Set-up and positioning
The patient is placed supine with legs apart on an operating table capable of securely holding someone who may weigh up to 800 lb and is strapped above and below the waist. After the induction of general anesthesia and endotracheal intubation, a bladder catheter is inserted, and then sequential compression devices are placed around the lower extremities to prevent intraoperative venous thrombosis. A nasogastric tube (18 Fr) was temporarily placed to decompress the stomach (removal before gastric stapling is required). Care is taken to ensure that excessive pressure is not applied to any parts of the limbs to avoid pressure injuries sustained after a lengthy procedure. Intravenous access through the upper extremity is usually sufficient. Occasionally, central access through the internal jugular or subclavian vein is necessary for monitoring. Monitors with the associated equipments (camera box, light source, insufflator) are placed above the patient’s shoulders on each side and aimed at the surgical team.
Access pneumoperitonium and port placement
Initial access is obtained by the Veress needle technique at the left anterior subcostal site, because this site is generally a safer position for needle placement than the rest of the abdomen. Carbon dioxide pneumoperitonium is established to a pressure of 15 mmHg. With this technique, we use five ports as shown in
A 10-mm optical port just above the umbilicus and to the left.
- A 12-mm port in the right mid-clavicular line (working port).
- A 12-mm port in the left mid-clavicular line (working port).
- A 10-mm port below the Xiphoid process (liver retractor).
- A 12-mm port on the left anterior axillary line.The surgeon (standing between the patient’s legs) operates through the right and the left upper abdominal 12-mm ports, and the assistant surgeon (standing on the left side of the patient) holds a camera in one hand and a grasper device in the other hand; the second assistant on the right side of the patient holds the liver retractor.
Creation of the gastric pouch
After positioning and port placement have been completed, the abdomen is inspected and adhesions are lysed with blunt and sharp dissection as needed; the patient is transferred to a steep reverse Trendelenburg position to facilitate the exposure of the upper abdomen. The upper stomach is exposed by retracting the liver anteriorly with a retractor from the 10-mm port just below the Xiphoid process
Ultrasonic dissectionis started 5-6 cm from the gastroesophageal junction on the lesser curvature, to access the retro-cavity behind the stomach. After it has been ascertained that the nasogastric tube has been withdrawn, using a Endo-GIA stapler, with 3.8 mm staple height and 60 mm cartridge length, the stomach is dissected horizontally, starting from the lesser curvature level through the 12-mm right port. Then, another Echelon 60 (Ethicon, Cincinnati, Ohio, USA), with 3.8 mm staple height and 60 mm cartridge length, is placed level with the left end of the horizontal suture line in the cranial direction towards the Hiss angle through the left 12-mm port, while the anesthesiologist inserts a calibrated tube through the mouth. After firing the second longitudinal stapler, dissection of the angle of Hiss is performed to ensure proper stapling up to it. Staple lines on both sides of the transected stomach are examined to ensure that they are intact and not bleeding.
Construction of the biliopancreatic limb and gastrojejunostomy anastomosis
First, the omentum is divided by ultrasonic dissection from the transverse mesocolon to its inferior edge. Dividing the omentum reduces tension on the Roux limb as it passes in front of the colon up to the gastric pouch, and then advanced toward the upper abdomen to expose the ligament of Treitz. The nearest jejunum loop that can reach the pouch from the ligament of Treitz without tension is taken
Gastrojejunostomy is performed with a linear stapler by opening the stomach and the jejunum with a harmonic scalpel, then introducing the Endo-GIA stapler, with 3.5 mm staple height and 60 mm cartridge length, through the 12-mm port on the left side of the surgeon, and then closing the opening by a V-LOC continuous stitch.
Construction of the Roux limb and jejuno-jejunostomy anastomosis
Then we measured 150 cm from the gastrojejunostomy anastomosis as the Roux limb length by a marked grasper on the right hand of the surgeon. At this point, the first assistant holds this point on the Roux limb through a grasper in the most lateral port and the second assistant holds the biliopancreatic limb through a grasper in the 10-mm port at the Xiphoid process; a suture is placed to approximate both limbs, and the second assistant, on the right side, holds this suture and then pulls it upward. The jejunum is positioned in a C configuration to facilitate the placement of the Endo-GIA stapler for division. The Endo-GIA stapler is placed through the 12-mm port on the left anterior axillary line, and it is applied perpendicular to the jejunum and parallel to the mesenteric vascular arcade to create the jejuno-jejunostomy with a 1.0 mm cartridge (2.5 mm staple height, 60 mm cartridge length) that is used to minimize staple line bleeding, followed by closure of the entrostomy opening by a continuous V-LOC suture
Then, a window is made by a harmonic in the mesentery of the small intestine just at its mesenteric border between the two anastomoses, without opening the jejunum mesentery, and then an Edo-GIA stapler with 2.5 mm staple height and 60 mm cartridge length is introduced through the 12-mm right side port to cut the intestine.
The blue dye test is performed by injecting 50 ml in the nasogastric tube with closure of the Roux limb to ensure the integrity of the gastrojejunostomy, and then a suction drain is placed. All port sites 10 mm and larger are closed with fascia stitches of 0 Polysorb. All carbon dioxide is evacuated, and the skin incisions are closed with interrupted 4-0 Polysorb
The nasogastric tube is removed at the end of the procedure. On postoperative day 1 (POD1), the patient is allowed to drink water. The patients were followed for any sign of complication during the 2-3 days of hospital stay before discharge; the patient can leave the hospital on or after POD3. Follow-up is performed 1 week after discharge, when sutures or clips are removed. From POD2 to POD9, the patient remains on a liquid diet. During the 3 weeks after surgery, food must be soft or chopped. After these 3 weeks, the patient may progressively start consuming small bites of food. The patient consults a dietician before discharge and 3 weeks after surgery.
After surgery, patients received long-term follow-up care from a physician specialized in the treatment of obesity, an expert in clinical nutrition, and a psychologist. The purpose of follow-up is not just to achieve a greater loss of weight, but also to prevent nutritional deficiencies. Patients are seen every 3 months in the first year after surgery, because this is the period of most rapid weight loss. The frequency of follow-up appointments depends on the dynamics of weight loss in the individual patient and any problems and complications that may arise.
A well-balanced diet is the best from a nutritional-medical point of view; it should be accompanied during the phase of rapid weight loss, and then permanently, after gastric bypass by the supplementation of vitamins (B <sub>12</sub> and D), trace elements (iron), minerals (calcium), and, if necessary, protein. With the follow-up, laboratory monitoring is necessary as the dietary supplementation may need readjustment.
Women of childbearing age who undergo bariatric surgery should use contraception during the rapid phase of weight loss to prevent malnutritional developmental disturbances in the unborn child.