laparoscopic Gastric bypass

  • Universitäts Klinik Witten Herdecke

    Prof. Dr. med. Gebhard Reiss

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  • Introduction

    The morbid obesity with its associated comorbidities presents worldwide an increased incidence and prevalence especially in the western world. According to WHO 600 Mio people worldwide are adipose.

    Different studies demonstrated that the adiposity and metabolic surgical-operations are more effective than conservative treatment of adiposity. 

    Besides Weight-loss other obesity-associated disorders e.g. Diabetes Mellitus Type 2, Arterial Hypertonia, Lipid-metabolic-disorder and sleep-apnea syndrome should be well-treated.

    Worldwide the distribution and acceptance of Bariatric surgery is increased in last 20 years (2003 around 15,000; and in 2013 around 470,000 Bariatric surgeries). The Bariatric surgeries reduce not only the weight, but also have a positive influence on the other obesity-associated syndromes.

    The Roux-en-Y-Gastric-Bypass (RYGB) is the Gold-standard surgical intervention in the Bariatric surgery (almost 45%).

    The new definition of “metabolic-surgery” extends for further indications except adiposity. It is more likely that Bariatric surgery will be increased meaningfully for the management of metabolic-syndrome.

    After Bariatric surgery especially the patients with Diabetes Mellitus Type 2 manifest the complete remission of the disease even before significant loss in the weight. Meanwhile it is considered to plan the Bariatric surgery for the Diabetic patients who are light or middle adipose.

    Nowadays Bariatric-laparoscopic- surgery is highly appreciated due to its better manageable technique and its minimal complications risks.

    The German health-insurance system don’t pay for the Bariatric-metabolic-surgeries that’s why each patient’s- case should be considered individually.

  • Physiological mechanisms of gastric bypass

    Although restriction and malabsorption are necessary for a successful therapy, hormonal and neuronal mechanisms of action seem to be crucial for the improved diabetic metabolic state.

    The complex interactions of hunger and satiety as well as metabolism and energy balance undergo specific changes throughout the surgery.

    After gastric bypass, many physiological changes occur due to the modified gastrointestinal anatomy. Not only gastrointestinal hormone secretion but also neuroendocrine signaling and the intestinal microbiome are affected.

    Compared to purely restrictive procedures (gastric banding), patients after bypass surgery not only achieve a reduced feeling of hunger, but also experience an early feeling of satiety. All techniques that deactivate the gastric fundus, as the main site of ghrelin production, have lasting effects on supressing the feeling of hunger.

    By disconnecting the proximal part of the small intestine, including duodenal receptors, the digested food rapidly infuses distal located intestinal sections. This leads to a stimulation of enterohormonal secretion with an improved glucose metabolism.

    More than 80% of the patients can quit their diabetic therapy after surgery. 

  • Technique of Proximal Gastric Bypass (RYGBP)

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    During a laparoscopic Roux-en-Y- gastric bypass, a small gastric pouch (20-30 ml) is created. The subcardiac region of the stomach is separated from the rest in stapler technique. It is important that there is no connection to the remaining stomach. Afterwards a anastomosis between the pouch and the alimentary Roux-Y limb is performed.

    The duodenum and a proximal part of the jejunum are disconnected from the physiological intestinal passage. The pulled up jejunum, which is called the "alimentary limb", is then anastomosed with the "Pancreato-Billiary Limb" 150 cm aborally of the gastroenterostomy. This "common channel" is where the nutrient absorption takes place.

  • Krankenhaus Nordwest

    Dr. Sylvia Weiner

  • Sana Klinik Offenbach a.M.

    Prof. Dr. Rudolf Weiner

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  • Indications

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  • Contraindications

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  • Preoperative diagnosis

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  • Special preparation

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  • Enlightenment

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  • Anesthesia

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  • Positioning

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  • OP-Setup

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  • Special instruments and holding systems

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  • Postoperative treatment

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date of publication: 26.04.2009
  • Krankenhaus Nordwest

    Dr. Sylvia Weiner

  • Sana Klinik Offenbach a.M.

    Prof. Dr. Rudolf Weiner

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  • Start of operation and stomach pouch formation

    41-4

    After beginning surgery (establishing of the capnoperitoneum, trocar placement, inspection of the abdominal cavity), the Angle of His is displayed.

    The following step is the creation of gastric pouch 2 cm below the gastroesophageal junction in the area of ​​the lesser curvature. The left gastric artery supplies the visceral side oft the gastric pouch and is respected to prevent bleeding complications and to guarantee the perfusion to the pouch. First of all the gastric transection is performed in a horizontal direction with a linear stapler (staple height 3.5 mm). The dissection is then continued in a triangular fashion towards the left crus of the diaphragm. The anatomical finish line is the left crus of the diaphragm. The gastric fundus needs to be cutt off completely in order to shut off the production site of the enterohormone ghrelin from the passage of food and prevent subsequent dilatation. Finally, sufficient hemostasis should be performed ultrasonically at the staple line.

  • Measurement of the biliodigestive loop and pull up in the upper abdomen

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    After complete transection of the stomach, the ligament of Treitz is clearly represented. In case of a high-fat greater omentum it is necessary to cut it. About 50 cm aboral of the Treitz ligament, the jejunal limb is antecolically brought up to the stomach pouch. In order to avoid a mix up of the limbs, it is helpful to place the oral limb on the right side and fix it with the instrument in your right hand. The use of auxiliary instruments can be helpful to determine dimensions.

    Alternative routes for the alimentary limb to stomach pouch.

