Laparoscopic conversion of sleeve gastrectomy to roux-en-y gastric bypass
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.
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.
A simple hiatal repair may be sufficient to treat symptomatic reflux after a sleeve gastrectomy in the short term, however, in our experience, the recurrence rates are significantly high. This may be due to the fact that there is no gastric fundus left to reinforce the repair with a fundoplication. The gastric bypass reduces the parietal cell mass and acid produced within the gastric pouch. A wide gastro-jejunostomy reduces the pressure within the gastric pouch. These factors helps to reduce long term recurrence of reflux. On the other hand, there is a significant risk of small bowel torsion and internal herniation after a bypass. The patient needs to be counselled adequately regarding risks and benefits of performing gastric bypass for reflux.
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.