Sleeve gastrectomy to roux-en-y conversion

Prep and drape
Ports placed
Hiatus hernia reduced
DJ Flexure identified
100cm small bowel measured to form biliopancreatic limb
50cm small bowel measured to form alimentary limb
Jejunojejunal anastomosis formed
Retrogastric dissection and mobilisation of stomach
Gastric pouch formed
Fully handsewn gastrojejunostomy created
Defects closed to prevent hernias

Severe reflux post-gastrectomy

Patients unable to tolerate general anesthesia, previous ventral hernia repair with mesh, liver cirrhosis with severe portal hypertension, or a complex history of open abdominal surgery with dense adhesions.

EndoGIA stapler
Harmonic shears
Purple reload
Standard length laparoscopic instruments
Tan reload

The patient is placed supine on the operating room table in a split leg position with both arms out. The patient is placed in reverse Trendelenberg. Pressure points are padded. Sequential compression stockings are placed. Subcutaneous heparin and antibiotics are administered prophylactically. Precautions were taken (cricoid pressure, oral sodium citrate solutions etc.) while the patient was going under general anaesthesia to prevent aspiration pneumonitis in view of the severe reflux.

An upper GI endoscopy was performed before the surgery, which revealed the significant hiatus hernia. A gastrograffin swallow helped to demonstrate the sleeve anatomy and in pre-op planning. The patient was reviewed by the anaesthetist before undergoing surgery as she had significant reflux. There was no need for pre-op VLCD meal replacements as she had already lost a significant amount of weight from the sleeve gastrectomy.

The hiatus needs to be dissected, with the right and left crus exposed completely. This facilitates the reduction of the sleeve into the peritoneal cavity and repair of the hiatal defect. The DJ flexure needs to be identified definitely, as for all gastric bypass procedures, to prevent anastomosing the wrong bowel loop onto the gastric pouch.

In the immediate post-op period, there is a risk of a leak from the staple line from gastric pouch formation. There could be an area of ischemia if the new vertical staple line crosses the old staple line from the sleeve gastrectomy. It is imperative that we are inside the old sleeve staple line when we trim the gastric pouch. Otherwise, the post-op risks are similar to standard gastric bypass and hiatal repair procedures.

Nil

Nil