Revisional Bariatric Surgery: Gastric Bypass & Gastrectomy

Case record

• Gastroscopy: Tortuous esophagus without mucosal lesions. Peristalsis preserved. Cardia at 40cm from incisors. At subcardial level there is a "blind" cul-de-sac, about 3cm in diameter, with preserved gastric mucosa. Stomach: Gastric tubulization. Mucosa of the body and antrum with patchy areas of erythema, without erosions or ulcers. Normal pylorus. Duodenum without remarkable findings.

• BIOPSY - Mild chronic inactive gastritis with intestinal metaplasia without dysplasia. - Absence of glandular atrophy. - No microorganisms with morphology compatible with Helicobacter pylori were observed. Absence of malignancy.

• *Upper-GI series (barium swallow): Esophagus with tertiary contractions. Hiatal hernia. GER. Gastric tubulization. Good emptying of the stomach. Duodenum without alterations.

• *Manometry: Ineffective esophageal motility, according to the Chicago classification v.4. 

• *IMPEDANCE - pHMETRY ESOPHAGEAL: Pathological acid reflux. DeMeester score 184.3.

• Conversion to Roux-en-Y gastric bypass Is proposed.

Technique description

Under general anesthesia, 12mm trocars umbilical, in epigastrium, right flank and left subcostal, 5mm Airseal trocars in left flank are placed. Careful dissection of previous gastric sleeve is performed.  Postpyloric section is carried out with Panther® PEAL 60mm reinforced cartridge endostapler. Afterwards, hemostasis of duodenal stump is performed with clips. Creation of a 45mL gastric pouch using the same stapling device. Gastrectomy of the remaining stomach is completed. 

Dissection of the His’ angle and hiatus corroborating small (3cm) hernia. Posterior hiatoplasty is performed with interrupted 2/0 silk sutures. Section of the greater omentum. Section of the jejunum at 50cm from the Treitz angle. A 45mm lineal latero-lateral gastrojejunostomy is performed; closure of the gastro-enterotomy with a running 2/0 PDS suture. Section of the jejunal stump. Mechanical lineal latero-lateral jejuno-jeyunostomy is performed (alimentary limb 100cm); closure of enterotomy with running 3/0 PDS suture.

Mesenteric and Petersen’s deffects closure with running 2/0 polypropilene sutures. Port-site revisión. Specimen removal through umbilical incision. Desufflation.

Procedure steps

1. Trocar placement
2. Postpyloric section and hemostasis of duodenal stump
3. Creation of gastric pouch
4. Gastrectomy of the remaining stomach
5. Dissection of the His' angle and posterior hiatoplasty
6. Section of the greater omentum
7. Gastrojejunostomy
8. Jejunal stump section
9. Jejuno-jejunostomy
10. Mesenteric deffects closure
11. Port-site revision
12. Specimen removal

Training Objectives

1. To understand the surgical strategy for severe gastroesophageal reflux after sleeve gastrectomy.
2. To identify the location and safe placement of trocars.
3. Identification of the anatomical structures involved as well as the appropriate routes for dissection.
4. Principles for the correct use of endo-staplers.
5. Basis for the correct realization of an adequate gastric reservoir.
6. Identify the basic maneuvers for the manipulation and measurement of bowel limbs.
7. Identify and understand the fundamental steps and key maneuvers in the preparation of mechanical gastrojejunostomy and jejunojejunostomy.
8. Recall the basics of intracorporeal suturing.
9. Principles, justification and performance of the different closures of mesenteric defects.
10. Systematic review of the abdominal cavity at the end of the procedure.