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A “Double Stapled” Technique for

Creation of the Entero-Enterostomy forLaparoscopic Roux-en-Y Gastric BypassRandy S. Haluck, MD, FACS

R oux-en-Y gastric bypass surgery for weight loss is a com-plex reconstructive procedure requiring creation of twoanastomoses, a gastro-jejunostomy and an entero-enteros-tomy. There are many techniques for constructing theseanastomoses and likely, as many variations as there are sur-geons performing weight loss surgery.

In ourpractice, we perform the large majority of our Roux-en-Y gastric bypass laparoscopically (LRYGB) and constructthese anastomoses using linear stapled techniques. Technicalchallenges and complications related to the entero-enteros-tomy are usually under-stated because early leaks at the gas-trojejunostomy are the most morbid of the surgical conse-quences of the operation. Small bowel obstructions afterLRYGB is reported in 1.5% to 5% of patients and are reportedto occur as early as postoperative day 3.1,2 In one study,40.5% of surgical explorations for SBO occurred within 6months after the initial LRYGB.1

Laparoscopic techniques using surgical staplers for this anas-tomosis require special attention as there are limitations based

on instrumentation and dexterity related to the ability to orientand align the bowel. Examples of this are 45 or 60 mm staplercartridges (in contrast to 75 and 100 mm cartridges for “open”staplers) and assuring ant-mesenteric to antimesenteric bowelapproximation. It is also more challenging to align edges forprecise stapling without compromising the lumen of the anas-tomosis as required for common-channel closure.

We had routinely performed the entero-enterostomy usinga single stapled technique for creation of the common chan-nel followed by transverse closure of the common channelusing the same staple load (Fig1). The stapler was an EthiconETS45 (Cincinnati, OH) laparoscopiclinear stapler with a 45mm cartridge with 2.5 mm staples (white load). Seromuscu-lar approximation/reinforcing sutures were placed on eitherend of the common channel. The more distal suture was oftenalso regarded as an “antiobstruction stitch” after Brolin.3 In aspan of approximately 3 months we experienced three early

postoperative bowel obstructions requiring surgical revisionon postoperative days 3, 13, and 3. Early bowel obstructions

such as these are certainly suggestive of a technical error orsuboptimal technique.

This experience caused us to examine our technique andchange to a “double stapled” (proximal and distal) staplerfiring technique to create the common channel as follows: Astay sutureis placednear theend of thebilopancreaticlimb tothe alimentary limb on the antmesenteric surfaces (Fig 2).

Enterotomies are made using an ultrasonic dissector (Har-monic Scalpel, Ethicon) followed by the 45 mm linear staplerinserted and fired to create one-half of the common channelin the proximal direction. A second stay suture is then placeddistally just beyond the anticipated end of the distal commonchannel. The anastomosis is then swung 180° to align thebowel with the stapler entering through a fixed port. Thestaple is inserted through the enterotomies and the secondhalf or distal common channel is created. The edges of the

common channel are grasped (or approximated with a stay-

suture) and aligned in this orientation for transverse closurewith the linear stapler. The stay sutures are left in place withthe distal suture also serving as an antiobstruction stitch.

There may be several reasons for a higher likelihood of ob-struction at the anastomosis using the single-stapled techniqueand ways the double-stapled technique avoids these. The firstconcept however is that fewer postoperative adhesions occur inlaparoscopic versus open operations and we believe that thebowel in the area of the anastomosis is less fixed and moresusceptible to twisting and kinking. It is very possible that thecommon alimentary limb just distal to the anastomosis can foldorkink(Fig3). When this happens, the orifice into thecommon

alimentary limb is occluded causing the obstruction. It is also

possible that as proximal distention occurs, greater pressure isexertedon thecommonlimb, exacerbatingthe obstruction. Thisis consistent with our intraoperative findings for the early ob-structions noted. The single stapled technique creates a rela-tively small common channel, which may be compromised bytransverse closure. The double-stapled technique certainly cre-ates a larger common channel orifice, which alone may reducethe likelihood of compromise during closure of the commonchannel or obstruction of the anastomosis if kinking, or adhe-sions occur (Fig 4). Furthermore, if the common limb doeskink, the orificeintothat limb remainspatent and allthree limbs

Department of Invasive and Bariatric Surgery, Penn State College of Medi-

cine, Milton S. Hershey Medical Center, Hershey, PA.

Address reprint requests to Randy S. Haluck, MD, FACS, Chief of Minimally

Invasive andBariatric Surgery, Penn State College of Medicine, Milton S.

Hershey Medical Center, C4628, 500 University Drive, Hershey, PA

17033. E-mail: [email protected]

166 1524-153X/08/$-see front matter © 2008 Elsevier Inc. All rights reserved.

doi:10.1053/j.optechgensurg.2008.10.007

mailto:[email protected]:[email protected]



Figure 1 Typical entero-enterostomy (jejunojenunostomy) showing the proximal alimentary limb (PA), the biliopan-creatic limb (BP), and the distal common alimentary limb (CA). The anastomotic orifice from the single stapled

technique is indicated by the dashed lines. CC indicates the transverse stapled common channel closure. A smallcommon channel may be easily compromised during stapled transverse closure.

Creation of the entero-enterostomy for LRYGB 167



Figure 2 Kinking of the anastomosis even with an antiobstruction suture in place causes occlusion of the orifice to the

common alimentary limb (CA). Distention of the proximal alimentary limb (PA) may further compress the distal

common alimentary limb. BP biliopancreatic limb.

168 R.S. Haluck



Figure 3 Entero-enterostomy showing the proximal alimentary limb, the biliopancreatic limb, and the distal commonalimentary limb. Dashed lines show a larger orifice from the double-stapled technique that is less likely to be compro-

mised during transverse stapled closure.

Creation of the entero-enterostomy for LRYGB 169



remain open, preventing obstruction and avoiding the condi-tion of proximal dilation compressing the distal bowel.

Since adopting this technique, we have performed over600 LRYGB without an instance of an early postoperativebowel obstruction as we had seen using the single stapledtechnique. The technique is not particularly time consumingand can be done without difficulty with an experienced ornovice assistant. Our mean operative time for the last 100LRYGB cases from three surgeons at our institution using thistechnique is 95.8 minutes.

Conclusion

Construction of the entero-enterostomy for LRYGB can be

technically challenging and result in early small bowel ob-

struction. A technique is presented that may make comple-

tion of the anastomosis easier and may be less susceptible to

early postoperative obstruction. The additional time to re-

orient the bowel and perform an additional stapler firing is

not prohibitive. Our results after adopting the double-stapled

technique are encouraging.

References1. Husain S, Ahmed A, Johnson J, et al: Small-bowel obstruction after

laparoscopic Roux-en-Y Gastric Bypass: Etiology. Diagnosis, and Man-

agement. Arch Surg 142:988-993, 2007

2. Felsher J, Brodsky J, Brody F: Small bowel obstruction after laparoscopic

Roux-en-Y Gastric Bypass. Surgery 134:501-505, 2003

3. Brolin RE: The antiobstruction stitch in stapled Roux-en-Y enteroenter-

ostomy. Am J Surg 169:355-357, 1995

Figure 4 Even with kinking of the common alimentary limb (CA), the orifice to the limb is preserved and the

anastomosis remains patent. There is also littledilation of theproximalalimentary limb(PA) andalso greater separationof the two limbs reducing compression on the common limb. CC indicates the transverse stapled common channel

closure. BP biliopancreatic limb.

170 R.S. Haluck

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