Laparoscopic single anastomosis gastric bypass

With the surgeon standing between the patient’s legs and the assistant on the right, an incision is made to the left of the umbilicus and the abdomen is entered using a 12mm optical viewing trocar. Additional ports are placed under direct vision as shown in the diagram. A Nathanson liver retractor is placed.
The edge of the omentum is swept cephalad and split to the level of the transverse colon using the Harmonic shears (Ethicon). This provides an unobstructed path for the selected small bowel loop to the gastric pouch.
The assistant retracts the transverse colon cephalad by sweeping the transverse mesocolon upwards. The ligament of Treitz is identified and 150cm of small bowel is counted in a clockwise direction. This point is hitched to the gastric antrum using a figure of eight 3-0 PDS suture (Ethicon).
Next, attention turns to creation of the gastric pouch. The surgeon moves to the patient’s right and the assistant stands between the legs. A long gastric pouch is created. First, the pars flaccida is opened and a retrogastric tunnel wide enough to accommodate a single firing of a 60mm stapler is created. A 60mm green load stapler is used (Echelon Flex Endopath stapler, Ethicon) though only small bites are taken initially. A 36Fr bougie is advanced under laparoscopic visualization to the level of the staple line. A second 60mm green load stapler is fired adjacent to the bougie, to trap it in position. Lesser sac adhesions are divided and the angle of His is dissected. The staple line is continued up to the angle of His with sequential firings of the 60mm blue load stapler.
Creation of the gastrojejunostomy begins by anchoring the bowel loop to the side of the pouch, taking care to incorporate the staple line. This is done with a figure of eight suture using 2-0 PDS (Ethicon), leaving a loop for the assistant to grasp. The bougie is advanced to the tip of the pouch to provide a firm surface against which the gastrotomy is made. The gastrotomy can be either ante- or retrogastric. The staple line is excised. An enterotomy is then made.
A hand-sewn single layer anastomosis is performed with 2-0 PDS, to create a stomal orifice of 12-14mm diameter. With the assistant grasping the loop of the anchoring stitch and retracting towards the spleen, the posterior wall is first completed with full thickness bites, ending on the outside of the pouch. The bougie remains in the gastric pouch while the anchoring stitch and posterior wall are completed, ensuring that it does not obscure the view.
Next, the loop of the anchoring stitch is cut and the assistant grasps the suture used to complete the posterior wall, retracting it to the right lower quadrant.
The anterior wall is then completed with full thickness bites, ending on the jejunal side with a seromuscular bite. Prior to completing the anterior wall, the bougie is advanced across the anastomosis and final bites are completed with the bougie across the anastomosis. Care is taken to avoid incorporating the bougie into the anastomosis. Finally, the two sutures are tied.
An air inflation test is completed to ensure both afferent and efferent limbs are patent with the secondary objective of testing the anastomosis for leak. The mesenteric defect is too wide to close. Ports and the liver retractor are removed. Fascial defects are not closed. Subcuticular closure is performed with 3-0 monocryl.
Post operatively, the patient is left nil by mouth for 24 hours then advanced to a liquid diet. Pain is managed with a multimodal regimen. Venous thromboembolism prophylaxis is utilized with stockings and subcutaneous low molecular weight heparin. A routine contrast swallow is not performed. Patients are typically discharged on post operative day 2 once they are tolerating adequate liquids.

Patients with a history of obesity and diabetes mellitus, without symptomatic reflux disease are candidates for single anastomosis gastric bypass. Because of the wide geographic spread of our patient population, we have a preference for this procedure for patients having a bypass bariatric procedure who live remote from our institution. This is because of the lower complication profile associated with the single anastomosis procedure compared to the Roux-en-Y gastric bypass.

Patients unable to tolerate general anesthesia, significant history of open abdominal surgery, previous ventral hernia repair with mesh, severe portal hypertension and a history of significant reflux. Prior fundoplication is not a contraindication to this procedure.

2-0 and 3-0 PDS suture (Ethicon)
36Fr bougie
Echelon Flex Endopath stapler with green and blue loads (Ethicon)
long laparoscopic instruments including two atraumatic graspers
Nathanson Liver retractor
needle driver and laparoscopic scissors
standard length Harmonic shears (Ethicon)
standard trocars (two 5mm trocars
two 12mm trocars)

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 boots are placed and subcutaneous heparin and antibiotics are administered prophylactically. We do not use an orogastric tube.

Single anastomosis gastric bypass is offered to obese patients. Patients are required to watch an educational video preoperatively. Patients are routinely assessed and educated by a nutritionist. They are referred for medical and psychological assessments as indicated. Patients are placed on a calorie-restricted high-protein liquid diet for two weeks preoperatively. No imaging or endoscopic evaluation is performed routinely preoperatively.

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No conflicts to disclose.

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