Gastric Bypass Revision

Hi. This is Dr. Matthew St. Laurent and today I will be presenting a laparoscopic Roux-en-Y gastric bypass revision. Our operation begins with a 5-millimeter optical trocar entry into the abdomen. The abdomen is then insufflated with carbon dioxide to create a working space. A cursory exam is performed and then we introduce our remaining trocars. We utilize a five-trocar technique for the operation. This includes a liver retractor that we insert underneath the xiphoid process to elevate the left lobe of the liver. Our operation begins by identifying our anatomy. The gastrojejunal anastomosis is identified here, which is the connection between the small stomach pouch and the small intestine. The esophageal hiatus is pointed out here and the stomach pouch created for the Roux-en-Y is identified here. As can be seen here, this is a very large stomach pouch that was created. We then identify the Roux limb of the small intestine. Our operation begins by mobilizing the redundant lateral portion of the Roux-en-Y segment. We utilize the ultrasonic shears to coagulate the blood vessels and take down these lateral fatty attachments. We continue this dissection superiorly until we encounter the gastrojejunal anastomosis. We then take down the adhesions between the small upper stomach pouch and the remnant stomach. It's important to completely mobilize the small gastric pouch so that an adequate resection can be performed. Here, we continue to use the ultrasonic shears to take down the lateral attachments. We continue with this dissection superiorly up to the level of the diaphragm until we have completely mobilized the small stomach pouch away from the remnant stomach and the lateral fibrofatty attachments. Here, you can see the whole lateral surface of the stomach has been completely mobilized. At this point, we then address the right side. We open up the lesser omentum window between the liver and the stomach. We continue with this dissection until we're able to identify the right leaflet of the diaphragm. At this point, we take down the areolar attachments between the stomach and esophagus and the lateral edge of the diaphragm. We continue to take down the ligament as attachments to the esophagus and stomach until the esophagus and stomach are freely mobile from the leaflets of the diaphragm. We continue in the posterior space, taking down additional areolar attachments until both the left and right leaflet of the diaphragm are well visualized. At this point, a primary posterior repair can then be performed to re-approximate the defect. We utilize a non-absorbable suture that is placed in a figure-of-eight pattern inward to nicely re-approximate the diaphragmatic edges. We want to make sure that this particular repair is not too tight. Otherwise, this could cause swallowing difficulties in the patient. Often times, multiple stitches are required in order to completely close this defect. In this particular case, just one suture is utilized. At this point, after completing the diaphragmatic repair, we introduce our calibrating balloon. This is used to demarcate the small upper stomach pouch that will be created. The balloon is inflated to 20cc and is then drawn back to the hiatus until the first penetrating vein can be seen right here in the video. At this point, we introduce our stapler, which will be used to cut transversely across the stomach to create the lower border of the stomach pouch. In this particular case, because of the large size of the pouch, two firings of the linear stapler are utilized to completely transect the stomach. Once we have completed the transection transversely, we then remove the lateral redundant portion of the stomach. We now use sequential vertical firings of the linear stapler to remove this excess gastric tissue along the lateral edge. During the process of these firings, we utilize a tissue reinforcement strip. This is to control hemostasis at the staple edge as well as help reduce the risk of a leak occurring. Several firings are utilized here, as can be seen, to completely transect the redundant gastric tissue. After the last firing, the redundant gastric tissue is removed from one of our lateral ports. At this point, we introduce the anvil of our circuital stapler. This is brought out through a small gastrostomy at the lower border of our gastric pouch. We utilize an introductory tube and then the tubing is divided and the anvil is left in place. At this point, we readdress the Roux limb. We open up the proximal portion of the Roux limb using the ultrasonic shears. This provides an opening for us to insert the handle of our stapler. Once we have created our enterotomy, we remove our lateral 15-millimeter trocar. We then dilate the muscle in order to introduce our stapler handle. The stapler handle is introduced into the abdomen and then apical cone is removed. The connecting column is then retracted and we then introduce the stapler handle into the enterotomy created in the proximal Roux limb. We make sure to advance the stapler just beyond where the previous gastrojejunal anastomosis was located so that this can be excluded. The spike is then used to penetrate the lateral wall and then is connected to the anvil located in then small upper stomach pouch. The stapling device is then completely closed and fired creating the gastrojejunal anastomosis. At this point, the stapler is removed from the excluded Roux limb segment. After removing the stapler, we make sure that there are two complete tissue rings to confirm that the anastomosis is complete. We remove the two redundant portions of tissue and then the stapler is closed down and subsequently irrigated. We irrigate the stapler so it's not to contaminate the subcutaneous tissue. The apical cone is removed and we reintroduce our 15-millimeter trocar in the lateral site. Here, you can see the redundant Roux limb and the excluded stomach that was previously resected. At this point, we want to remove this excess redundant tissue so we utilize a subsequent firing of the linear stapler. The resected specimen is then placed in a retrieval bag and brought out through the lateral incision. We then reintroduce our 15-millimeter port so that we can complete the actual operation. At this point, we proceed with reinforcing the gastrojejunal anastomosis. We like to place sutures along the edges of the actual anastomosis to help reduce any tension and decrease the risk of any bleeding or any leak. We use a non-absorbable 2-0 silk suture of both the left lateral aspect of the anastomosis as well as on the right side and anteriorly, as seen here. At this point, the anastomosis is now complete. We proceed with testing the anastomosis using an upper endoscopy. We clamp the Roux limb just distal to the anastomosis and proceed to place saline in the upper abdomen so that the anastomosis is under the saline bath. An upper endoscopy is performed with an air insufflation test to look for any leaks at the anastomosis. Once we have confirmed that there is no leak, we proceed with removing the air from the small intestine and then remove the scope from the patient's mouth. The irrigation is then withdrawn from the abdominal cavity. With our revisional patients, we also like to reinforce the anastomosis using a fibrin sealant. This also helps control any bleeding as well as reduce the risk of any leaks. At this point, we remove our Nathanson liver retractor and begin our abdominal closure. We need to close our lateral ports that are larger to prevent any herniation at these sites. We use absorbable suture here in order to close the actual defect. At this point, we remove our remaining trocars and proceed with evacuating the remaining carbon dioxide to complete the operation. The patient's postoperative course was unremarkable. He had an upper GI performed the day of surgery, which was normal. He was subsequently started on a clear liquid diet on post-op day one and eventually discharged home on the same day.