Laparoscopic Gastric Bypass

Transcription

1 Restrictive and Malabsorbative procedure Laparoscopic Gastric Bypass Dr. H. Lönroth Professional Education 1

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3 Introduction Gastric bypass as a therapy for morbid obesity was first published by Mason and Ito The concept behind this procedure is based on the classical observation of weight loss following subtotal gastrectomy. In this procedure the stomach in the region of the gastric fundus is separated from the remaining part of the stomach and the small fundus pouch is anastomosed with a drawn-up loop of jejunum. A wide range of morbidities are demonstrated to be associated with, and are probably caused by obesity, which leads to the conclusion that life expectancy is shorter, especially in severely obese patients. Moreover, the quality of life of obese patients is generally demonstrated to be impaired and the probability of being incapacitated and unable to work is increased. Surgery is the only treatment option, which has proved to result in substantial and sustained long-term weight loss for patients with a BMI exceeding 35 kg/m 2 with comorbidities. There is increasing evidence that the weight reduction following bariatric surgery not only restores the patient s quality of life but also reduces risk factors associated with morbidity and mortality. Many surgical techniques have been used to achieve weight loss, including different restrictive and malabsorptive procedures. The most frequently used restrictive procedures in recent years have been vertically banded gastroplasty (VBG) and adjustable gastric banding. Many consider the Roux-en-Y gastric bypass (RGBP) to be the choice of bariatric surgery, as it combines excel- 3

4 lent weight loss with few disturbances in eating habits. The side effects, such as iron, calcium and vitamin B12 deficiencies, have been considered easy to track and substitute. The original gastric bypass, presented in the 1960s by Mason and Ito, has undergone many modifications. The size of the pouch, the length of Roux-limb and the diameter of the stoma are still under debate. At the same time, the benefits of laparoscopic techniques have been clearly demonstrated by Nguyen and others. The benefits of laparoscopic approaches compared to open approaches include: less pain, more rapid mobilization, a shorter hospital stay and a more rapid return to normal activities. There are also fewer wound infections and avoidance of the previously high incidence of incisional hernias. The major feature of a gastric bypass is the total division of the stomach with staples creating a small pouch that is connected to a Roux-en-Y limb thus by-passing the main stomach. Summary The Roux-en-Y gastric bypass has become, at least in the USA, a gold standard in bariatric surgery. The procedure is complex and can be carried out laparoscopically. The extent of weight loss is 60 80% of the initial weight and weight loss remains relatively stable. The demand for bariatric surgery is rapidly increasing. A well-organized institution for bariatric surgery with internists, physiotherapists, dieticians, and patient support groups as well as a well-trained team of surgeons is essential for the long-term success of any method of bariatric surgery. Under these conditions bariatric surgery is not only safe but also the best treatment option available for morbidly obese patients. Outcome of laparoscopic bypass Surgical criteria of success should not only take weight loss into account but also the improvement of illnesses associated with obesity and the improvement of quality of life. Following a gastric bypass operation, an average weight loss of 2/3 of the excess weight occurs within 2 years. Weight loss induced in conjunction with gastric bypass surgery is associated with a significant reduction in diabetes mellitus, hypertension, disturbances in pulmonary function, sleep apnea and improvement in quality of life. All these have been demonstrated in the Swedish Obese Subjects Study (SOS study), which has enrolled 2000 patients and 2000 controls in a long-term, multicentre study. Recent results from the SOS study also indicate that end-point mortality is reduced markedly following bariatric surgery. 4

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6 Instrument overview The following is an overview of selected instruments used at the Department of Surgery, Sahlgrenska University Hospital, when performing laparoscopic bariatric surgery. Echelon 60 ENDOPATH Stapler* 60 mm stapler Product Code: EC60 Reloads: ECR60W White, ECR60B Blue, ECR60D Gold, ECR60G Green Company: Ethicon Endo-Surgery ETS Endocutter* ETS Straight Endocutter 45 mm Product Code: 6SB45 Reloads: TR45W White, 6R45B Blue, TR45G Green Company: Ethicon Endo-Surgery HARMONIC ACE Curved shears with ergonomic handle, hand control and gray torque wrench. 36 cm long, 15 mm active blade, 5.5 mm diameter Product Code: ACE36E Used in combination with Harmonic Generator 300. Company: Ethicon Endo-Surgery * use either Echelon 60 or ETS 45 6

