morbid obesity. Variations in construction of the gastrojejunostomy (GJ) include the hand-sewn technique2 described by Higa as well as the circular stapler technique.1 We prefer the linear stapler technique3 to construct our GJ because it is less technically demanding and time saving when compared to the circular or hand-sewn techniques. The skills and technology employed have enabled us to successfully perform over 2,300 hundred cases to date. This chapter describes our linear technique of the GJ during the LRYGBP.
Case preparation and setup is paramount to performing the procedure in a safe, consistent, and expeditious manner. Patients receive a preoperative dose of low molecular weight heparin, sequential compression device, and antibiotic prophylaxis. A footboard is attached to the operating table in anticipation of steep reverse Trendelenburg position. A supply cart with any potential extra supplies is maintained within the operating room. We use four reusable 5-mm trocars and two disposable 12-mm trocars to perform the procedure. The reusable trocars limit the overall expense of the procedure when compared to disposable trocars. The abdomen is entered using a direct entry approach with a 12-mm direct-view trocar and a zero degree 10-mm laparoscope. The remaining 5-mm trocars and 12-mm trocar are inserted under direct visualization (Figure 23–1). An Allis clamp is placed into the epigastric liver and positioned under the left lobe of the liver and attached to the diaphragm to maintain exposure of the upper stomach. The procedure is divided into three steps: pouch construction, enteroenterostomy, and the gastroenterostomy formation.
Location of trocar sites.
The construction of the gastric pouch is initiated by dividing the peritoneal attachments along the left crus to expose the angle of His. The angle of His serves as a target point when forming the vertical staple-line during pouch formation. An endoscopic ruler is used to measure 5 cm from the angle of His along the lesser curvature of the stomach. Blunt dissection is used to create a window into the lesser sac, 5 cm from the angle of His, adjacent to the lesser curvature to avoid injury to the vagal nerve branch. A 45-mm linear surgical stapler with a 3.5-mm staple is then positioned and fired horizontally. The lesser sac window allows for precise placement of the stapler jaws onto the stomach. A 50F blunt tip bougie is ...