Objectives:
1. Divide jejunum 40 cm distal to the ligament of Treitz
2. Measure Roux limb
3. Create jejuno-jejunostomy
Position: Flat Position
Instruments:
Surgeon:
Duckbill graspers (long one in right hand, short one in left)
Endoscopic staplers
Endostitch (2-0 Surgidac and 2-0 silk)
Alligator grasper
Clip applier if needed
Assistant:
Duckbill graspers
1. Reflect the greater omentum superiorly and tuck it beneath the liver to expose the transverse mesocolon
2. Find ligament of Treitz
3. Pull out the proximal jejunum to create a C loop
4. Measure 40 cm from the ligament of Treitz. Rotate the bowel in a clockwise fashion with both hands, keeping it in a pizza shape.
5. Stapler 60mm white load x1 to divide small bowel ("airplane maneuver")
6. Stapler 45mm gray load x1 to divide the mesentery (close the stapler and check bowel viability prior to firing)
7. Check the Roux limb length and double barrel the two limbs.
8. Mark the Roux limb: Hold the Penrose flat and close to assistant, position needle up, close against Penrose, open, then toggle. Then hold upper tip of biliopancreatic staple line with duckbill and pass needle around staple line below the duckbill from right to left. Tie suture, creating an air knot. Assistant will place duckbill on top of Penrose to keep knot loose.
9. Measure 75 cm (if BMI < 50) or 150 cm (if BMI > 50) Roux limb
10. Stay suture: Hold Roux limb posterior to antimesenteric border and pass suture from right to left. Hold tip of staple line of biliopancreatic limb and pull towards 9 o'clock. Place suture anterior to antimesenteric border and tie.
11. Create enterotomies. Hold corner of the biliopancreatic limb with duckbill and apply Harmonic scalpel with tips up. Rotate scalpel so that tips are facing away from screen and open. Insert lower jaw into enterotomy, withdraw, and reinsert scalpel with jaws closed. Withdraw scalpel with tips open to spread.
For the enterotomy on the Roux limb, pull bowel towards 9 o'clock to reduce redundancy. Hold the bowel posterior to the antimesenteric border and keep edge of jejunum vertical. Rotate tips of scalpel so tips point down. Fire the scalpel, holding tight, and avoid slipping off. Keep this enterotomy small. Rotate scalpel so that tips are facing away from screen and open. Insert lower jaw into enterotomy, withdraw, and reinsert scalpel with jaws closed. Do not spread.
12. Stapler 60mm white load x1 to create side to side jejuno-jejunostomy. Hold Roux proximal to the enterotomy and insert white jaw into the Roux limb (on the right). Lower stapler to the floor and rotate stapler clockwise. Hold BP limb and insert metal jaw of stapler. Rotate stapler to make jaws parallel. Elevate stapler and move cephalad. Hold the BP limb next to the enterotomy and pull into the stapler to avoid sliding. Avoid pulling bowel away from stapler.
Fire stapler and keep right hand immobilized. Release duckbill and remove. Stabilize stapler with left hand, open jaws, then close quickly. Remove stapler.
13. Corner suture to keep the two limbs parallel with Surgidac Endostitch. Hold stay suture & pull towards 9:00. Suture "inner thighs;" pass needle through Roux then through BP limb and tie.
14. Stay suture to approximate the edges of the enterotomy in transverse direction with Surgidac Endostitch to the right of the anastomotic staple line. Hold BP limb at anterior edge of enterotomy to the left of the staple line. Pass needle out to in. Regrasp posterior edge of enterotomy to the left of the staple line. Pass needle in to out & tie.
15. Hold BP edge of enterotomy at 8:00. Position enterotomy between 2:00 and 8:00. Insert 60mm white load with white jaw on right and slide in around enterotomy. Rotate jaws clockwise using wheel (do not rotate wrist) & allow assistant to pull down excess bowel. Rotate jaws counterclockwise & allow assistant to pull down excess bowel. Fire stapler to close enterotomies while assistant holds the Roux limb in place. Include minimal amount of tissue to avoid narrowing of the anastomosis. Remove stapler; remove tissue with alligator.
16. Brolin's antiobstruction stitch. Hold Roux limb and pull towards 8:00. Take a bite of posterior aspect of the Roux limb (inner thigh) and suture to the biliopancreatic limb with Surgidac Endostitch.
17. Close mesenteric defect. Start at the inferior aspect of the defect and apply running silk suture sewing superiorly (small superficial bites to avoid mesenteric vessels). Follow yourself and tie to the tail of the Brolin's stitch.
Gianluca Bonanomi, MD and Prag Thirunavukarasu, MD
Perils to avoid
• Tearing bowel with graspers
• Making ends of divided bowel ischemic
• Placing sutures anywhere except antimesenteric borders
• Placing enterotomies anywhere except antimesenteric borders
• Making enterotomies too large or stretching enterotomies
• Backwall injury to bowel with stapler
• ***Releasing grasp on bowel when using stapler
• Narrowing anastomosis with closure of enterotomy
• Creating kink in small bowel with Brolin stitch, corner stitch, or mesenteric closure
• Neglecting bleeding from staple line
• Creating bleeding in mesentery during closure |
