Role of the s u r g i c a l technologist in bariatric s u r g e r y Bobbie Moore, CST Obesity has reached epidemic proportions in the a designated team of professionals on each and United States. According to a 1999-2000 survey every gastric bypass case. With this in mind, it is of adults 20 years of age and older, 64% of adults more important than ever that surgical technolo- in the United States are considered overweight gists be prepared for their role in this procedure. for their height (BMI of at least 25). Of them, Bariatric surgery or gastric bypass surgery 30%, 59 million Americans, are categorized as is becoming the tool of choice in treating clinical- obese (BMI 30+). Numerous research studies ly severely obese patients. The word bariatric is confirm the connection between overweight and derived from the Greek word baros, which means obesity and the increased risk of health condi- pressure or weight (excess weight or obesity is tions such as Type 2 diabetes, hypertension, implied). Doctors have used various procedures in ischemic stroke, coronary artery disease, osteo- bariatric surgery over the years; however, the three arthritis, and cancer, such as colon cancer, post- procedures that have been performed most often menopausal breast cancer and endometrial can- during the past 20 years are the biliopancreatic cer. Annual medical costs attributed to over- diversion with duodenal switch (BPD–DS) (Figure weight, obesity and their associated health prob- 1), adjustable band gastroplasty (Lap Band) (Fig- lems are in the billions of dollars. ure 2), and the Roux-en-Y Gastric Bypass (RNY) Gastric bypass surgeryis becoming the most (Figure 3). The Roux-en-Y gastric bypass is con- common tool to treat this disease. As a result, sidered the gold standard by the American Society there is a need for a dedicated and skilled surgi- of Bariatric Surgeons (ASBS). The gastric bypass cal team. The American Society of Bariatric Sur- can be performed as an open or laparoscopic pro- geons has emphasized the importance of having cedure. This article will discuss the latter. MAY 2005 The Surgical Technologist 13 256 MAY 2005 1 CE CREDIT IN CATEGORY 1 Considerations the bariatric surgery patient. Disposable endo- The standards for performing gastric bypass sur- mechanical staplers and their various disposable gery have been set by the ASBS and Association cartridges for reloading are also needed for the of periOperative Registered Nurses (AORN). transection of the bowel and stomach tissue. In these standards, both groups have identi- The surgical technologist needs to be aware fied the importance of a multidisciplinary team of each surgeon’s specific needs so that the pro- approach to the gastric bypass. This multidisci- cedure flows smoothly. He or she must also know plinary team includes, but is not limited to, rep- the size and length of staple (eg, 2.0 mm for mes- resentatives from the surgery, pulmonary, radi- entery or thin tissue, 2.5 mm for the bowel, and ology, physiology, nutrition services, psycholo- 3.5 mm or 4.8 mm for the stomach or other thick gy departments and the postanesthesia care unit tissue) and the number of staple reloads (30 mm, (PACU). In the operating room (O.R.), the team 45 mm, or 60 mm linear length) used during consists of the bariatric surgeon, anesthesia pro- each portion of the procedure. Surgeons have a vider, circulator, surgical technologist, and an specific staple length that they prefer and a spe- assistant surgeon or a nonphysician surgical cific order in which they use them. The surgical assistant. technologist should understand the rationale for While surgical technologists normally do using a 2.5 mm staple on bowel and a 3.5 mm or not interact with patients prior to their arrival in 4.8 mm on the stomach. If the incorrect size is the operating room suite for the procedure, they used, a staple-line leak could occur and cause the should understand the events that have influenced patient to return to surgery. If a staple is not long the decision to undergo surgical intervention. The enough, it could cause a disruption in the staple decision is complex and is impacted by many per- line that would result in various complications. sonal, physical, financial and social factors. Trocars will also be used in the laparoscopic The bariatric surger y patient undergoes procedure. Although trocar preference will vary, extensive preoperative education and evalu- most surgeons will use two 5 mm, two 10 mm, ation. Comprehensive laboratory testing and and one 12 mm. In addition, a liver retractor will numerous consultations may be performed. In also be utilized. addition, each patient must fit within the guide- Keep in mind the possibility of conversion lines set by the National Institutes of Health to an open procedure due to technical consider- (NIH) and individual insurance company stan- ations and ensure that the appropriate laparoto- dards