Approach to Marginal Ulceration Following RYGB Surgery: Laparoscopic Excision of the Marginal Ulcer and Retrocolic, Retrogastric Rerouting of the Roux Limb with Truncal Vagotomy and Hiatal Hernia Repair
23891 views
Procedure Outline
Table of Contents
- 1. Anesthesia
- 2. Patient Positioning
- 3. Endoscopy/Port Placement
- 4. Lysis of Adhesions and Hiatal Dissection
- 5. Vagotomy
- 6. Hiatal Hernia Repair
- 7. Division of Roux Limb
- 8. Partial Gastretomy/Resection of Ulcer
- 9. Rerouting of Roux limb
- 10. New GJ Anastomosis
- 11. Endoscopy for Testing of Anastomosis
- 12. Reducing the Jejunum and Closing Petersen's Defect
- 13. Revision of JJ Anastomosis
- 14. Retrieving the Specimen from the Abdominal Cavity
- 15. Closure
- General anesthesia achieved in the operating room.
- Patient positioned supine with pressure points padded and foot support at end of bed to allow deep reverse Trendelenburg.
- Mobilization of liver.
- Hiatal dissection.
- Identify and divide posterior vagus nerve.
- Identify and divide anterior vagus nerve.
- Identify GE junction.
- Placement of sutures.
- Remove adhesions and mesentery.
- Dissection of stomach.
- Division of gastric remnant.
- Dissection of remnant off of pouch.
- Dissection of remnant/pouch/roux limb confluence (resection of ulcer).
- Completion of remnant dissection.
- Oversew staple line of remnant.
- Mobilize jejunal mesentery.
- Evaluation of Jejunal anastomosis.
- Evaluation of Jejunal common channel.
- Division of attachments of Roux limb to mesocolon.
- Identification of ligament of Treitz/creation of mesocolonic window.
- Passage of Jejunum through transverse mesocolon.
- First layer of anastomosis (posterior outer layer).
- Second and third layers of anastomosis (posterior and anterior inner layers).
- Fourth layer of anastomosis (anterior outer layer).
- Close mesenteric defects.
- Remove specimen.
- Close port sites.
