**9. Operative technique**

The addition of a bypass component to a simple SG would entail a more technically challenging surgery. Advanced laparoscopic skills are essential to safely perform organ manipulations, adequate dissection, landmark identifications, suturing and anastomosis to ensure a complete and successful surgery. Although several procedures are mentioned above, this chapter will give a more comprehensive discussion to SGDJB and SGPJB, which are the more commonly performed sleeveplus procedures in the Asia-Pacific region.

#### **9.1 Duodenojejunal bypass**

There have been two operative techniques describing SGDJB: the Roux-en-Y (RNY) and the loop technique. The RNY SGDJB was first described by Kasama in 2009 as an alternative option to RYGB which precludes screening of the remnant stomach for gastric cancer in high-risk populations as in Japan [19]. The loop technique was then described by Huang in 2013 in an attempt to mitigate some long-term complications associated with RYGB [20].

#### *9.1.1 Roux-en-Y technique*

After induction of anesthesia, the patient is placed in the French position. Five ports are inserted, the camera port at the supra-umbilicus, a 5-mm port at the subxiphoid for liver retraction, two 12-mm ports at the left subcostal margin and 10 cm caudally, and a 15 mm port at the right upper abdomen.

A standard SG is done over a 36 French bougie using linear staplers beginning 4 cm from the pylorus and proceeding proximally. Dissection of the posterior wall of the duodenum is done and transected at 1-2 cm distal to the pylorus. The jejunum is transected at 50-100 cm from the ligament of Treitz serving as the biliopancreatic limb. The transected distal jejunum to serve as the alimentary tract is measured to 150-200 cm where the jejunojejunostomy anastomosis of the biliopancreatic limb is done. The mesenteric defect is closed by hand-sewn technique. The omentum is divided to avoid tension on the antecolic reconstruction of the duodenojejunal endto-side anastomosis [19] (**Figure 3**).

#### *9.1.2 Loop technique*

After anesthesia is initiated, the patient is placed in supine position. Five ports are also used. Two 12-mm ports at the left and right of the umbilicus at the midclavicular line; the left serving as the camera port. A 15-mm port is inserted into the umbilicus and two 5-mm ports at both subcostal margins.

A standard sleeve gastrectomy is done over a 36 French bougie using a linear stapler beginning at 4 cm proximal to the pylorus and proceeding cranially. At the duodenum 2 cm distal to the pylorus, the posterior wall is dissected creating a tunnel where the linear stapler is inserted and used for transection. The jejunum is then measured 200-300 cm from the Ligament of Treitz where an enterotomy is created. A 1.5 cm duodenotomy is created at the proximal limb and anastomosed to the enterotomy by hand-sewn technique. The jejunum 4 cm proximal to the duodenojejunostomy is anchored to the antrum serving as an anti-torsion suture. The Petersen's defect is closed. The remnant stomach is fixed posteriorly to the retroperitoneal fat and a Jackson-Pratt drain is placed behind the duodenojejunal anastomosis [20] (**Figure 4**).

#### *9.1.3 Pearls*

The SGDJB can be quite intimidating to some surgeons due to the intimate relationship of the duodenum to the surrounding structures. Proper identification of landmarks to guide dissection is important to avoid mishaps.

The location of the common bile duct running behind the first portion of the duodenum, serves as a boundary to the second portion where the transection is done. The gastroduodenal artery (GDA) is also located in this area just to the left of the common bile duct (**Figure 5**). Hence, dissection of the duodenum from the pancreas must be done carefully to avoid injury and bleeding due to the proximity of the GDA and high vascularity of the area.

