laparoscopic gastric bypass: addressing potential complications
TRANSCRIPT
Laparoscopic Gastric Bypass:Addressing Potential
Complications
George S. Ferzli, MD, FACS
New York, NY
GASTRIC BYPASS WITHROUX-en-Y LIMB
Roux-en-Y Gastric Bypass
50 mL POUCH WITH A ROUXLIMB
COMBINED RESTRICTIVEAND MALABSORPTIVE
Complications ofGastric Bypass
• Overall as high as 20%, including:– Anastamotic leak (1-3%)– GI hemorrhage (1.5-2.5%)– Stomal stenosis (4-14%)– Bowel obstruction (.5-8%)– Pulmonary embolus (.01-1%)– Mortality (.1-4%)
Schwartz et al. Laparoscopic Roux-en-Y gastric bypass: Preoperative determinants of prolonged operative times, conversion to open gastric bypass, and postoperative complications. Obes Surg 2003 Oct; 13(5): 734-8
Podnos et al. Complications after laparoscopic gastric bypass: a review of 3464 cases. Arch Surg 2003 Sept; 138(9): 957-61
Laparoscopic Gastric Bypass
• Identifying potential sources of complications– Jejunal division, mesenteric division
• Ischemia, bleeding– Jejuno-jejunostomy
• Leak, stenosis
Laparoscopic Gastric Bypass
– Mesenteric defect at jejuno-jejunostomy• Internal herniation/bowel obstruction
– Gastric pouch• Improper size, bleeding
– Gastro-jejunostomy• Leak, stenosis
Laparoscopic Gastric Bypass:Jejunal Division
• Identification of ligament of Treitz
• Once identified, measure distally to point to jejunal division
Laparoscopic Gastric Bypass:Jejunal Division
• Will Roux limb reach gastric pouch?– Assure tension-free
anastamosis
– Gastro-jejunal anastamosis will sit at inferior liver edge for easy access
Laparoscopic Gastric Bypass:Jejunal Division
• Mark proximal jejunum– Distinguishes this
proximal end from distal Roux limb
– Prevent closed loop “O” when forming jenuno-jejunostomy
Laparoscopic Gastric Bypass:Jejunal Division
• Minimal mesenteric division– Unnecessary to divide
vessels beyond mesenteric border of small bowel
– Avoid potential ischemia to Roux limb
Laparoscopic Gastric Bypass:Jejuno-jejunostomy
• Proper orientation of segments– Side-to-side, abutting
anti-mesenteric borders of small bowel
• Generous anastamosis– Prevent potential
stricture/obstruction– Hand-sewn closure of
common enterotomy
Laparoscopic Gastric Bypass:Jejuno-jejunostomy
• Generous anastamosis– Single full-length
60mm stapled anastamosis
– Hand-sewn closure of common enterotomy
Laparoscopic Gastric Bypass:Mesenteric Defect
• Created at jejuno-jejunostomy– Potential site for internal
herniation
• Closed with shallow, interrupted peritoneal stitches– Avoid deep stitches
which may compromise vasculature
Laparoscopic Gastric Bypass:Gastric Pouch
• Enter lesser sac at lesser curvature– At approximately first
gastric vein, avoids excessively large pouch
– Horizontal stapled division without complete gastric transection
Laparoscopic Gastric Bypass:Gastric Pouch
• Vertical division to angle of His– Calibration tube in
place allows for appropriately-sized gastric pouch
Laparoscopic Gastric Bypass:Gastric Pouch
• Vertical division to angle of His– Assured complete
transection at angle of His
Laparoscopic Gastric Bypass:Gastro-jejunostomy
• Ante-colic/Ante gastric– Anastamosis easily
accessible at inferior liver edge
– Avoids dissection in transverse mesocolon
– May need to split omentum if tension exists
Laparoscopic Gastric Bypass:Gastro-jejunostomy
• Assure proper orientation of Roux limb– Sutures taken at anti-
mesenteric border of Roux limb
Laparoscopic Gastric Bypass:Gastro-jejunostomy
• 1cm anastamosis– Maximizes restrictive
component of procedure
– Avoid excessive suturing
• Minimize potential ischemia at anastamosis
Laparoscopic Gastric Bypass:Gastro-jejunostomy
• 1cm anastamosis– Calibration tube passes
freely
– Avoid taking posterior wall with anterior sutures
Laparoscopic Gastric Bypass:Gastro-jejunostomy
• Leak test under direct vision
• Dye and air both utilized, under pressure– Decreases likelihood of
missing small leaks– Direct visualization
allows for immediate repair/reinforcement
Laparoscopic Gastric Bypass:Addressing Potential Complications
• Systematic, step-wise approach
• Rigorous adherence to surgical principles– Avoid excessive dissection– Avoid tension at anastamoses– Avoid excessive suturing
• The best way to avoid complications is to think about them!