clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer

Laparoscopic approach (A-1):

The patient is placed in the lithotomy position in steep reverse Trendelenburg tilt with arms positioned upwards. The operating surgeon stands between the legs, first assistant on the left, and the second on the right side of the patient. Two monitors are placed at the head of the bed. Afterwards, six trocars are inserted:

1.One 10/12mm on the right in the mid-clavicular line distal to the costal arch for the liver retractor

2.One 5mm right in the mid-clavicular line 15cm caudal to the costal arch for the grasper and needle driver

3.One 10/12mm in the midline 15cm caudal to the xiphoid as the optic port

4.One 10/12mm in the midline halfway between the xiphoid and umbilicus for the linear cutter, grasper, and ultracision

5.One 10/12mm on the left in the mid-clavicular line just distal to the costal arch for the linear cutter, grasper, needle holder, and ultracision

6.One 5mm on the left in the mid-clavicular line 15cm caudal to the costal arch for the grasper

Open approach (A-2):

Upper midline incision entering the peritoneal cavity.

Bariatric retractor (Pilling bariatric retractor, Pilling Co., Ft. Washington, PA) for exposure.

A-1

A-2

A-1

A-2

A-3

Laparoscopic approach:

The patient is brought into the supine position; the surgeon and first assistant move to the right side of the patient and the camera is inserted through the right upper port after removing the liver paddle.

The transverse colon is lifted up by two graspers inserted through the left-sided cannulas and the ligament of Treitz is identified.

Transection of the jejunum 50cm distally with 60-mm Endo GIA (white cartridge, 2.5-mm staples minimize staple line bleeding).

Afterwards the mesentery is transected perpendicular to the bowel wall with Ultracision shears or an Endo GIA stapler using white vascular staples (2mm).

The Roux-en-Y limb is measured (150cm or 250cm for superobese patients with BMI >50kg/m2).

Fixation of the biliary limb is done with a one stay suture to the Roux-en-Y limb and a jejunojejunostomy is created with a 60-mm Endo GIA stapler using a white cartridge (A-1). The site of stapler insertion is closed with a running 4-0 polydioxanone suture.

The mesenteric defect should be closed with interrupted stitches of non-reabsorbable suture (Ethibond, Ethicon Co., Cincinnati, OH) (A-2) to prevent internal herniation.

The alimentary Roux-en-Y limb is brought antecolic to the proximal gastric pouch, being very careful to avoid a twist in the mesentery; if the omentum is thick and bulky, it can be transected vertically to allow a path for the Roux limb to be brought antecolic. Open approach:

The proximal jejunum is transected about 50–75cm distal to the ligament of Treitz in an area that both maximizes the blood supply to the proximal aspect of the Roux limb and allows a long transection of the mesentery to gain length. The mesentery is divided by cautery and requires ligation of just one vessel in the arcade that connects the primary feeding vessels from the superior mesenteric artery.

The Roux limb is then brought retrocolic (not antecolic as with a laparoscopic approach) and then antegastric through a wide defect in the gastrocolic ligament.

The defects in the mesocolon and Petersen’s hernia (potential infracolic space posterior to the Roux mesentery and anterior to the retroperitoneum) are closed.

A-1

A-2