Laparoscopic Gastric Bypass: Addressing Potential Complications

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Laparoscopic Gastric Bypass: Addressing Potential Complications George S. Ferzli, MD, FACS New York, NY

Transcript of Laparoscopic Gastric Bypass: Addressing Potential Complications

Page 1: Laparoscopic Gastric Bypass: Addressing Potential Complications

Laparoscopic Gastric Bypass:Addressing Potential

Complications

George S. Ferzli, MD, FACS

New York, NY

Page 2: Laparoscopic Gastric Bypass: Addressing Potential Complications

GASTRIC BYPASS WITHROUX-en-Y LIMB

Roux-en-Y Gastric Bypass

50 mL POUCH WITH A ROUXLIMB

COMBINED RESTRICTIVEAND MALABSORPTIVE

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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

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Laparoscopic Gastric Bypass

• Identifying potential sources of complications– Jejunal division, mesenteric division

• Ischemia, bleeding– Jejuno-jejunostomy

• Leak, stenosis

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Laparoscopic Gastric Bypass

– Mesenteric defect at jejuno-jejunostomy• Internal herniation/bowel obstruction

– Gastric pouch• Improper size, bleeding

– Gastro-jejunostomy• Leak, stenosis

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Laparoscopic Gastric Bypass:Jejunal Division

• Identification of ligament of Treitz

• Once identified, measure distally to point to jejunal division

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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

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Laparoscopic Gastric Bypass:Jejunal Division

• Mark proximal jejunum– Distinguishes this

proximal end from distal Roux limb

– Prevent closed loop “O” when forming jenuno-jejunostomy

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Laparoscopic Gastric Bypass:Jejunal Division

• Minimal mesenteric division– Unnecessary to divide

vessels beyond mesenteric border of small bowel

– Avoid potential ischemia to Roux limb

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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

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Laparoscopic Gastric Bypass:Jejuno-jejunostomy

• Generous anastamosis– Single full-length

60mm stapled anastamosis

– Hand-sewn closure of common enterotomy

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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

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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

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Laparoscopic Gastric Bypass:Gastric Pouch

• Vertical division to angle of His– Calibration tube in

place allows for appropriately-sized gastric pouch

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Laparoscopic Gastric Bypass:Gastric Pouch

• Vertical division to angle of His– Assured complete

transection at angle of His

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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

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Laparoscopic Gastric Bypass:Gastro-jejunostomy

• Assure proper orientation of Roux limb– Sutures taken at anti-

mesenteric border of Roux limb

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Laparoscopic Gastric Bypass:Gastro-jejunostomy

• 1cm anastamosis– Maximizes restrictive

component of procedure

– Avoid excessive suturing

• Minimize potential ischemia at anastamosis

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Laparoscopic Gastric Bypass:Gastro-jejunostomy

• 1cm anastamosis– Calibration tube passes

freely

– Avoid taking posterior wall with anterior sutures

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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

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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!