to be considered for surgical intervention. my supplies are available. These include a body mass index (BMI) greater than 40 or BMI of 35 with significant comorbidi- Positioning, Prepping and Draping ty such as Type II diabetes, hypertension, gastro- Proper positioning, prepping and draping is esophageal reflux disease (GERD), sleep apnea essential with the bariatric patient, not just for or others. Insurance companies may also man- gastric bypass surgery, but for the other surgi- date specific medical weight-loss parameters for cal/diagnostic procedures this patient popu- patients prior to surgical consideration. Postop- lation may undergo. Although generally seen eratively, follow-up care, including monthly sup- as a major role of the circulating nurse, ensur- port groups, is recommended for patients for a ing proper patient positioning is the responsi- minimum of five years. bility of the entire surgical team. Understand- ing the importance of proper body alignment, Instrumentation support and the correct use of positioning aids The surgical technologist should open laparo- and other equipment will assist in recognizing scopic instruments, such as those used on a lap- potential intraoperative complications before aroscopic colectomy, along with some addi- they occur. Key points are noted below for ref- tional extra long instruments to accommodate erence and review. 14 The Surgical Technologist MAY 2005 Special Considerations FIGURE 1 • If a urinary catheter is ordered, several assis- tants may be needed to provide retraction of Malabsorptive:Malabsorptive: the panniculus and thighs for access to the urethra during catheter placement. bibiliopancreaticliopancreatic • Properly fitted sequential compression devic- es should be utilized to prevent formation of didiversionversion with deep vein thrombosis. • Surgical team members may need step stools dduodenaluodenal to work within the sterile field. • A bariatric operating table, with side attach- switch.switch. ments specifically made for the table, should be utilized. • A padded footboard is also needed. Positioning • The patient is placed in the supine position to provide good joint support. • The team should assess the following poten- tial pressure point areas: elbows, heels, and areas of safety strap placement. • Arms should be secured with padding and fastening straps. • Avoid the hyperextension of the patient’s boards, if possible. The prep extends from the shoulder or forearm on the armboard. mid-chest line to the mid thigh and laterally as • If the arm is tucked to the side, ensure good far as possible. A grounding pad is placed and, circulation and alignment. if ordered, a Foley catheter is inserted. • Place a pillow under the patient’s knees to • The primar y surgeon will stand on the decrease back strain. patient’s right side, and the surgical tech- • Abduct thighs with comfortable physiologi- nologist and the assistant will stand on the cal external rotation. patient’s left. Two video towers should be • Avoid pressure on the lateral aspect of the used, so that the surgeon and the assistant lower leg. will each have a monitor. • Use safety straps to secure the legs. Incisions Prepping • A subumbilical incision is initiated and a • Pay special attention to skin folds under the blunt tip trocar is placed and used to create panniculus to ensure that all surgical site the pneumoperitoneum. areas are clean and adequately prepped. • Four to five additional trocars are placed as described below. Draping • Standard draping for an abdominal incision Port Placement is used. • Right anterior axillary line (AAL) • Left AAL Procedure • Right midclavicular line (MCL) • The patient is placed on the table in the supine • Left MCL position with his or her arms extended on arm- • Subxiphoid, if necessary for liver retraction MAY 2005 The Surgical Technologist 15 FIGURE 2 • Transect the gastric pouch using an endo GIA (either a 3.5 [Blue] or 4.8 [Green] staple Restrictive: length) requiring two to three loads (ie car- tridges) depending on linear length used (eg, adjustable band 30 mm, 45 mm, or 60 mm). • Use one “firing” (ie placement of staples) gastroplasty across, and one to two firings upward toward the Angle of His to create a pouch approxi- (illustration mately 30 cc in size. shows one type of Creating the Roux Limb • Divide the jejunum approximately 20 cm lap band). below the ligament of Treitz. • Measure the length of the Roux limb approx- imately 150 cm down the distal portion of the jejunum. FIGURE 3 • The jejunojejunostomy is performed by mak- ing an enterotomy in both portions of the Combination: jejunum, using a side-to-side anastomosis (a 2.5 white, 45 mm or 60 mm load) to create the Roux-en-Y Roux limb. • Reattach the biliopancreatic limb to the jeju- gastric bypass. num farther down in the digestive tract to decrease malabsorption problems. • Close the enterotomy, using an endo GIA 2.5 load.