The positioning of the patient requires an adequate surgical table capable of safely bearing the weight and must also be capable of changing position during the procedure. We must pay especially close attention to the pressure areas, since due to the patient's weight, there is a greater risk of ischemic, vein, and nervous injuries.
The patient is placed supine with abducted legs; right upper member abducted and left upper arm along side the body. The anesthesiologist is at the patient's head.
The laparoscopy monitor should be placed to the right of the patient, next to the head of the table.
The surgery is divided into three distinctive stages. In the first stage, the surgical table is placed in a moderate reverse Trendelenburg. During this stage, the surgeon stands between the legs of the patient. The first assistant, who also operates the camera, is placed to the left of the surgeon, the second assistant on the right, and the scrub nurse holder next to the second assistant (Figure 28–2).
Positioning of the team during the first and third stages of the surgery.
During the second stage of the surgery, the table is placed in moderate Trendelenburg. The laparoscopy monitor is moved toward the trunk of the patient; the surgeon is at the left of the patient, close to the patient's shoulder, having the first assistant to his left. The second assistant should be placed to the right of the patient (Figure 28–3).
Positioning of the team during the second stage.
During the third and last stage of the surgery, the whole team should return to the start position.
Positioning of the Trocars
The pneumoperitoneum is done using the Veress needle into the left upper quadrant, close to the costal margin, at the level of the mid-clavicular line. CO2 pressure should be maintained at 15 mm/Hg during the procedure.
A total of six6 trocars are used (Figure 28–4):
- Trocar 1 (10 mm) is introduced in the midline, supraumbilically and about 20 cm below the xiphoid process. In morbidly obese patients, the umbilical scar should never be used as an anatomic point of reference for the introduction of the trocars.
- Trocar 2 (12 mm) is positioned on the outer border of the left abdominal rectus close to the costal margin, at the level of the mid-clavicular line.
- Trocar 3 (10 mm) is introduced close to the xiphoid process.
- Trocar 4 (5 mm) is introduced in the right upper quadrant, close to the costal margin, at the level of the right axillary line.
- Trocar 5 (12 mm) is introduced halfway up an imaginary line traced between trocars 1 and 4.
- Trocar 6 (10 mm) is introduced about 10 cm below trocar 2, at the same level of that one.
Positioning of the trocars.
The procedure is entirely done with a 10-mm and 30° optical system.
First Stage of the Surgery
The first stage of the surgery is the cholecystectomy and the gastrectomy.
During the cholecystectomy, optical system is placed at portal 1, and the grasping forceps at portal 4 so that the assistant can lift the falciform ligament, thus exposing the gallbladder. The surgeon then works with a grasping forceps at portal 5 and a dissection forceps at portal 2. The exposure of the liver is made by means of portal 3 by using the liver retractor. The cholecystectomy is made by sectioning the cystic artery and ducts with a metallic clip and later dissection with a harmonic scalpel. The gallbladder is left in the right hypochondrium over the liver to be removed from the abdominal cavity at the end of the surgery (Figure 28–5).
Gastrectomy and Duodenal Section
During the gastrectomy, the optical system stays in portal 1; the first assistant uses the grasping forceps in portal 4 to expose the stomach. The surgeon uses portal 2 for the harmonic scalpel and portal 5 for the grasping forceps, thus exposing and dissecting the stomach. The second assistant pushes the liver away by means of portal 3.
The gastrectomy is made in the cranium-caudal direction following the great curvature and starting about 15 cm below the angle of His. This dissection is always made with the harmonic scalpel, and close to the gastric wall, aiming at reducing bleeding, and it extends down to 2 cm distal from the pylorus (Figure 28–6).
Dissection of the great curvature.
After the greater curve is freed by means of a small hole in the lesser gastric curvature, about 3 cm above the pylorus, from this point on the lesser curvature is dissected in the caudal direction, down to 2 cm distal to the pylorus in order to fully free the proximal duodenum. After this stage, the duodenal transaction is done with a linear endostapler (Figure 28–7).
