Chapter 27

The Roux-en-Y Gastric Bypass with ring had already been popularized by Capella and Fobi1,2 through the open technique for the treatment of morbid obesity.3 It started being performed by laparoscopy in 1994 by Wittgrove and Clark.4

The videolaparoscopic benefits have been shown by many authors, 5–9 including less postoperative pain, less incisional hernias and adhesions incidence, less cardiopulmonary repercussion, lower trauma stimuli, and shorter hospital stay.

These data show a description of the videolaparoscopic gastric bypass with ring and Roux-en-Y diversion, with hand-sewn gastrojejunal anastomosis.

### Patient Care

Patients go to the hospital the night before surgery. Two hours before the procedure, they receive instructions from the surgical team, prophylactic low-weight heparin, and sedation. During surgery, the patients are submitted to leg sequential compression devices, antibiotic prophylaxis, and total venous anesthesia.

### Trocars and Team Position

The trocar sites are very important to carrying out the procedure in an ergonomic and comfortable position.)10 The surgeon stays on the right side of the patient. Five trocars are used (Figure 27–1). The Verres needle is inserted on the left hypochondrium to start the pneumoperitoneum.

###### Figure 27–1.

Trocar placement.

• Trocar A—The first 10-mm trocar punction is made in the umbilicus on the female and brevilineal patients. In other patients, this trocar is inserted at 15 cm from the Xifoid appendix, on the midline. A 30°–40° laparoscope is inserted through this trocar.
• Trocar B—The second port is 5 cm to the left and parallel to trocar A in the hemiclavicular line, with a 12-mm trocar.
• Trocar C—The third puncture is done at the left anterior axillary line, under the costal margin, with a 12-mm trocar.
• Trocar D—The fourth port is positioned under the Xifoid appendix, where a 5 or 10-mm trocar is inserted for liver retraction.
• Trocar E—The fifth puncture is done at the right hemiclavicular line, under the costal margin.

We use Trocar B and E as working ports; eventually, trocar C can be used for that purpose. The operating table is turned right to improve ergonomics. The five ports were enough for the great majority of patients, but in super-obese, longilineal patients, or with severe steatotic liver, other punctures may be necessary for a safe surgery.

### Gastric Pouch and Enteroenteric Anastomoses

The first step is the dissection of the His angle and the perigastric (cardia) fat tissue removal, which improves the pouch final stapling.

The lesser curvature of the stomach is opened 8–10 cm far from the esophagogastric junction to reach the retrogastric space, and that is where gastric transection starts with an endoscopic linear stapler, through trocar E, in an oblique and ascending way. During this step, it is important ...

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