7 Endoscopic Needle Holder Product Code: E0705R. Company: Ethicon GmbH ENDOPATH XCEL Bladeless Trocars Bladeless Trocar, 12 mm in diameter, 100 mm in length. Product Code: B12LT. Bladeless sleeve, 12 mm in diameter 100 mm in length. Product Code: CB12LT. Company: Ethicon Endo-Surgery ENDOPATH Babcock 10 mm in diameter, 360 mm in length. Product Code: 10BB. Company: Ethicon Endo-Surgery Others Clickline Metzenbaum Scissors Product Code: 34321MW. Company: Karl-Storz Endoskope RoBi Rotating Bipolar Forceps Product Code: 38322ON. Company: Karl-Storz Endoskope Storz Atraumatic Spring Handled Forceps Product Code: 33321ON. Company: Karl-Storz Endoskope Clickline Babcock Product Code: 33531BLS. Company: Karl-Storz Endoskope Nathanson Liver Retractors Product Code, Large: G Product Code, Extra Large: G Company: Cook Medical For detailed product information please read the instructions for use. 7

8 Step Port placement b d e a c (a) An optic view port is inserted above the umbilicus and slightly to the left of the midline. The distance between the xiphoid process and the port should be approximately 15 cm and usually the port is placed about 5 cm above the umbilicus. (b) At the level of the xiphoid process a 5 mm trochar is inserted to create the channel through which a 5 mm Nathanson liver retractor is inserted. (c) On the left lateral part of the anterior abdomen the assistant port is inserted as depicted. The surgeon needs two working ports (d) placed on the patient s left side of the Treitz ligament and (e) on the patient s left side as shown. A triangulation is thus created with a camera port (a) between the two working ports (d) and (e). 8

9 Step Access to the bursa This dissection is performed in two sequences. The left crux of the diaphragm can be visualized by pulling the fundus down and opening the peritoneum using ultrasound scissors. The fundic part of the stomach can then be pushed down slightly to facilitate the next step. 1 By lifting the stomach and counter-stretching the minor omentum an opening through the omentum can be dissected close to the minor curvature of the stomach and approximately 4 cm distally to the cardia. 9

10 Step 2 Dividing the stomach The stomach can be divided using a 45 or 60 mm stapler. On the upper part of the stomach this division can be made using blue cartridges. The first cartridge is fired from the port (d) in a horizontal direction, after which the stapling continues in a vertical direction from port (e) reaching up to the angle of His. The landmark for the division will thus be the left crux of the diaphragm. It is recommended that the pouch size be less than 30 ml. 10

11 Dividing the omentum Step 3 To simplify the mobilization of the proximal jejunum the major omentum is divided in a longitudinal direction, aiming from port (e) towards the pouch. Usually it is sufficient to divide the omentum to the level of the transverse colon, leaving the gastrocolic ligament intact. 11

12 Step 4 Mobilizing the proximal jejunum After identifying the ligament of Treitz the jejunum is lifted up to the pouch in front of the colon and the stomach remnant. The most proximal part of the intestine is placed on the patient s left side by twisting the intestine 180 in a clockwise direction. The efferent part of the intestine will thus be on the patient s right side. Using ultrasound scissors a small opening is made in the intestine and an opening in the pouch is also made through the staple line. Since the mucosa of the pouch will be trapped in the staple line this is the easiest way to gain access to the lumen. Danger point! Blunt dissection of the pouch may create a lumen that is in the submucosal space thus preventing proper access to the pouch. If there is difficulty reaching the lumen this is usually handled best by introducing a gastric tube into the pouch. By pushing the tube towards the wall of the pouch a cut can be made at this point thus reaching into the lumen. 12

13 Connecting the intestine to the pouch Step 5 A 45 mm stapler with a blue cartridge is introduced with the anvil into the intestine and the stapler cartridge into the opening of the pouch. The intestine is thus connected to the pouch in a longitudinal direction. Danger point! Avoid excessive pushing of the stapler when connecting the intestine to the pouch. This could cause perforation of the intestine posterior to the anastomosis. 13