    Tip: In order to avoid confusion of a too short limb, the alimentary’s limb accessibility for the pouch should be checked. Nevertheless, if the limb will be too short, a primary sleeve-like-stomach- and / or thinning of the alimentary limb or even a retrocolic retrogastric approach is recommended.

  • Parallel fixation of the noose on the stomach pouch

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    The jejunal limb is attached to the gastric pouch with two fixation sutures, tensionless.

    Note: If the limb will be fixed too far cranially, a distal pouch reservoir with an overflow phenomenon occurs; if the fixation is too far caudally, the risk of a dumping syndrome increases. Therefore, it should be attached to the second staple line and adapted to form and size of the pouch.

    Tip: In order to avoid a twisted loop ("blue loop" syndrome), the limb is brought up under view (the mesentery points to the left). Anyway, if a rotation come out, cancellation and correction need to be performed. In order to avoid a mix-up of the loops, a consistent identification of the Treitz ligament is important. If a mix-up took place, an immediate surgical intervention is the only way to solve the problem successfully. Otherwise a cardiac arrest is threatened by the overstretched stomach (distension).

  • Antecolic retrogastric gastroenterostomy (linear anastomosis of the posterior wall)

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    To establish the gastroenterostomy, the gastric pouch and the alimentary limb are opened parallelely via an ultrasonic dissector. The stomach pouch is opened on the posterior wall.
    This can be done with an electric hook / scissors, ultrasound or ligasure.
    The posterior wall of the anastomosis is closed by a linear stapler (blue magazine). Afterwards the open anterior gastric wall remains.

    Tip: In order to avoid posterior perforation, the incision should be made carefully with the fixation suture held in place. In case of need it can be overstitched. If a transection of the intestinal continuity has been already done before the gastroenteroanastomosis was plant, and the distance from the end of the alimentary limb is too long, a resection of the small intestinal lobe needs tob e carried out.

  • Attachment of gastroenterostomy (suture closure of the anterior wall)

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    Prior to the closure of the stomach and intestinal openings, the insertion of a calibration tube into the aboral jejunum limb will be performed.
    Subsequently, closure with a continuous suture and covering the anastomosis by additional single button sutures.
    Alternatively, the gastroenterostomy can also be created by using a circular stapler or by complete hand suture.

    Tip: In order to avoid a postoperative anastomotic stenosis, place an 8mm probe over the anastomosis to avoid grasping the posterior wall when closing the anterior wall.

  • Examination of the anastomosis

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    After completion the anastomosis, the density of the anastomosis is checked by methylene blue examination or gas insufflation. During inspection, careful attention must be paid to all sides. Subtle testing and rinsing with water is needed to discover even small amounts of blue solution on the back wall.

     

    Note:

    In primary surgery the gastrojejunostomy is performed as a combined anastomosis with linear anastomosis of the posterior wall and suture closure of the anterior wall. In revision and switch operations, a complete hand suture anastomosis is performed.

  • Transection of the small bowel continuity / discontinuation of the biliodigestive loop

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    After creating a mesentery window, the oral part of the small bowel loop should be disposed with a stapler (blue magazine 45 mm).

    Note:

    The transection of the intestinal continuity after creating the gastroenteroanastomosis is deprived for experienced centers. Alternatively, the transection of the intestinal continuity can be performed before the gastroenteroanastomosis.

     

    Tip:

    To prevent potential herniation, rotation, torquing or kinking of the enteroanastomosis (EE) due to extensive skeletalization, only a small and bowel nearby opening is carried out.

    In order to avoid these complications, the enteroanastomosis is fixed with non-absorbable suture material (broline stitch) at the end of the operation.

  • Fixation suture on the biliodigestive stump / dimension of the alimentary loop

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    After completion of the anastomosis, a fixation suture is placed on the limb of the afferent loop. Subsequently, the efferent loop is measured via marking instruments or measuring facilities. The measurement is carried out in an unstretched cindition, mesenterial.

    Read more about the length of the alimentary loop here.

    Tip: In order to avoid (unseen) small intestine perforation caused by forceps, atraumatic instruments should be used only. In the case of a perforation, a consequent overstitching of all defects should be carried out.

  • Plant of Entero-Entero Anastomosis / opening of the intestinal loops

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    The entero-entero-anastomosis (EE) is performed as a side-to-side anastomosis. Here, both limbs are opened by use of an ultrasonic dissector and the Roux-Y anastomosis is carried out with via linear staplers.

    Tip: A posterior perforation will be overstitched. A careful incision in a tensioned fixed suture can help to prevent perforation.

  • Plant of Entero-Entero Anastomosis

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    The tissue in the distal openings is closed by a single-button suture. This can be used as a holding seam while closing the proximal staple suture openings via a continuous suture with absorbable sutures.
    By consistent seam closure and final inspection from all sides prevents one from insufficiency.

    Tip: If necessary, an overstitching should be performed in case of insufficient sutures as an early reintervention.

  • Antiobstruction stitch (Brolin stitch)

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  • Closure of the Petersen Space

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  • Krankenhaus Nordwest

    Dr. Sylvia Weiner

  • Sana Klinik Offenbach a.M.

    Prof. Dr. Rudolf Weiner

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  • Intraoperative complications

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  • Postoperative complications

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  • Krankenhaus Nordwest

    Dr. Sylvia Weiner

  • Sana Klinik Offenbach a.M.

    Prof. Dr. Rudolf Weiner

Single Access

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  • Summary of the literature

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  • Current studies on this topic

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  • Literature on this topic

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  • Literature search

    Literature search under: http://www.pubmed.com