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

A Laparoscopic Gastric Bypass Roux-EN-Y (known collectively with other weight loss surgeries as bariatric surgery) is a type of weight loss surgery that reduces the size of the stomach and reroutes the small intestine to bypass most of it. This results in the patient feeling full faster and absorbing fewer calories. It is a minimally invasive procedure that is performed using small incisions and a laparoscope. The surgery is intended for individuals who are severely overweight and have been unsuccessful in losing weight through other methods.

Position
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.

Equipment
Camera, light cord, bovie, ligasure/harmonic scalpel, insufflation tubing, GIA stapler, and suction irrigator.

Step 1: Incision
During this step, the surgeon will inject local anesthesia and make 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. The insufflation tubing will be attached to the trocar to inflate the belly. The surgeon will then proceed to place the remaining 12mm ports.

Step 2: Viewing the Abdomen
Once the abdomen is prepared, the surgeon will view the area to look for anything abnormal. They will use a 10mm scope for a clear view of the area. The patient will be tilted feet down to enable the surgeon to manipulate abdominal contents. The surgeon will use a variety of bowel graspers and wave grasper to achieve this.

Step 3: Preparing for Dissection
Depending on the surgeon’s preference, 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 located and measured to see if it can reach the pouch. If it cannot, the surgeon may opt for a sleeve gastrectomy instead.

Step 4: Dissecting the Jejunum and Mesentery
Maryland forceps will be used to create a plane between the jejunum and mesentery. Graspers without teeth will be used to put the jejunum in the correct position where it can be dissected. The GIA stapler and staple loads will then be used on the plane that was just created on the small bowel. Normally, the surgeon will use a 45mm stapler. 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 inspect their work to check for anastomosis.

Step 5: Dissecting the Omentum
The LigaSure will be used to dissect the omentum from the stomach wall. The GIA stapler will then be used on that plane, creating a pouch. The surgeon will inspect the staple site for any loose staples, which will be removed if found. The 60mm stapler will then be placed in the vertical plane.

Step 6: Creating a Gastronomy
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 created, and the stapler will be used again to attach the walls together.

Step 7: Closing the Mesenteric Defects
All of the mesenteric defects will be fixed or closed, and the laparoscopic needle drivers may be used again to close remaining portions.

Step 8: Closing the Incisions
The incisions can then be closed, and the surgery will be completed.

The Surgery Sparknotes

1. Incision made with 11 or 15 blade, 12mm trocar placed, insufflation tubing attached, 0 degree laparoscope inserted.
2. Liver retractor placed, abdomen viewed, bowel graspers and wave grasper used.
3. Omentum dissected with LigaSure or Harmonic scalpel, Biliopancreatic and Roux limbs oriented and measured.
4. Maryland forceps used to make a plane between jejunum and mesentery, jejunum positioned with graspers.
5. GIA stapler used to divide jejunum, suture used to mark Roux limb, anastomosis checked.
6. LigaSure used on surrounding tissue, Orogastric tube inserted, omentum dissected and stapled to create pouch.
7. Graspers used to dissect to gastroesophageal junction, staple load used to create gastronomy.
8. Mesenteric defects fixed/closed, incisions closed.