Selection of patients for bariatric procedures is based on evidenced-based guidelines. Patients must have failed dietary therapy and have a body mass index (BMI) greater than 40 kg/m2 without associated medical conditions or a BMI greater than 35 kg/m2 with associated medical condition(s). In addition, practical considerations for the patient to be a candidate for the procedure include psychiatric stability, a motivated attitude, and comprehension of the nature of the procedure and the changes in eating that will follow the procedure.
A team approach is necessary for the optimal care of the patient with morbid obesity. Prior to the initial clinic visit, the patient must provide evidence of a medically supervised diet, counseling and referral from a primary care physician, and completion of a reading assignment to include a comprehensive review of bariatric surgery including the types of procedures, expected results, and possible complications or attendance at a seminar regarding the same. At the initial visit the patient is expected to attend a group session on bariatric surgery and a presentation by the nutritionalist on dietary issues preoperatively and postoperatively. In addition, the patient has individual assessment and counseling with the surgical team and the dietician. Subsequent evaluations may include, as indicated, a full psychological evaluation, specialty medical evaluation, ultrasound of the gallbladder, and a pulmonary evaluation including baseline arterial blood gases. Finally, preoperative assessment by anesthesiology is warranted.
General endotracheal tube anesthesia is required for the procedure. The anesthesiologist should be prepared for the potential of a difficult intubation including the availability of flexible brochoscopy to assist placement of the endotracheal tube.
The patient is transferred to the operating room table with a lateral transfer device. The patient is placed in the supine position and secured to the operating room table with Velcro leg straps and a spindle sheet for the pelvis. The arms are placed on arm boards, and sometimes the left arm is tucked at the side. Additional securing of the patient to the table with tape may be appropriate. Figure 1A shows the room setup.
Preoperative antibiotics are administered and venous thromboembolism prophylaxis is employed. Hair on the abdominal wall is removed with a clipper. A Foley catheter is placed and an orogastric tube is positioned.
The abdomen is prepared and draped in the standard surgical fashion. A small transverse skin incision is made in the left upper quadrant through which a Veress needle is inserted and pneumoperitoneum is established to a maximum pressure of 15 mm Hg. The Veress needle is withdrawn and a 12-mm port is placed. A 10-mm 30-degree laparoscope is inserted into the abdominal cavity and the peritoneal cavity and viscera inspected to ensure that there is no evidence of port insertion injury. Next, a supraumbilical 10-mm port, a right upper quadrant 15-mm port, and right and left upper quadrant 5-mm ports are placed under direct visualization (Figure 1B). The greater omentum is elevated, exposing the transverse colon and ligament of Treitz (Figure 2A).
In some centers, staple lines are reinforced with absorbable material such as polyglycolic/trimethylene carbonate copolymer fiber. The staple lines that may benefit from reinforcement are so indicated. The jejunum is divided approximately 30 cm from the ligament of Treitz with an endoscopic stapler (Figure 2B). The small bowel mesentery is divided with an endoscopic linear stapler with reinforcement to provide extra length to the Roux limb. It may be helpful to mark the proximal portion of the efferent limb of the Roux loop of jejunum with a blue Penrose drain in order to avoid confusing the divided ends of the jejunum. This will be later anastomosed to the gastric pouch. The efferent Roux limb is then measured 150 cm from the division of the bowel (Figure 2B), at which point a side-to-side jejunojejunostomy is performed between the distal Roux limb and the biliopancreatic limb (Figure 3). The two small bowel segments are aligned along their antimesenteric surface with a 2-0 Polysorb suture. Two small enterotomies are made on the antimesenteric surface with an ultrasonic device. A side-to-side jejunojejunostomy is performed with an endoscopic linear stapler. The enterotomy is closed transversely with an endoscopic linear stapler. A 2-0 non-absorbable anti-torsion suture is placed. The mesenteric defect at the jejunojejunostomy is closed with a running 2-0 non-absorbable suture. The Roux limb is then traced back proximally to verify appropriate orientation. The greater omentum is divided with the ultrasonics device, taking care to avoid injury to the underlying transverse colon (Figure 2A). This provides space for passage of the Roux limb in an antecolic fashion to the gastric pouch.
