A Double Stapled Technique for Creation of the Entero-Enterostomy for Laparoscopic Roux-en-Y Gastric Bypass

Randy S. Haluck, MD, FACS

oux-en-Y gastric bypass surgery for weight loss is a complex reconstructive procedure requiring creation of two anastomoses, a gastro-jejunostomy and an entero-enterostomy. There are many techniques for constructing these anastomoses and likely, as many variations as there are surgeons performing weight loss surgery. In our practice, we perform the large majority of our Rouxen-Y gastric bypass laparoscopically (LRYGB) and construct these anastomoses using linear stapled techniques. Technical challenges and complications related to the entero-enterostomy are usually under-stated because early leaks at the gastrojejunostomy are the most morbid of the surgical consequences of the operation. Small bowel obstructions after LRYGB is reported in 1.5% to 5% of patients and are reported to occur as early as postoperative day 3.1,2 In one study, 40.5% of surgical explorations for SBO occurred within 6 months after the initial LRYGB.1 Laparoscopic techniques using surgical staplers for this anastomosis require special attention as there are limitations based on instrumentation and dexterity related to the ability to orient and align the bowel. Examples of this are 45 or 60 mm stapler cartridges (in contrast to 75 and 100 mm cartridges for open staplers) and assuring ant-mesenteric to antimesenteric bowel approximation. It is also more challenging to align edges for precise stapling without compromising the lumen of the anastomosis as required for common-channel closure. We had routinely performed the entero-enterostomy using a single stapled technique for creation of the common channel followed by transverse closure of the common channel using the same staple load (Fig 1). The stapler was an Ethicon ETS 45 (Cincinnati, OH) laparoscopic linear stapler with a 45 mm cartridge with 2.5 mm staples (white load). Seromuscular approximation/reinforcing sutures were placed on either end of the common channel. The more distal suture was often also regarded as an antiobstruction stitch after Brolin.3 In a span of approximately 3 months we experienced three early

Department of Invasive and Bariatric Surgery, Penn State College of Medicine, Milton S. Hershey Medical Center, Hershey, PA. Address reprint requests to Randy S. Haluck, MD, FACS, Chief of Minimally Invasive and Bariatric Surgery, Penn State College of Medicine, Milton S. Hershey Medical Center, C4628, 500 University Drive, Hershey, PA 17033. E-mail: rhaluck@hmc.psu.edu

postoperative bowel obstructions requiring surgical revision on postoperative days 3, 13, and 3. Early bowel obstructions such as these are certainly suggestive of a technical error or suboptimal technique. This experience caused us to examine our technique and change to a double stapled (proximal and distal) stapler ring technique to create the common channel as follows: A stay suture is placed near the end of the bilopancreatic limb to the alimentary limb on the antmesenteric surfaces (Fig 2). Enterotomies are made using an ultrasonic dissector (Harmonic Scalpel, Ethicon) followed by the 45 mm linear stapler inserted and red to create one-half of the common channel in the proximal direction. A second stay suture is then placed distally just beyond the anticipated end of the distal common channel. The anastomosis is then swung 180 to align the bowel with the stapler entering through a xed port. The staple is inserted through the enterotomies and the second half or distal common channel is created. The edges of the common channel are grasped (or approximated with a staysuture) and aligned in this orientation for transverse closure with the linear stapler. The stay sutures are left in place with the distal suture also serving as an antiobstruction stitch. There may be several reasons for a higher likelihood of obstruction at the anastomosis using the single-stapled technique and ways the double-stapled technique avoids these. The rst concept however is that fewer postoperative adhesions occur in laparoscopic versus open operations and we believe that the bowel in the area of the anastomosis is less xed and more susceptible to twisting and kinking. It is very possible that the common alimentary limb just distal to the anastomosis can fold or kink (Fig 3). When this happens, the orice into the common alimentary limb is occluded causing the obstruction. It is also possible that as proximal distention occurs, greater pressure is exerted on the common limb, exacerbating the obstruction. This is consistent with our intraoperative ndings for the early obstructions noted. The single stapled technique creates a relatively small common channel, which may be compromised by transverse closure. The double-stapled technique certainly creates a larger common channel orice, which alone may reduce the likelihood of compromise during closure of the common channel or obstruction of the anastomosis if kinking, or adhesions occur (Fig 4). Furthermore, if the common limb does kink, the orice into that limb remains patent and all three limbs

166

1524-153X/08/$-see front matter 2008 Elsevier Inc. All rights reserved. doi:10.1053/j.optechgensurg.2008.10.007

Creation of the entero-enterostomy for LRYGB

167

Figure 1 Typical entero-enterostomy (jejunojenunostomy) showing the proximal alimentary limb (PA), the biliopancreatic limb (BP), and the distal common alimentary limb (CA). The anastomotic orice from the single stapled technique is indicated by the dashed lines. CC indicates the transverse stapled common channel closure. A small common channel may be easily compromised during stapled transverse closure.

168

R.S. Haluck

Figure 2 Kinking of the anastomosis even with an antiobstruction suture in place causes occlusion of the orice to the common alimentary limb (CA). Distention of the proximal alimentary limb (PA) may further compress the distal common alimentary limb. BP biliopancreatic limb.

Creation of the entero-enterostomy for LRYGB

169

Figure 3 Entero-enterostomy showing the proximal alimentary limb, the biliopancreatic limb, and the distal common alimentary limb. Dashed lines show a larger orice from the double-stapled technique that is less likely to be compromised during transverse stapled closure.

170

R.S. Haluck

Figure 4 Even with kinking of the common alimentary limb (CA), the orice to the limb is preserved and the anastomosis remains patent. There is also little dilation of the proximal alimentary limb (PA) and also greater separation of the two limbs reducing compression on the common limb. CC indicates the transverse stapled common channel closure. BP biliopancreatic limb.

remain open, preventing obstruction and avoiding the condition of proximal dilation compressing the distal bowel. Since adopting this technique, we have performed over 600 LRYGB without an instance of an early postoperative bowel obstruction as we had seen using the single stapled technique. The technique is not particularly time consuming and can be done without difculty with an experienced or novice assistant. Our mean operative time for the last 100 LRYGB cases from three surgeons at our institution using this technique is 95.8 minutes.

struction. A technique is presented that may make completion of the anastomosis easier and may be less susceptible to early postoperative obstruction. The additional time to reorient the bowel and perform an additional stapler ring is not prohibitive. Our results after adopting the double-stapled technique are encouraging.

References
1. Husain S, Ahmed A, Johnson J, et al: Small-bowel obstruction after laparoscopic Roux-en-Y Gastric Bypass: Etiology. Diagnosis, and Management. Arch Surg 142:988-993, 2007 2. Felsher J, Brodsky J, Brody F: Small bowel obstruction after laparoscopic Roux-en-Y Gastric Bypass. Surgery 134:501-505, 2003 3. Brolin RE: The antiobstruction stitch in stapled Roux-en-Y enteroenterostomy. Am J Surg 169:355-357, 1995

Conclusion
Construction of the entero-enterostomy for LRYGB can be technically challenging and result in early small bowel ob-