Laparoscopic surgical procedures and postoperative care for manual gastrojejunostomy

Surgical procedure

Choosing the right location for the operating port can prevent obstruction of the exposure of the proximal stomach during small intestine dissection.

The larger the patient's body size, the more difficult the surgery becomes. Just as it is difficult to create the operating space for constructing the Roux branch in ordinary patients, the insufficient length of the surgical instruments and the difficulty in exposing the proximal stomach also hinder the surgery on obese patients.

Significantly, different scholars have found different methods and operating hole positions to solve these problems while keeping the specific operating hole position unchanged.

We use five operating ports, a setup that allows for cholecystectomy when needed.

Do not create an insulated port when creating the first operating port; use a visible, bladeless sleeve.

The laparoscope is placed on the midline of the abdomen, 8 to 12 cm below the xiphoid process. Other operating ports are located in positions that facilitate the construction of Roux branch, gastric pouch, and gastrojejunostomy.

Choosing the right angle for the operating cannula can reduce the resistance of the abdominal wall to the instruments, making the surgery more precise and less strenuous.

While preserving the original skin opening, new pathways can be created by changing the direction under the skin.

After the operation, the fascia needs to be sutured at the operating hole, which can improve surgical efficiency and reduce postoperative pain.

Pull the greater omentum toward the head to expose the Treitz ligament.

For patients with adhesions between the greater omentum and pelvic tissues or strangulated abdominal hernias, we prefer to incise the gastrocolic ligament, open the transverse mesocolon from above, and directly expose the Treitz ligament.

Abdominal hernias are repaired when there is significant postoperative weight loss and nutritional status that ensures successful repair, and when intestinal contents are unlikely to contaminate the artificial segment.

The proximal jejunum was cut using a 2.5mm linear anastomosis device, and the mesentery was cut using a separate linear anastomosis device or an ultrasonic scalpel.

Measure the length of the Roux branch and perform side-to-side anastomosis.

Generally, retaining Roux's branch less than 150cm does not increase the risk of malabsorption complications.

The intestinal incision is closed with a single layer of absorbable suture, while the mesenteric opening is closed continuously with non-absorbable suture to reduce the possibility of intestinal hernia.

Roux took the retrocortical portion of the colon and fixed it to the transverse mesocolon with non-absorbable sutures, while closing the Petersen's space to reduce the risk of intestinal hernia.

Some surgeons prefer to construct anterior Roux branches of the colon, believing it can reduce the risk of postoperative intestinal obstruction.

Sometimes, if the mesentery is too short, constructing a retrocolic Roux branch is not safe. In such cases, an anterior Roux branch anastomosis should be decided before cutting the jejunum. The jejunum should be cut further away from the Treitz ligament than in a retrocolic anastomosis, generally 50-100 cm, to reduce tension at the gastrojejunostomy site.

Increased length of the bile duct and pancreatic branch can lead to insufficient iron and calcium absorption. Theoretically, this increases the probability of developing iron and calcium deficiency, which is difficult to address through oral supplementation alone.

Whether the Petersen gap should be closed when constructing the anterior Roux branch of the colon remains controversial.

Clearly, these patients are at risk of intestinal volvulus.

Therefore, we believe that the risk of postoperative bowel obstruction should be eliminated rather than simply reducing its probability.

However, the long-term stability of the sutures in closing these gaps remains to be tested.

At this point, a liver-blocking device can be inserted to facilitate the separation of the proximal stomach.

Sometimes an excessively large liver can obstruct the view, which is an indication for conversion to open surgery.

However, for most patients, tilting the liver to the right rather than the front provides sufficient visibility.

When encountering a patient with hepatomegaly, surgeons may choose to halt the operation, identify the cause of the enlarged liver (usually fatty liver), and develop a treatment plan (such as weight loss medication) so that surgery can be performed in the future under more favorable conditions.

Thus, by stopping the surgery and making the right decisions, the occurrence of surgery-related complications can be reduced.

Dissect the perigastric tissue along the lesser curvature of the stomach, 3-5 cm below the junction of the esophagus and cardia, until reaching the retrogastric space.

Sometimes during this process, it is found that the stomach and pancreas are tightly adhered. In this case, a gastrocolic window can be opened behind the stomach to expand the surgical field.

