Mayo stand and back table instruments for Laparoscopic Gastric Bypass Roux-EN-Y surgery setup

Clamping & Occluding

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  Curved Hemostat

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  Kocher Forceps

Cutting & Dissecting

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  #3 Knife Handle

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  Laparoscopic Metz Scissor

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  Straight Mayo Scissor

Grasping & Holding

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  Adson Forceps

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  Laparoscopic Anvil Grasper

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  Laparoscopic Maryland Dissector Grasper

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  Laparoscopic Wave Grasper

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  Toothed Forcep

Misc

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  Camera Cord

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  Laparoscope

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  Light Cord

Retracting & Exposing

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  Army-Navy Retractor

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  Fisher Style Liver Retractor

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  Hasson S Retractor

Suctioning

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  Suction Irrigator

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  Yankauer Suction

Suturing & Stapling

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  Bariatric and Laparoscopic Needle Holder

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  Mayo-Hegar Needle Holder

What to expect during Laparoscopic Gastric Bypass Roux-EN-Y

The patient will be positioned supine on the table, and they will need to be strapped in well since they will be overweight. A foot board may be placed to ensure they don’t slide off of the table when it is rotated or angled.

After the patient is draped, you will throw off your camera, light cord, bovie, ligasure/harmonic scalpel, insufflation tubing, and suction irrigator.

The surgeon will begin by injecting local and making an incision with either an 11 blade, or a 15 blade loaded onto a #3 knife handle. A 12mm trocar will be placed through that incision, and a 0 degree laparoscope will be inserted through the trocar after placement. Usually you will start with a 10mm scope first. The insufflation tubing will be attached to the trocar to inflate the belly. The rest of the 12mm ports will be placed. There are usually 4-6 trocar placements, and most surgeons use 12mm trocars.

A liver retractor will be placed to move the liver out of the way. The patient will be tilted feet down.

The abdomen will be viewed to look for anything that isn’t normal. A variety of bowel graspers, and wave grasper will be used to manipulate the abdominal contents. Depending on the surgeon, either a LigaSure or a Harmonic scalpel will be used on the omentum. The orientation of the Biliopancreatic and Roux limbs will be found and measured. The jejunum will be found and will be measured to see if it will be able to reach the pouch. If it can’t be, the surgeon may do a sleeve gastrectomy instead.

Maryland forceps will be used to make a plane between the jejunum and mesentery. Graspers without teeth will be used to put the jejunum in the position where it can be dissected.

Your stapler and staple loads will then be used. Staplers are a surgeon’s preference, but normally they will use a 45mm one.

The stapler will be used on the plane that was just created on the small bowel. Before the stapler is taken off of the plane, the surgeon will use a suture with the laparoscopic needle driver to mark the Roux limb. The stapler will then be used on the jejunum to divide it into the Roux and Bilopancreatic limbs. The surgeon will then look over their work and to check for anastomosis.

The LigaSure will be used on more surrounding tissue and the angle of His. An O’Reilly retractor may be used during this process.

An Orogastric tube will be put into the stomach, all while the surgeon is manipulating the stomach to make sure it is completely emptied.

The omentum will then be dissected from the stomach wall using the LigaSure and graspers. The stapler will then be used on that plane. This staple load will create a pouch. The surgeon will then make sure there aren’t any loose staples around the staple site, and they will be removed if any are found. The 60mm stapler will then be put in the vertical plane.

Graspers will be used to bluntly dissect down to the gastroesophageal junction through the tunnel that was created with the staple load. The O’Reilly retractor may be used again during this step. Another staple load will be put in near the gastroesophageal fat pad.

The Roux limb will be found again, and a hole will be made with the hook cautery.

A gastronomy will be made, using the stapler again to attach the walls together. All of the mesenteric defects will be fixed/closed. The laparoscopic needle drivers may be used again to closed remaining portions.

The incisions can then be closed.