To facilitate the dissection, counter-traction of the duodenum may be done by pulling the stomach laterally to the left using a traction suture over the gastric antrum. In patients with excessive periduodenal fat, the dissection of a tunnel below the duodenum becomes difficult. In these cases, the right gastroepiploic vessels may be sacrificed. Once a clear tunnel between the duodenum and pancreas has been created, a vascular tape may be inserted and used to lift the duodenum to assist insertion of a stapler for the duodenal transection (**Figure 6**). The surgeon must take care not to injure the common bile duct, pancreas and vasculatures around the first part of the duodenum. A side-to-side or end-to side duodenojejunal *Sleeve-Plus Procedures in Asia: Duodenojejunal Bypass and Proximal Jejunal Bypass DOI: http://dx.doi.org/10.5772/intechopen.96042*

anastomosis may be done, each having its own precautions. A side-to-side anastomosis must be done 1 cm distal to the pylorus to avoid its injury. A temporary stay suture between the pylorus and proximal jejunum allows for easier hand-sewn anastomosis. The other option of an end-to-side anastomosis would require the posterior wall of the proximal duodenum to be partially devascularized to allow some tissue clearance for the hand-sewn anastomosis. Use of a stapler in both orientation of anastomosis may risk pyloric injury. The loop technique requires only a single anastomosis, and an anti-torsion suture anchoring afferent limb of the jejunal loop to the stomach. This is done to avoid torsion or kinking of the jejunal limbs. The RNY technique would require another entero-enteric anastomosis which would translate to more operative time. Closure of both the Petersen and mesenteric defect prevents potential internal herniation of bowel.

**Figure 4.** *SGDJB loop technique.*

*Sleeve-Plus Procedures in Asia: Duodenojejunal Bypass and Proximal Jejunal Bypass DOI: http://dx.doi.org/10.5772/intechopen.96042*

**Figure 5.** *Anatomical landmarks and relationships of the proximal duodenum.*

#### **Figure 7.**

*Sleeve gastrectomy with proximal jejunal bypass.*

### *9.1.4 Challenges*

Apart from being an irreversible procedure with no long-term data available yet to compare it to RYGB, the procedure is technically demanding and might preclude super obese patients. It also requires a fastidious surgeon with

#### *Sleeve-Plus Procedures in Asia: Duodenojejunal Bypass and Proximal Jejunal Bypass DOI: http://dx.doi.org/10.5772/intechopen.96042*

meticulous skills in manipulating an area of intimately-related vital structures, so as to have an uneventful surgery.

Duodenal dissection and manipulation must be done carefully to avoid inadvertent damage to the duodenal wall. Injury to the duodenum proximal to the dissection is resolved with the duodenojejunal anastomosis. But injury distal to the transection may result in a leak if not repaired properly.

Bile duct injury may occur if the duodenal transection is done too distally. Avulsions and lacerations are repaired over a T-tube inserted into the bile duct. Complete transections would require a biliary reconstruction.

Bleeding is not infrequent due to the vascularity around the proximal duodenum and may range from oozing to torrential. Oozing due to multiple small vessels is controlled with simple packing until hemostasis is achieved. Added manipulation is avoided to prevent more tissue injury and aggravate hemorrhage. Severe bleeding from an injured gastroduodenal artery may necessitate suture repair, ligation or conversion to an open laparotomy.

Another shortcoming of the SGDJB is the inaccessibility to the Ampulla of Vater for endoscopic management of biliary obstructions. Therefore, patients with cholelithiasis preoperatively are offered cholecystectomy concomitantly with the bariatric surgery or subsequently if it develops postoperatively, regardless of symptoms.

#### **9.2 Proximal Jejunal bypass**

The surgery is performed under general anesthesia with the patient in reverse Trendelenberg position. Initial entry and camera port is done along the left upper quadrant followed by the other working ports: 15 mm at the umbilicus, 5 mm at the right upper quadrant, and 5 mm at the left subcostal area.

A standard SG is done over a 36 French bougie using linear staplers beginning 4 cm from the pylorus and proceeding proximally. The ligament of Treitz is identified and jejunum is divided at 20 cm. The distally transected jejunum is measured to a distance varying from 250 to 300 cm and is anastomosed to the proximal biliopancreatic jejunal limb. The mesenteric defect is closed to avoid internal hernia and the remnant stomach is fixed posteriorly to the retroperitoneal fat [45] (**Figure 7**).