After the duodenal transection, the stomach is cranially pulled in order to facilitate the dissection of the lesser gastric curvature, which is made up to the level of the left gastric artery, always close to the gastric wall, so as to prevent bleeding.
Once the level of the left gastric artery is reached, the full gastric transaction from the greater curve is done with the linear endostapler (Figure 28–8).
At this point the orogastric catheter is removed. The remaining stomach is left with a volume of approximately 400 mL.
The divided stomach is left in the patient's left hypochondrium to be removed at the end of surgery together with the gallbladder.
Second Stage of the Surgery
During this stage, the surgeon positions himself at the level of the patient's left shoulder, having the first assistant on his left and the second assistant on the right of the patient.
The surgical table is placed in a moderate Trendelenburg position. The optical system is placed in portal 2 by the first assistant.
The surgeon uses portals 5 and 6 by grasping forceps for measuring the intestinal loops, and one of them has a mark cut 10 cm from the distal extremity. Via portal 3, the introduction of the needle holder for stitches is done when necessary. The second assistant uses portal 4 for exposing the loops and helping with the stitches.
Measurement of the Loop and Enteroanastomosis
In the second part of the operation, the ileocecal junction is identified, and the ileal loop is measured from this point. The measurement is made with two forceps, measuring at 10 cm increments on the antimesenteric margin, completely stretched in order to obtain a correct measurement. When the 50 cm measurement is completed, a stitch is applied, and the enteroanastomosis will be performed at this point (Figure 28–9).
Measurement of the intestinal loop.
The measurement of the loop continues up to 250 cm from the ileocecal valve, at which level it is divided using the linear endostapler, which is introduced into the cavity through portal 5 (Figure 28–10).
Thus, we have already defined the alimentary limb, which will later be anastomosed to the stomach.
At this point of the surgery, a Penrose drain is stitched to the margin of the alimentary limb to help in passing it through the orifice made on the mesocolon (Figure 28–11).
We proceed now to the opening of the mesentery down to its root, which can be done with the linear endostapler or by using the harmonic scalpel. At this point, one can sporadically use metallic clips to improve hemostasis (Figure 28–12).
Opening of the mesentery.
Care is taken to run grasping forceps along the entire alimentary limb and to arrange it on the right side of the abdominal cavity, thus identifying the stitch left 50 cm from the ileocecal valve. We have already identified the alimentary limb and the biliopancreatic limb; at this time, therefore, the enteroanastomosis in isoperistatic position is done. This is done first by opening a small orifice into both loops with the harmonic scalpel and passing a linear endostapler through this orifice. The orifice of the endostapler is closed in a running seromuscular suture (Figure 28–13).
Once the anastomosis is concluded, the mesenteric opening should always be closed with running suture (Figure 28–14).
Third Stage of the Surgery
At this point, the entire surgical team returns to the position of the first stage of the surgery, as well as the laparoscopy set.
The first assistant is responsible for the optical system, which is introduced into portal 1 and, by means of a grasping forceps, into portal 4. The surgeon uses portals 2, 5, and 6 for exposure, mesocolon opening, and gastroenteroanastomosis. And the second assistant uses portal 3 to expose the liver.
The transverse colon is pulled cephalic in order to identify the ligament of Treitz, and about 2 cm above it the mesocolon is opened about 3 cm in order to pass the alimentary limb (Figure 28–15).
Opening of the mesocolon.
After the proper positioning of the alimentary limb through the transverse mesocolon, the continuous seromuscular suture between the posterior wall of the stomach and the alimentary limb is made. This suture is made so as to facilitate the simultaneous introduction of the linear endostapler into the stomach and the loop in order to perform the gastroenteroanastomosis. The orifice of the endostapler is closed by means of a running seromuscular suture (Figure 28–16).
After the gastroenteroanastomosis is finished, the mesocolon opening is closed. The gastroenteroanastomosis can also be done in the same way described above, but with the alimentary limb in a precolic position, at the surgeon's option.
After the surgical procedure is finished, portal 2 is widened to 2 cm, and through it gallbladder and the stomach are removed. In this place, the aponeurosis is closed with separate stitches.