Surgical Technique

Disposition of patient
The patient was taken to the operating room after signing a detailed consent form. Low dose subcutaneous heparin was administered on call to the OR. The patient was positioned supine with the legs apart and was carefully strapped to the OR table. The surgeon stood between the patient’s legs. A laparoscopy tower was placed to the left of the patient’s head. General anesthesia with endotracheal intubation was used. A nasogastric tube was inserted and abdominal insufflation up to 15 mm Hg obtained with the insertion of a Veress needle at the patient’s umbilicus.

Disposition of the trocar
Trocars were placed under direct view of a transumbilical 5mm laparoscope as for laparoscopic adjustable gastric band (lapband)4, but a 12 mm disposable trocar was used in the right upper quadrant and a 5mm trocar was used halfway between the xyphoid appendix and the umbilicus for insertion of a 0 degree 5mm laparoscope (Storz, Tüttlingen, Germany). The patient was placed in steep reversed Trendelenburg. The liver was retracted with a 10 mm disposable fan shaped retractor (US Surgical, Norwalk, CT) inserted through the subxyphoid port. The root of the left diaphragmatic crus was exposed by caudad traction on the stomach fundus by the assistant to the patient’s left. and the phrenogastric ligament was incised at the level of the angle of Hiss.

Dissection of the lesser curvature and angle of Hiss
Dissection was then initiated at the lesser curvature. The third vessel (counting from proximal) was identified at this lesser curvature and a plane developed between Latarjet’s pedicle and the serosa of the stomach at that level. By continuing the dissection posteriorly the lesser sac was entered.

Realisation of gastric pouch
A small incision was the made by cautery at the upper level of the dissected area and a grasper coming from the right upper quadrant was inserted in this defect and pushed laterally until it protruded at the level of the fundus, not far from the greater curvature (fig1). An incision was then made at that level by cautery and the tip of the grasper was allowed to be pushed outside. This latter opening was then widened generously.

Realisation of gastro-jejenal anastomosis
The anvil of the 25 mm circular stapler was then introduced intraperitoneally by slightly enlarging the trocar opening located in the left upper quadrant at the midclavicular level. The stem of the anvil was grasped by the grasper emerging out of the stomach and pulled towards the lesser curvature until it emerged out of the stomach. A purse string was performed with 2/0 Prolene in order to reinforce the punch hole through which the anvil’s stem had been pulled out. The gastrostomy was closed with one firing of the linear stapler, blue load.

The linear stapler, blue load of staples was then introduced through the right upper quadrant 12 mm trocar, aimed at the lesser curvature dissection level and fired. The stapler was reloaded and introduced in the left upper quadrant 12 mm trocar and aimed from the left lateral section level towards the angle of Hiss. Two firings of the stapler disconnected the small upper stomach from the rest of the stomach. Hemostasis of the suture line was carried out by placement of hemostatic “medium” clips.

The patient was now placed in Trendelenburg position, the greater omentum was transectedlongitudinally, by use of the Harmonic Scalpel from its free edge up to the transverse colon.The omentum and transverse colon were swept superiorly and the angle of Treitz was identified. From that site, the bowel was lifted towards the hiatus and a loop identified that could reach this level easily with minimal traction. The bowel was then scored with the electrocautery so as to keep perfect orientation and permanent identification of what was to be the alimentary and the biliary loop. A generous incision was made on the proximal part of the loop, care being taken not to transect the bowel entirely.

The circular stapler was introduced through the same opening as the anvil and advanced to the hole in the bowel loop. The shaft was advanced into the lumen over some 5 cm. The spike of the circular stapler was pushed through the bowel wall by turning the hanle of the stapler and the pike was joined with the anvil’s stem and clicked together. The device was fired and the stapler pulled out. The doughnuts were verified, confirming the integrity of the anastomosis.

150 cm were measured from this level distally on the small bowel by running the bowel against a grasper with a marking at 5cm from the tip. The bowel was again scored by cautery at that level and this spot was stitched loosely to the loop just proxiùmal to the gastro enterostomy. A small hole was made in both limbs 1 cm from the stitch and the linear stapler white load was introduced into the openings and fired. In case 45 mm loads were used the stapler was fired twice; one firing was judged sufficient with 60 mm loads. The enterotomy openings were closed manually with silk 2/0 or PDS 3/0 (Ethicon, Neuilly, France).

Jejeno jenual anastomasis
The mesentery of the bowel at the level of the circular stapler introduction site was coagulated with the Harmonic scissors until a window was created. The linear stapler, white load, introduced in this window was used to transect and staple shut the bowel on both sides of this introduction defect hereby concluding the Roux-en-Y construction.

A nasogastric tube was introduced by the anesthesiologist. The operating field was immersed in saline solution and 50 cc of air was insufflated through the nasogastric tube by the anesthesiologist. No air bubbles testified of the integrity of the gastro enteral anastomosis. A Penrose drain was placed in the vicinity of both anastomotic sites and the trocar sites were closed in layers.