Roux-en-Y gastric bypass for morbid obesity - Home Study Program

AORN Journal,  Oct, 2002  by Cynthia J. Barrow

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THE SURGICAL PROCEDURE

After the circulating nurse cleanses the patient's skin with a povidone-iodine solution, the scrub person and surgeon place sterile drapes, isolating the abdomen. The scrub person folds the lower portion of the laparotomy drape into a pouch to catch instruments that may slide as a result of positioning. The anesthesia care provider maximally lowers the OR bed and places it in reverse Trendelenburg's position. The surgical procedure is accomplished in a methodical fashion proceeding in the following manner.

* The surgeon makes an upper midline incision from the xyphoid process to the supraumbilical area. After opening the peritoneal cavity, the surgeon explores the patient's abdomen and palpates the gallbladder for gallstones. If gallstones are found, a cholecystectomy is indicated at the time of the bypass procedure. (64) The surgeon places a wound protector around the abdominal incision, inserts a self-retaining abdominal retractor with 4-inch side blades, and attaches the abdominal retractor to the OR bed (Figure 4).

[FIGURE 4 OMITTED]

* After mobilizing the distal esophagus, the surgeon encircles it with a soft rubber 18-inch by 1/2-inch drain secured by a clamp. The surgeon incises the omentum along the lesser curvature of the stomach at a point below the second branch of the left gastric artery. Using a large right-angle clamp, the surgeon creates a tunnel from that point to the angle of His and places a large (eg, 28-Fr or 30-Fr) red rubber catheter behind and encircling the stomach (Figure 5). The red rubber catheter serves as a guide for stapler placement around the stomach.

[FIGURE 5 OMITTED]

* The surgeon identifies the ligament of Treitz and mobilizes approximately 30 cm of the proximal jejunum. Using a gastrointestinal anastomosis stapler, he or she divides the jejunum at this location and tags the proximal end with a silk suture for later identification. The surgeon creates openings in the transverse mesocolon and greater omentum. The distal jejunum (ie, the Roux limb) is passed through these openings and positioned in the region of the proximal stomach. The anesthesia care provider then withdraws the nasogastric tube into the esophagus.

* The surgeon inserts a stapler capable of placing four rows of staples into the open end of the red rubber catheter (Figure 6). Guided by the catheter, he or she passes the stapler behind the stomach. The surgeon deploys the stapler to create a gastric pouch approximately 6 cm by 4 cm with a 30-mL capacity. The scrub person helps the surgeon replace the stapler cartridge without removing the stapler from the abdomen, and the surgeon deploys it two more times, creating three superimposed layers of staples across the proximal stomach (Figure 7).

[FIGURES 6-7 OMITTED]

* The surgeon makes a 1-cm longitudinal incision on the anterior wall of the proximal gastric pouch and a similar longitudinal incision on the Roux limb. Beginning with a posterior row of interrupted 3-0 silk sutures, the surgeon creates a side-to-side gastrojejunostomy. Using a continuous suture of absorbable 3-0 synthetic polyester suture material, the surgeon completes the second layer of the posterior row.