SURGEON AT WORK

A Technique of Enteroenterostomy to PreventAlimentary Limb Obstruction in LaparoscopicRoux-en-Y Gastric BypassArif Ahmad, MD, FRCS(Eng), FRCS(Edin), Kevin Cho, MD, Collin Brathwaite, MD, FACS, FCCP

Laparoscopic Roux-en-Y gastric bypass (RYGBP) hasrapidly become a widely accepted treatment option forpatients with morbid obesity, producing weight loss asdramatic as the open operation while minimizing theincidence of postoperative wound infection and inci-sional hernia.1 Pain is less and recuperation is improved.2

Currently, the technique for stapled closure of theenterotomy in laparoscopic RYGBP consists of aligningthe alimentary and biliopancreatic limbs, creating anenterotomy on the antimesenteric side of each loop, andinserting a linear stapler through the enterotomies intothe proximal segments of bowel. The stapler is fired onceor twice in the same direction to create a side-to-sideanastomosis between the two loops of bowel. In the finalstep, traction is used to pull up the enterotomy. Thestapler is then laid across and fired to close theenterotomy.

Stapled closure of the enterotomy may result in nar-rowing and potential obstruction of either the alimen-tary limb or the biliopancreatic limb,3 because it is oftendifficult to assess and control the amount of tissue beingtransected during this closure. On the other hand, thetrue corner of the enterotomy must be visualized andincorporated in the staple line to ensure complete clo-sure. For this reason, sutures are placed on the edges ofthe enterotomy before stapling. This step requires care-ful consideration because narrowing of the alimentarylimb is a significant technical hazard at this stage.4 Nar-rowing of the biliopancreatic limb is less likely, but in-advertent closure of the enteroenterostomy may occur,resulting in biliopancreatic limb obstruction and, inturn, anastomotic dehiscence.5

Our objective is to describe a method of stapled en-teroenterostomy that avoids narrowing of the alimentaryor biliopancreatic limb, yet offers an easy and secureclosure of the enterotomy.

METHODSInitially, the bowel loops selected for enteroenterostomyare aligned parallel to each other by using an Endo Stitch(United States Surgical Corporation) to place inter-rupted 2-0 Vicryl (Ethicon) sutures. We recommendplacing at least three sutures to ensure correct alignment:one in the middle and two at its edges (Fig. 1). Enteroto-

No competing interests declared.

Presented as a poster at the annual meeting of the Society of American Gas-trointestinal Endoscopic Surgeons (SAGES), Los Angeles, CA, March 2003.

Received March 5, 2003; Revised June 4, 2003; Accepted August 11, 2003.From the Department of Surgery, State University of New York at StonyBrook School of Medicine, Stony Brook, NY.Correspondence address: Arif Ahmad, MD, Department of Surgery, StateUniversity of New York at Stony Brook School of Medicine, HSC, Level 18,Rm 060, Stony Brook, NY 11794.

Figure 1. Bowel loops aligned with interrupted sutures before cre-ation of enterotomies.

159© 2004 by the American College of Surgeons ISSN 1072-7515/04/$30.00Published by Elsevier Inc. doi:10.1016/j.jamcollsurg.2003.08.025

mies are made on the antimesenteric side of each loop, inthe center of the aligned loops. A 45-mm cartridge of a2.5-mm laparoscopic linear stapler is then directed prox-imally through the enterotomy to create an enteroenter-ostomy proximal to the enterotomy (Fig. 2). The linearstapler is then inserted distally to create an enteroenter-ostomy distal to the enterotomy (Fig. 3). The resultingcommon enterotomy lies in the middle of the two en-teroenterostomies. The edges of the enterotomy are heldup by the three sutures, and care is taken to incorporatethe center and edges, aligning them transverse to theenteroenterostomy. It is important to ensure that thecenter and the edges of the enterotomy have been incor-porated in the staple line. This is facilitated by placingsutures at these locations as described previously. Thelinear stapler is now fired transversely to close the com-mon enterotomy (Fig. 4). The final appearance of theanastomosis is produced by transverse closure of the en-

terotomy defect with enteroenterostomies both proxi-mal and distal to this line of closure (Fig. 5).

