When you have reached entraced into the top abdomen; ports are placed. Retraction of the liver is frequently crucial for exposure. Using surgical instruments a tunnel is created circumferentially by dissection around the proximal stomach. A grasper is used to pass an encircling silicone band (lap-band) around the proximal stomach and make sure its "locked". Sutures fix the band in position to avoid it slipping. The band tubing is brought into a deep subcutaneous position and connected to its reservoir, when its inside the abdominal wall, allowing percutaneous access to inject or withdraw saline to alter the dimensions of the band. The wounds are closed. The abdomen is entered through an upper midline cut. cholecystectomy may be done, if gallstones are known in preperation of procedure. When the gastro hepatic ligament is incised the proximal stomach and distal esophagus can be mobilized. A drain or catheter may be required for traction. Between the first and 2nd branches of the left gastric artery, the stomach is then stapled (3 rows) or stapled and transected after being positive that tubes (e.g. nasogastric or esophageal stethoscope) are withdrawn first. The drain or catheter can help to steer placement of the stapler. There should be a 30 ml capacity for the proximal pouch. At 45 cm distal to the ligament of Treitz, the jejunum is split. An 8 to 12 cm segment may be excised to allow more flexing for the ensuing gastric pouch anastomosis (without undue tension in these obese structures). Connect the distal jejunum and proximal limb (45 to 150 cm from the site of division, depending on the desired weight loss assessment) employing a linear stapler. attach the gastric pouch and distal limb, usually retrocolic, by an incursion into the transverse mesocolon. Hand-sewn or staple methods may be employed. The anesthesia doctor uses a Maloney or hurst dilators down the throat prior the anterior anastomotic layer is finished to make certain a stoma of this kind of diameter. Then enter and inserted a nasogastric tube, and diluted blue dye (methylene) is instilled to check and see if their is anastomotic leakage. Leave the tube in the jejuna limb. A gastrostomy may be performed to decompress the excluded gastric remnant. You can then close the mesenteric defects. Antibiotic hydration of the subcutaneous tissues can be done. The wound is closed. This procedure may be performed laparoscopically, employing a disposable endoscopic circular stapler as one of your medical tools, the anvil of which is passed perorally in the esophagus (when possible) in conjunction with a percutaneously passed snare wire that can be required retrogradely to seize the anvil for the pouch-jejunal anastomosis. Using a linear stapler, i.e. GIA. Also hand-assisted method using a hand port, e.g. LAP-PORT may be employed. |
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