Technical steps and patient management of linear cutting device gastrojejunostomy

Linear cutting closure technique for gastrojejunostomy

Since Wittgrove et al. first reported the Y-shaped gastric bypass in 1994, this book has undergone several revisions.

In the initial description of the surgical procedure, gastrojejunostomy was performed using a 21mm circular stapler with the anvil inserted through the mouth.

Although no esophageal injury was found in the initial 1,400 patients reported, concerns remain about the potential for esophageal damage and the high incidence of anastomotic stenosis.

Other anastomosis methods, including manual anastomosis and linear cutting closure techniques, have been recommended by many people.

Regardless of the outcome of the debate, the key to choosing a gastrojejunostomy technique should be based on our existing clinical evidence, as well as the surgeon's opinion and expertise.

Laparoscopic gastric bypass

The patient is placed in a supine position, with the surgeon positioned on the patient's left and the assistant on the right.

The trocar containing the camera was inserted into the abdominal cavity through the left upper abdomen, and the abdominal pressure was set to 15 mmHg.

We first established the Roux loop of the jejunum and then performed a jejunal side-to-side anastomosis.

Mark the Treitz ligament and place the adjacent proximal jejunum in a C-shape.

The jejunum is cut off with a linear cutting closure device at a distance of 30-50 cm from the Treitz ligament.

Then, use 1-2 white spikes to cut the small intestinal mesentery to increase the mobility of the Roux loop.

After the jejunum is cut, we place a single-lumen drainage tube in the distal intestinal loop. The length of the Roux loop is generally 75 cm from the cut.

For patients with a BMI greater than 50, the Roux loop length should be 150cm.

Then the Roux intestinal loop and the bile-pancreatic intestinal loop were closed by lateral incision.

The specific method involves inserting a straight-line cutting closure device into the lumen of both tubes and then stimulating them to connect the ends without affecting their digestive function.

The gap where the closure device is placed is sewn shut by another straight closure device, and then two more stitches are sewn to secure it.

The first stitch is placed at the intersection of the two intestinal loops to reduce tension; at another location, the end of the biliary-pancreatic functional intestinal loop is fixed to one side of the Roux intestinal loop.

The mesentery was sutured with non-absorbable sutures.

Once the jejunojejunostomy and Roux loop have been completed, the patient is placed in a head-up, feet-down position to better expose the upper abdominal organs.

The omentum was cut in half using a Harmonic electrosurgical unit to reduce the tension of the Roux loop in front of the colon.

The greater omentum must be separated all the way down to the level of the transverse colon to provide a passage for the Roux loop.

Then the Roux loop is pulled from the anterior colon and anterior stomach to the level of the stomach through the omentum.

Position the patient with their head elevated and feet lower than their body.

Use a 5mm liver retractor to retract the left lobe of the liver.

The gastrohepatic ligament was partially cut using an ultrasonic scalpel.

After the anesthesiologist removes the gastric tube, a white stapled capsule (60mm, 2.8mm cutter) is used to cut the lesser omentum from the gastric body on the lesser curvature side. A blue stapled capsule (45mm, 3.5mm cutter) is then used to stimulate the gastric body near the cardia (1-2cm below the fat pad) to create a small gastric pouch with a volume of approximately 15ml.

It separates the His angle and creates a channel between the larger and smaller abdominal cavities.

This approach allows for greater space to be placed for the cutting and closing device at the base of the last severed small gastric sac, and also allows for the removal of the gastric base.

Check both sides of the cutting closure device for bleeding and for its integrity.

The small gastric pouch is then separated from the residual stomach by the left stapling surface of the cutter to provide space for gastrointestinal anastomosis.

The end of the Roux intestinal loop was sutured to the posterior aspect of the small gastric pouch with 2-0 Surgidac sutures.

Then, an ultrasonic scalpel is used to cut open the intestinal wall at the junction of the intestinal loop and the gastric pouch.

The blue staple cartridge is inserted 1.5 cm from the intestinal loop and the gastric sac, and then an end-to-side gastrointestinal anastomosis is performed.

The remaining gastrointestinal incision was sutured in two layers. The first layer was sutured continuously from both ends of the anastomosis using 2-0 Polysorb sutures.

Before the two sutures are joined in the middle and knotted, the endoscope should be inserted through the esophagus and sent to the Roux loop via the gastrointestinal anastomosis.

Then, an endoscope can be used as a support to completely suture the remaining part of the intestine.

The second layer of sutures uses 2-0 Surgidac sutures, close to the Roux intestinal loop, around the closure line of the small gastric pouch, and sutures from the greater curvature to the lesser curvature.

After the endoscope is positioned, a soft intestinal clamp is placed across the Roux loop at the distal end of the endoscope.

An air-water pressure test was conducted by injecting a portion of air into the intestinal tract while burying the anastomosis under the flushing water.

If air bubbles are generated, it indicates that the anastomosis is not secure and further reinforcement with local suturing is needed.

After inspection, a fibrin adhesive is used for further reinforcement.

Cover the anastomosis site with omentum and secure it with 2-0 Surgidac sutures.

The 15Fr Jackson-Pratt spherical drainage tube was placed behind the anastomosis and pulled out through the puncture hole in the upper right quadrant.

Postoperative management

Patients should remain fasted on the day of surgery and do not require routine use of a nasogastric tube.

On the first day after the operation, an upper gastrointestinal contrast study was performed using meglumine diatrizoate and diluted barium.

If there is no stenosis or fistula, the patient can be given 30 ml of clear liquid food every half hour for the next 24 hours.

Patients are usually discharged two days after the surgery.

If the amount and nature of the drainage fluid are normal, the Jackson-Pratt drainage tube can be removed during the outpatient follow-up examination one week after surgery.

Technical considerations

During a reconstructive gastric bypass surgery, the patient's stomach wall may be too thick, rendering the blue staples ineffective.

Direct suturing cannot guarantee the required height, while suturing with blue staple cartridges is not high enough.

In this case, we can use an endoscope inside the gastrointestinal lumen as a guide to perform manual anastomosis to ensure the safety of gastrojejunostomy.