Tips and tricks for jejuno-jejunostomy in laparoscopic gastric bypass

This video demonstrates a technique of jejunojejunostomy in an antecolic Roux-en-Y gastric bypass procedure. The surgeon shows how to measure the alimentary and biliary limb and to complete the anastomosis without twisting of the bowel. He also demonstrates the closure of mesenteric defects, which could be potential sites of herniation.

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Tips and tricks for jejuno-jejunostomy in laparoscopic gastric bypass

Authors

M Vix, M Simone, F Rubino, J Marescaux

Abstract

This video demonstrates a technique of jejunojejunostomy in an antecolic Roux-en-Y gastric bypass procedure. The surgeon shows how to measure the alimentary and biliary limb and to complete the anastomosis without twisting of the bowel. He also demonstrates the closure of mesenteric defects, which could be potential sites of herniation.

Classification

tips and tricks

Keywords

jejuno-jejunostomy, laparoscopy, gastric bypass

Media type

Surgical video

Duration

08'00''

Publication

2006-07

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E-publication

WeBSurg.com, Jul 2006;6(07).
URL: http://www.websurg.com/doi-vd01en1997.htm

Tips and tricks for jejuno-jejunostomy in laparoscopic gastric bypass

1. Identification of the Treitz ligament 00'05''

In this video we show how to prepare the anastomosis for a gastric bypass. The 1st step is to split the omentum. We then find the ligament of Treitz. This is facilitated by mobilization of the transverse colon and the greater omentum upwards. We start to measure the biliary limb which we excluded from the transit of nutrients. We routinely measure a length of 75cm distal to the ligament of Treitz. We use a clockwise rotation of the bowel and we use a standardized grasper with the steri-strips placed at a distance of 5cm from the tip. Sometimes it is possible to use a string of 5 or 10cm which we can hold with the grasper during the measurement of the bowel. We use atraumatic fenestrated graspers on the bowel. The extremity of the bowel is fixed with a stitch on the stomach to identify where we will do the jejuno-jejunostomy lateral-lateral anastomosis with the alimentary limb. We mark with the dermic pencil the biliary limb in order to avoid making a mistake.

2. Identification of the biliary limb 01'28''

We then measure a length of about 150cm in order to choose the site for the entero-enteral anastomosis. The alimentary limb is now measured by pushing the bowel limbs in an anti-clockwise fashion.When the 2 bowel limbs for the anastomosis are side by side, we fix them together with a stitch. This position also allows comfortable introduction of the Endo-GIA for the anastomosis as the bowel loops lie on the same axis as the Endo-GIA introduced from the trocar on the left flank.

3. Entero-enterostomy 02'05''

The 2nd assistant holds the alimentary limb for the correct positioning of the anastomosis to be performed. The enterotomy should be as small as possible and great care should be taken in making sure that the mucosa is actually opened. Incomplete opening of the mucosa can then lead to dissection of the small bowel wall or tearing when introducing the Endo-GIA for the anastomosis. We use a white cartridge of 60mm length.

4. Use of linear stapler 02'36''

The assistant should hold the bowel only to expose the enterotomy. When the blade of the stapler is engaged in the enterotomy, the bowel should be immediately released by the assistant to allow a safe anastomosis to be performed. For the closure of the enterotomy, we always prefer an intracorporeal suture since a stapled closure may result in a stenosis.

5. Closure of enterotomy 03'02''

We use 2 running sutures started at each corner of the enterotomy. The lower corner suture is placed first because when the enterotomy is still wide open, it is easier to make sure that the stitch incorporates the real corner it is not leaving open inferior to it. Furthermore, the running suture can be grasped and used to expose the enterotomy while suturing. We use a 2/0 braided suture.

6. Closure of the mesentery 03'46''

We routinely close all mesenteric defects as it is being shown that there is an internal hernia after laparoscopic gastric bypass. To do so, the end of the duodenal limb is pulled in order to proper expose the mesenteric defect and a 3/0 running monofilament suture is used. To perform this step, the surgeon often remains between the legs and uses backward orientated stitches from the lower part of the defect towards the upper part of the inferior margin of the bowel, and indeed this is what is being performed in this case. Sometimes we prefer to pass the stitches vertically on the axis of the mesentery as this allows more tissue to be taken and less risk to entrap vessels within the stitch. The running suture is left loose just until the last stitch and when it is gently pulled at the end. The last stitch should incorporate the serosa of the bowel to ensure a complete closure of the defect. The suture is then finished with an intracorporeal knot or with a clip. If a clip is used, we must make sure that some tissue is also incorporated in order that it does not to become loose. We make a small indentation below the bowel and then a hole in the mesentery, and through this, we introduce the 60mm white linear stapler.

7. Alimentary limb 05'20''

The mesentery can then be opened with the Ligasure or other device in order to have a good length of the bowel that goes towards the gastric pouch and avoids any tension on the JJ anastomosis.