Finally, it is important to close the mesenteric defect

Figure 2. Linear stapler fired proximally through the enterotomy tocreate a proximal enteroenterostomy.

Figure 3. Linear stapler fired distally to create a distal enteroen-terostomy.

Figure 4. Linear stapler fired transversely to close the commonenterotomy.

160 Ahmad et al Enteroenterostomy Technique in Gastric Bypass J Am Coll Surg

and place an antiobstruction stitch (Brolin stitch) justdistal to the enteroenterostomy in the standard fashion.

DISCUSSIONIn a commonly used technique that involves unidirec-tional firing of the linear stapler, the enteroenterostomyis created in only a proximal direction to the enterotomy.Subsequent closure of the enterotomy can result in nar-rowing of the enteroenterostomy and obstruction at thesite of closure (Fig. 6). As mentioned earlier, obstructionof the biliopancreatic limb, although rare, may lead todisastrous consequences, including anastomotic dehis-

cence. Some surgeons have successfully avoided theproblem of narrowing by using simple suture closure ofthe common enterotomy.3

In the technique we describe, narrowing at the enter-otomy site does not occur because it is positioned in thecenter of proximal and distal enteroenterostomies cre-ated by bidirectional firing of the linear stapler. If, dur-ing closure of the enterotomy, narrowing of one of theloops of bowel occurs, the enteroenterostomies on eitherside of this narrowing provide an alternative channel forenteric contents, preventing bowel obstruction (Fig. 7).

Many experienced bariatric surgeons with advancedlaparoscopic skills have abandoned the stapled tech-nique of enterotomy closure because of the inherentdanger of narrowing and obstruction. Instead, simplerunning suture closure of the enterotomy is used bythese surgeons. The technical difficulty of hand-suturedclosure of the enterotomy using a single-layer techniquewill vary according to the technical skill of the surgeoninvolved. With the bidirectional firing technique wehave described, we have been satisfied in all instanceswith both the luminal diameter and the secure closure ofthe enterotomy. Two additional reloads of the staplercost approximately $250 at our institution.

Since February 2002, we have used this techniqueroutinely in 75 successive patients, in both open andlaparoscopic procedures, without any cases of obstruc-tion or leakage. Bidirectional firing of the linear staplereffectively prevents alimentary limb obstruction in sta-pled enteroenterostomy.

Figure 5. Final appearance of the bowel anastomosis showingtransverse closure of the enterotomy defect. Enteroenterostomiesspan proximally and distally to this line of closure.

Figure 6. Unidirectional firing of the linear stapler might result innarrowing of the enteroenterostomy and obstruction at the site ofclosure.

Figure 7. Bidirectional firing creates enteroenterostomies on eitherside of a potential narrowing, providing an alternative channel forenteric contents and preventing bowel obstruction.

161Vol. 198, No. 1, January 2004 Ahmad et al Enteroenterostomy Technique in Gastric Bypass

Author ContributionsStudy conception and design: AhmadAcquisition of data: AhmadAnalysis and interpretation of data: Ahmad, ChoDrafting of manuscript: Ahmad, ChoCritical revision: BrathwaiteSupervision: AhmadOther (specify): Preparing figures: Cho

Acknowledgment: We are grateful to Mr Gerald Bushart fortechnical assistance in preparing photos and graphics.

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3. Nguyen NT, Neuhaus AM, Ho HS, et al. A prospective evalua-tion of intracorporeal laparoscopic small bowel anastomosis dur-ing gastric bypass. Obes Surg 2001;11:196–199.

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5. Jones KB. Biliopancreatic limb obstruction in gastric bypass at orproximal to the jejunojejunostomy: a potentially deadly, cata-strophic event. Obes Surg 1996;6:485–493.

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