Upper GI

Roux-en-Y Gastric Bypass (Laparoscopic) (Variant)

OPERATION: Laparoscopic Roux-en-Y Gastric Bypass (LRYGB)
ANAESTHETIC: General anaesthesia
ANTIBIOTICS: IV cefuroxime (or equivalent) within 30 minutes of incision
POSITION: Supine, arms out to sides. Footboard secured. Sequential compression devices applied. Urinary catheter inserted. Steep reverse Trendelenburg for upper abdominal work.

INDICATION:
Morbid obesity. BMI [value]. [Associated comorbidities: type 2 diabetes / hypertension / obstructive sleep apnoea / other]. Standard bariatric criteria met. Preoperative multidisciplinary assessment completed including dietitian, psychologist, and physician review.

PROCEDURE:
WHO Checklist performed. VTE prophylaxis administered. Abdomen prepared and draped.

PORT PLACEMENT:
Veress needle inserted in the left upper quadrant. Pneumoperitoneum established. Five extra-long ports placed across the upper abdomen: 11 mm port approximately 15 cm below xiphoid just left of midline (camera port); 12 mm port right midclavicular line rostral to camera port (main working port); 5 mm port right subcostal midclavicular line; 5 mm port right flank for liver retraction; 5 mm port left upper quadrant (initial Veress site). 45 degree laparoscope used throughout. Patient placed in steep reverse Trendelenburg.

GASTRIC POUCH FORMATION:
Lesser omentum divided using an energy device. Left gastric artery identified — replaced or accessory left hepatic artery excluded and preserved if present. Neurovascular bundle along the lesser curve transected with a vascular load linear stapler. Transverse stapler application across the stomach 2-3 cm distal to the gastro-oesophageal junction, followed by further firings oriented vertically along the lesser curve towards the angle of His. A 20-30 mL vertically oriented gastric pouch created. Gastric fundus excluded from the pouch. Staple line defects oversewn. Haemostasis confirmed.

ROUX LIMB CREATION:
Table returned to neutral position. Ligament of Treitz identified by lifting the transverse mesocolon superiorly. Jejunum measured 100 cm distal to the ligament of Treitz. Small mesenteric window created. Jejunum divided with a white load linear stapler. Roux limb brought up in antecolic antegastric fashion to the gastric pouch.

GASTROJEJUNOSTOMY:
Back row of anastomosis fashioned with a running seromuscular suture from the angle of His. Gastrotomy created in the pouch and corresponding enterotomy in the Roux limb. Anastomosis created with a linear stapler (blue load, 2 cm depth). Anastomosis tested with flexible endoscopy — no leak confirmed by air insufflation under saline irrigation. Common enterotomy closed in two layers with running suture and additional stapler firing. Jejunum divided just to the left of the gastrojejunostomy with a white load stapler, completing the biliopancreatic limb.

JEJUNOJEJUNOSTOMY:
Roux limb measured 150 cm from the gastrojejunostomy. Functional side-to-side jejunojejunostomy created between the Roux and biliopancreatic limbs using a white load stapler. Common enterotomy closed with an additional stapler firing. Anti-obstruction stitch placed. Mesenteric defect closed with a running suture. Petersen's defect closed with a purse-string suture.

Haemostasis confirmed. All ports removed under direct vision. All skin incisions closed with absorbable subcuticular sutures.

FINDINGS:
Gastric pouch 20-30 mL. Biliopancreatic limb 100 cm. Roux limb 150 cm. Both anastomoses confirmed patent and haemostatic. No twist or tension in Roux limb.

EBL: Minimal. COMPLICATIONS: None.

POST-OPERATIVE INSTRUCTIONS:
Upper GI contrast study on day 1 to exclude anastomotic leak. Clear fluids commenced if contrast study normal. Discharge day 2 if tolerating fluids and pain controlled. Vitamin and mineral supplementation commenced. Follow-up at 1 week and 1, 3, 6, 12 months.