COMPREHENSIVE ATLAS OF SURGICAL TECHNIQUES
The camera is introduced through the umbilicus. Four operating trocars are entered along the subcostal line.
A) The omental bursa is opened at the proximal part of the smaller curvature.
B) The peritoneum is opened in front of the left crus and is posteriorly dissected at the cardial region to allow the next creation of the small gastric pouch.
C) The proximal stomach is horizontally stapled to create the distal stump of the pouch.
D) The proximal stomach is now vertically stapled to finalize the pouch, separated from the distal stomach.
A) The greater omentum is vertically separated by ultracison to allow a tension-free antecolic ascent of the intestine.
B) The angle of Treitz is visualized and a distance of around 40cm is measured. At this level the jejunal loop is attracted to the gastric pouch.
The loop is opened to allow the insertion of one of the jaws of the endostapler. The anesthetist now enters a 32-French gastric tube into the pouch and slightly pushes it to allow the hook-opening of the posterior pouch wall.
A) One jaw of the endostapler is entered in the jejunum. The other one reaches contact with the tube. By a coordinated maneuver (anesthetist pulling, surgeon pushing) the second jaw of the endostapler is introduced into the gastric pouch.
B) The gastroenteronastomosis is carried out by firing the stapler.
The enterogastrotomy is closed with a running resorbable 3-0 suture.
A distance of 180 cm is measured from the gastroenteroanastomosis thus determining the length of the alimentary loop. At this distance the intestine is carried to the vicinity of the presiously performed gastroenteroanastomosis.
A) An laterolateral jejunojenunal anastomosis is performed betwen the future biliopancreatic and alimentary loops with the endostapler.
B) The enterotomy is also suture closed.
The short jejunal segment between biliopancreatic and alimentary loops is transversally interrupted by stapling thus finalizing the creation of the two loops.
A Jackson-Pratt drain in left near the gastroenteroanastomosis.