Robotic assisted Roux-en-Y gastric bypass
by Rana C Pullatt

Video Atlas of Laparoscopic Surgery: Bariatric Surgery (Volume 1)

by Rana C Pullatt
About Video

This video demonstrates performance of a single docking Roux-en-Y gastric bypass using the da Vinci SI system. Surgical procedure: The patient is placed supine with the left arm tucked. The table is angled 20 degrees to the right from horizontal. The patient is positioned in steep reverse Trendelenburg position. The robot is brought over the left shoulder for docking. The camera port is placed after veress needle is introduced into the fascia just to the left of the umbilicus one open hands breath below the xiphoid process. A liver retractor is introduced from a right subcostal port placed in the anterior axillary line. A robotic trocar is placed in the right subcostal region in the mid clavicular line just below the costal margin. A 12 mm trocar is placed in the right side between the robotic trocar and the camera port. Two robotic trocars are placed in the left side, one in the mid clavicular line and the other one is placed a hand width lateral to that. Initially the robotic camera is introduced without the robot being docked. The ligament of Treitz is identified, a loop of bowel about 50 cm distal to the ligament is identified and is brought up and is secured to the excluded stomach using a 2-0 silk suture. The robot is then docked with the patient in moderate reverse Trendelenburg position. A hook cautery and two cardieres are used for the initial part of the operation, alternatively instead of the cardieres double fenestrated graspers may be used. The angle of His is dissected and the lesser sac is opened. A small gastric pouch is created by division of the stomach below the left gastric vessels. Generally three fires of the stapler are done to create a small gastric pouch, one horizontal and two vertical fires. The bowel loop which was previously secured to the excluded stomach is then released and a two layer anastomosis is performed with 2-0 vicryl sutures. This is performed over a 34 Fr Ewald tube. The loop gastrojejunostomy is thus complete. Once this is completed the loop of bowel is divided as it enters the gastric pouch creating a Roux limb and a biliary limb. About 100 cm distal on the alimentary limb the biliary limb is plugged back in to create a Roux-en-Y configuration. This is done in a side-to-side fashion after jejunostomies are performed and a single fire of the linear stapler with a white load. The common enterotomy is closed with another fire of the stapler with a blue load; alternatively the common enterotomy can be closed with a 2-0 Vicryl. The mesenteric defect is closed using a 2-0 silk suture. Petersen’s space is closed using a 2-0 silk suture. The gastrojejunal anastomosis is checked with an endoscope for hemostasis and an air leak test, this completes the procedure.

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