14 Step 6 Closing the gastroenterostoma A stay suture is placed on the right-hand side of the remaining opening. From the left-hand side a single-layer running suture is made closing the opening. Care is taken to make seromuscular stitches on the intestinal side but full thickness on the stomach wall. The rationale for this is to achieve proper hemostasis of the pouch wall. Danger point! The risk of a leak can be difficult to assess without proper testing. Consequently a leak test with air bubbling and/or methylene blue introduced into the pouch should always be performed at the end of the operation. 14

15 Preparing the Roux limb Step 7 An instrument with distance markings, such as a Babcock with a 10 cm landmark, can be used to measure the Roux limb. There is a lack of consensus and hard evidence for deciding the length of the Roux limb. At the author s institution a length of 120 cm Roux limb is usually performed. An entero-entero anastomosis is then made to the proximal jejunum with side-to-side stapling with a 45 mm white cartridge. 15

16 Step 8 Closing the entero anastomosis The stay suture is put at one end of the anterior opening and a single layer running suture is made from the other end, usually in the longitudinal direction. This over and over suture is made with seromuscular stitches. Danger point! Excessive suturing may narrow the entero-entero anastomosis or even narrow the efferent part of the intestine. This will cause high intestinal obstruction with a risk of dilation of the remnant stomach. This complication may be misunderstood and can be fatal! 16

17 Preparing division of the intestine Step 9 Using ultrasound scissors a small opening is made through the intestinal mesentery between the gastro-entero anastomosis and the entero-entero anastomosis. 17

18 Step 10 Dividing the intestine By dividing the intestine between the gastro-entero anastomosis and entero anastomosis an omega loop is turned into an antecolic antegastric Rouxen-Y. The division should be made in the close vicinity of the pouch thus minimizing the risk of having a blind end close to the gastro-entero anastomosis. 18

19 Laparoscopic gastric bypass with antecolic antegastric Roux-en-Y Step 11 To consider: This construction leaves two spaces that could be passages for internal herniations. One is behind the entero-entero anastomosis and the other is behind the Roux limb in the space between the jejunum and the transverse colon. Closure of internal hernias may be indicated although the incidence of internal herniations is very low at some institutions. Moreover, closure of the internal spaces does not totally exclude the risk of future herniation. 19

20 Notes

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22 Literature Mason EE, Ito C. Gastric bypass in obesity. Surg Clin North Am. 1967:47(6): Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopic gastric bypass, Roux-en-Y preliminary report of five cases. Obes Surg 1994; 4: Nguyen NT, Goldman C, Rosenquist CJ, et al. Laparoscopic versus open gastric bypass: a randomized study of outcomes, quality of life, and costs. Ann Surg. 2001;234:279-89; discussion Lönroth H, Dalenbäck J. Other laparoscopic bariatric procedures. World J Surg 1998:22(9): Lönroth H, Dalenbäck J, Haglind E, Lundell L. Laparoscopic gastric bypass. Another option in bariatric surgery. Surg Endosc 1996:10(6): Olbers T, Björkman S, Lindroos A, Maleckas A, Lönn L, Sjöström L. Body composition, dietary intake, and energy expenditure after laparoscopic Roux-en-Y gastric bypass and laparoscopic vertical banded gastroplasty: a randomized clinical trial. Ann Surg 2006:244(5): Olbers T, Fagevik-Olsen M, Maleckas A, Lönroth H. Randomized clinical trial of laparoscopic Roux-en-Y gastric bypass versus laparoscopic vertical banded gastroplasty for obesity. Br J Surg 2005:92(5): Olbers T, Lönroth H, Fagevik-Olsen M, Lundell L. Laparoscopic gastric bypass: development of technique, respiratory function, and long-term outcome. Obes Surg 2003:13(3): Olbers T, Lönroth H, Dalenbäck J, Haglind E, Lundell L. Laparoscopic vertical banded gastroplasty an effective long-term therapy for morbidly obese patients? Obes Surg 2001:11(6):

23 The decision to apply this technique in an individual case or not is left to the discretion of the surgeon responsible. Ethicon Endo-Surgery is not liable for any harm to the patient resulting from the application of this technique in an individual surgical procedure. 23

24 Ethicon Endo-Surgery bariatricedge sm Ethicon Endo-Surgery (Europe) GmbH Hummelsbütteler Steindamm Norderstedt Germany 2008, Ethicon Endo-Surgery (Europe) GmbH BR