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Video preload image for 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
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  • Title
  • 1. Endoscopy/Port Placement
  • 2. Lysis of Adhesions and Hiatal Dissection
  • 3. Vagotomy
  • 4. Hiatal Hernia Repair
  • 5. Division of Roux Limb
  • 6. Partial Gastrectomy/Resection of Ulcer
  • 7. Rerouting of Roux Limb
  • 8. New GJ Anastomosis
  • 9. Endoscopy for Testing of Anastomosis
  • 10. Reducing the Jejunum and Closing Petersen's Defect
  • 11. Revision of JJ Anastomosis
  • 12. Retrieving the Specimen from the Abdominal Cavity
  • 13. Closure

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

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Deborah D. Tsao, BS1; Janey Sue Pratt, MD2
1Stanford University School of Medicine
2Massachusetts General Hospital

Procedure Outline

  • 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.
  1. Remove adhesions and mesentery.
  2. Dissection of stomach.
  3. Division of gastric remnant.
  4. Dissection of remnant off of pouch.
  5. Dissection of remnant/pouch/roux limb confluence (resection of ulcer).
  6. Completion of remnant dissection.
  1. Oversew staple line of remnant.
  2. Mobilize jejunal mesentery.
  3. Evaluation of Jejunal anastomosis.
  4. Evaluation of Jejunal common channel.
  5. Division of attachments of Roux limb to mesocolon.
  6. Identification of ligament of Treitz/creation of mesocolonic window.
  7. Passage of Jejunum through transverse mesocolon.
  1. First layer of anastomosis (posterior outer layer).
  2. Second and third layers of anastomosis (posterior and anterior inner layers).
  3. Fourth layer of anastomosis (anterior outer layer).
  • Close mesenteric defects.
  • Remove specimen.
  • Close port sites.

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Filmed At:

Massachusetts General Hospital

Article Information

Publication Date
Article ID25
Production ID0104
Volume2024
Issue25
DOI
https://doi.org/10.24296/jomi/25