Handle with care to avoid thermal damage to surrounding internal organs and the vagus nerve.

A proximal small gastric pouch was constructed near the lesser curvature of the stomach using a 3.5mm linear stapler with 6 rows of staples.

Based on our experience, using only a 4-row stapler without reinforcing the sutures to prevent anastomotic errors is unreliable.

Dissecting the easily expandable fundus of the stomach is essential for achieving ideal long-term weight control. This requires precise cutting at the His angle level behind the stomach and also helps prevent esophageal or splenic injury.

A stomach sac no larger than 20ml is ideal.

The stomach sac was horizontally cut below the anastomosis device inserted through the upper right operating port.

The subsequent stapler is inserted through the upper left operating port to perform cutting in sequence.

The high subcostal port allows a standard-length stapler to reach the His angle in every patient's surgery.

It is best to separate the fat around the esophageal hiatus before cutting to clearly observe the esophageal-cardiac junction.

Occasionally, when the stomach wall is thick, a 4.5mm stapler is needed for cutting.

After the first horizontal incision, a 34Fr gastric tube is inserted into the stomach orally to help estimate the size of the gastric pouch and prevent accidental damage or severing of the esophagus.

The Roux branch of the colon is pulled forward to the front of the gastric remnant, close to the newly formed gastric pouch.

Some surgeons prefer to use retrogastric anastomosis, but that makes the procedure and exposure more difficult when a second surgery is needed.

The anastomosis is performed manually, and two layers are reinforced to ensure the continuity of the gastrointestinal tract.

When performing gastrojejunostomy, start from the posterior lateral wall and use 3-0 absorbable sutures for continuous suturing.

The anastomosis is performed from distal to proximal, with the free side of the Roux branch close to the incision line below the gastric pouch, and the incision line is sutured in during the anastomosis.

An intestinal incision is performed at the site of the anastomosis between the gastric sac and Roux branch.

Then, a second full-thickness continuous suture is performed in front of the end point of the first suture.

The anterior wall anastomosis begins with continuous suturing from the distal anterior wall of the intestinal incision, as mentioned earlier. The first layer is a full-thickness suture, followed by a second layer of seromuscular suture.

Before the anastomosis is completed, a 34Fr gastric tube is carefully passed through the anastomosis to help determine the size of the anastomosis and to ensure that the anastomosis is patent.

The front seams are knotted and secured to their respective rear seams.

The condition of the anastomosis and proximal cutting line can be examined by injecting blue dye, air, or using an endoscope through a gastric tube.

However, we do not routinely examine or drain the anastomosis unless a clinical suspicion of a problem with the anastomosis is found.

When withdrawing the cannula from each operating port, check for active bleeding. The holes in the skin are sutured with absorbable sutures.

Postoperative care

Postoperative antibiotics were administered for 24 hours, and antithrombotic therapy continued until the patient was discharged.

Analgesics are administered via a patient-controlled analgesia pump system and intravenous infusion.

Oral analgesics were administered after the patient was given a liquid diet.

Metoclopramide is routinely used after surgery, and other types of antiemetics may also be used depending on the situation.

Performing routine gastrointestinal imaging on patients after surgery is of little significance for postoperative management and may lead to delayed discharge.

Although the postoperative upper gastrointestinal contrast radiography showed normal results, the possibility that the doctor suspected anastomotic leakage based on clinical manifestations could not be ruled out.

The patient can consume clear liquid food on the day of surgery and is required to get out of bed with the help of family members.

If the patient can tolerate a clear liquid diet, the oral medications taken before surgery can be started immediately.

Most patients can be discharged the day after surgery.

The patient was given a clear liquid diet for one week after surgery, and then gradually returned to a normal diet over 3 to 4 weeks.

It is recommended that patients take H₂ blocking drugs or proton pump inhibitors for 30 days after surgery.

Follow-up is routinely conducted at 1 week, 3 weeks, 3 months, 6 months, 9 months and 1 year after surgery, and annually thereafter.

During follow-up visits, patients receive nutritional, psychological, and exercise counseling and guidance, and are encouraged to participate in support group activities.

A complete nutritional assessment should be conducted annually after surgery, and nutritional monitoring and assessment should be carried out immediately if adverse clinical symptoms occur.