Mark D. Kligman

Exposure of the ligament of Treitz for Roux limb construction during laparoscopic gastric bypass requires either division or displacement of the omentum. Factors compromising this exposure include: (1) a bulky omentum, (2) hepatomegaly, (3) adhesions between the omentum and lower abdominal wall or pelvic contents and (4) inability to identify the transverse colon because of overlying adipose tissue. The lesser sac approach is an alternative method for Roux limb construction during laparoscopic gastric bypass when access to the inframesocolic abdomen is difficult. In this technique the lesser sac is entered through the gastrocolic ligament. The transverse mesocolon is then opened and the ligament of Treitz is identified. The jejunum is pulled into the lesser sac and the Roux limb is constructed. The jejunojejunostomy is reduced into the inframesocolic compartment, the mesenteric defects are closed, and the remaining portion of the procedure is completed. This technique provides an alternative method for completion of a laparoscopic gastric bypass in patients who would otherwise require more extensive surgery.

Gastrojejunal anastomotic leaks remain a major source of morbidity following laparoscopic gastric bypass. Intraoperative pneumatic testing has been offered as a method to reduce the incidence of this complication. This study's purpose was to assess the efficacy of intraoperative pneumatic testing during laparoscopic gastric bypass, to evaluate the types of air leaks detected, and to develop an algorithm for management that takes into account air leak categorization and drainage. A retrospective analysis was performed on the initial 257 consecutive patients undergoing laparoscopic gastric bypass by a single surgeon over a 36-month period. The gastrojejunostomy was constructed using a linear stapler technique. All patients underwent intraoperative endoscopic pneumatic testing with a clamp applied to the Roux limb. All patients underwent water-soluble upper gastrointestinal radiography on the first postoperative day. Patients were divided based on the pneumatic testing results into groups for data analysis: persistent air leak (group 1), non-reproducible air leak (group 2), and no air leak (group 3). The overall age (41.7±9.3 years), body mass index (BMI) (47.3±6.4 kg/m²), conversion rate (2%), and length of stay (1.9±2.0 days) were not statistically different among groups (p>0.05). In group 1, the air leak site was repaired, and 11 (92%) were drained. In group 2, the air leak site could not be identified, and all 12 (4.7%) were treated by drainage alone. In group 3, drains were placed in 12 (5.2%) due to difficult construction of the gastrojejunostomy. Overall postoperative gastrointestinal leak rate was 0.78%. No postoperative clinical or radiological gastrointestinal leaks occurred within the region tested pneumatically. Intraoperative complications related to pneumatic testing occurred in 1 (0.39%) patient. Intraoperative pneumatic testing of the gastrojejunal anastomosis is a safe and rapid means of evaluating anastomotic integrity. Application of this technique permitted timely repair of flawed anastomoses, thereby averting potential postoperative leaks.