The patient is placed in the reverse Trendelenburg position and the orogastric tube is removed. A liver retractor is inserted in one of the proximal ports. The left lateral segment of the liver is retracted anteriorly exposing the gastroesophageal junction. The pars flaccida is divided bluntly providing exposure to the lesser sac. The lesser omentum is divided with an endoscopic linear stapler with reinforcement to the lesser curvature approximately 4 cm from the gastroesophageal junction. Once this is completed, a distal gastrotomy is made with the ultrasonics device (Figure 4). A 25-mm circular stapler is usually employed for the gastrojejunostomy. This may be reinforced. The anvil of the stapler is inserted into the stomach through the distal gastrotomy. A second small gastrotomy is made along the lesser curvature approximately 4 cm distal to the gastroesophageal junction using an articulating dissector and an ultrasonics device (Figure 5). The tip of the anvil is delivered through the proximal gastrotomy (Figure 6). The distal gastrotomy is then closed with an endoscopic stapler.
Attention is then turned toward creation of a 30 mL gastric pouch (Figure 6). The first staple line is made transversely, closely approximating the anvil with a reinforced endoscopic linear stapler (3.8-mm staple). The next several staple lines are made longitudinally toward the angle of His with a reinforced endoscopic linear stapler. Complete division of the stomach is verified by laparoscopic visualization. Next, the proximal efferent Roux limb is brought in an antecolic fashion to the gastric pouch. If placed, the blue Penrose drain is removed and the proximal 3 cm of mesentery is divided with an endo-GIA gray stapler. The jejunal staple line is opened with the ultrasonics device. The 25-mm circular stapler is inserted into the enterotomy of the Roux limb (Figure 7). The spike of the circular stapler is advanced through the antimesenteric surface of the jejunum. The anvil of the gastric pouch is connected to the stapler (Figure 7). A stapled gastrojejunostomy is performed (Figure 8). The jejunal enterotomy is closed with an endoscopic linear stapler resecting the distal 3 cm of the Roux limb that is passed from the field. A 2-0 absorbable anti-tension suture is placed at the gastrojejunal anastomosis.
Next, an intraoperative upper endoscopy is performed to determine patency of the gastrojejunal anastomosis and the presence of intraluminal bleeding. If bleeding is encountered, it may be controlled with a reinforcing suture. The gastric pouch is insufflated under saline. No bubbles should be identified, indicating absence of an anastomotic leak. If bubbles are seen, the staple line should be oversewn.
The liver retractor is removed. The fascia of the 15-mm port site is closed with two interrupted 0 absorbable sutures. It may be helpful to use a Carter-Thompson device for this purpose. The remainder of the ports are withdrawn under direct visualization and inspected for evidence of bleeding. The camera is withdrawn and the abdomen is deflated. The subcutaneous tissues are irrigated with saline solution and all skin incisions are closed with 4-0 absorbable subcuticular sutures. The skin is cleaned and dried. Steri-Strips are applied.
Appropriate fluid resuscitation is required and urine output monitored with a Foley catheter for the first 24 hours. A nasogastric tube is not necessary. A contrast study may be obtained on postoperative day 1 to determine the presence or absence of a leak from the gastrojejunostomy or obstruction. If there is no leak or obstruction, or in the absence of a contrast study, if the patient exhibits no tachycardia or temperature greater than 100°F, then a trial of water with advancement to liquids as tolerated may be started. The timing of discharge is usually 2 to 3 days but may be influenced by many factors. The patient is seen within 30 days to assess oral intake and wound healing. Patients with diabetes may experience decreasing insulin requirements and even hypoglycemic episodes that precede significant weight loss. Long-term follow-up is required in all patients.