27.2 Instrumentation, Room Setup, and Adjuncts for Laparoscopy in the Morbidly Obese

Ninh T. Nguyen, M.D., F.A.C.S.

A. Instrumentation

The two most commonly performed bariatric surgical procedures are the laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding. These procedures are technically challenging operations and require certain specialized instrumentation. The following instruments are considered an integral part of these bariatric procedures. 1. The Veress insufflation needle is often used for initial introduction of pneumoperitoneum and is the preferred method of access. a. The initial intra-abdominal pressure in the morbidly obese tends to be high, in the range of 9 to 10mmHg. Intra-abdominal pres- sure of the nonobese is normally less than 4mmHg. b. An alternative method of access is the Hasson open cannula tech- nique. The Hasson technique is not commonly performed in the morbidly obese because the thick layer of subcutaneous tissue makes it difficult to provide exposure of the fascial layer through a small skin incision. 2. Trocars with normal length are sufficient in most cases; however, in the super-superobese (body mass index >60kg/m2), longer trocars can be helpful. a. Normally five or six trocars are used for laparoscopic bariatric surgery. Five abdominal trocars should be sufficient in most cases, but in difficult cases affording poor exposure, a sixth trocar is placed. b. The trocars range in size from 5 to 15mm in diameter. Normally, three 5-mm trocars are placed to introduce grasping instruments, an 11-mm trocar is placed for the laparoscope, and a 12-mm trocar is placed for the mechanical stapling instruments. For laparoscopic adjustable gastric banding, a 15-mm trocar is required for insertion of the band. c. The initial trocar position can be either at the umbilicus or at the left midclavicular line. Technique for introduction of the trocar is very important in the morbidly obese. All trocars should be placed through the surgical incision and perpendicular to the abdominal cavity. If a trocar is placed tangentially, so that the 27.2. Setup for Laparoscopy in the Morbidly Obese 289

A

B

Figure 27.2.1. A. Correct placement of trocar in morbidly obese patients. B. Incorrect placement of trocar.

surgical incision and the fascial entrance are in different planes, its movement will be severely limited (Fig. 27.2.1). 3. The liver retractor is used to retract the left lobe of the liver for expo- sure of the gastroesophageal junction and the gastric cardia. There are two different types of liver retractor. The Nathanson liver retractor (Cook Surgical, Bloomington, IN) is placed in the subxiphoid posi- tion, and the Snowden Pencer retractor (Snowden Pencer, Tucker, GA) is placed through a 5-mm trocar positioned at the right anterior axil- lary line in the subcostal region. Once positioned, these devices are attached to a self-retaining mechanical arm. 4. The ultrasonic devices (Harmonic Scalpel, Ethicon Endo-Surgery, Cincinnati, OH; AutoSonix Ultrashears, US Surgical, Norwalk, CT) are instruments that utilize ultrasonic vibration to achieve hemostasis and tissue cutting. 5. Laparoscopic mechanical staplers are used for division and recon- struction of intestinal continuity. Mechanical staplers consist of either the linear or circular stapler. 290 N.T. Nguyen

a. Linear staplers can be used for creation of the gastric pouch, the jejunojejunostomy, and the gastrojejunostomy in laparoscopic gastric bypass. b. Some surgeons use the circular stapler for creation of the gastro- jejunostomy anastomosis. In this procedure, the anvil of the cir- cular stapler is placed into the gastric pouch. The original description for placement of the anvil into the gastric pouch is the transoral technique, similar to the technique for percutaneous gastrostomy tube (PEG) placement. The size of the circular stapler used for construction of the gastrojejunostomy is 21 or 25mm. 6. Laparoscopic instruments consist of the following: scissors, atrau- matic graspers, needle drivers, suturing instruments, and clip appliers. Suturing instruments consist of either a conventional needle driver or specialized instruments to facilitate intracorporeal suturing.

B. Room and Equipment Setup

1. Room layout for laparoscopic bariatric surgical procedures is very similar to that for other laparoscopic operations. General considera- tions include the size of the operating room and the location of the doors, as the fiberoptic gastroscope is commonly brought in for eval- uation of the gastrojejunostomy anastomosis. Figure 27.2.2 shows a typical setup for a laparoscopic bariatric surgical procedure. 2. Video equipment should include a three-chip camera, a 10-mm laparoscope with 45-degree angle, a light source, an insufflator, and two monitors. A monitor is placed on the right and left sides of the patient at the head of the operating table. 3. The operating room table should have the capacity to bear heavy patients and to move them in Trendelenburg and reverse Trendelen- burg positions.

C. Patient Preparation and Adjuncts

1. A bowel preparation is performed the day before the surgery. 2. The patient is positioned supine with both arms extended on the arm board. An egg-crate mattress is placed underneath both arms to avoid pressure injury. The surgeon stands on the patient’s right side and the assistant stands on the patient’s left side. A foot board is used to securely position the patient’s feet on a flat platform in preparation for placement into reverse Trendelenburg position. The patient’s legs are taped securely to the bed and a safety strap is placed around the patient’s thighs. 3. Sequential compression device and graduated compression stockings are applied to the lower extremities as prophylaxis for deep venous thrombosis. 27.2. Setup for Laparoscopy in the Morbidly Obese 291

Figure 27.2.2. Room setup and patient position for laparoscopic bariatric surgery.

4. A Foley catheter and an orogastric tube are inserted to evacuate the bladder and stomach before insertion of the Veress needle. 5. Prophylactic antibiotics are used prior to making the initial surgical incision.

D. Selected References

Ammori BJ, Vezakis A, Davides D, Martin G, Larvin M, McMahon MJ. Laparoscopic cholecystectomy in morbidly obese patients. Surg Endosc 2001;15:S91. 292 N.T. Nguyen

Higa KD, Boone KB, Ho T. Complications of the laparoscopic Roux-en-Y gastric bypass: 1,040 patients—what have we learned? Obes Surg 2000;10:509–513. Miles RH, Carballo RE, Prinz RA, et al. Laparoscopy: the preferred method of cholecys- tectomy in the morbidly obese. Surgery 1992;112:818–823. Nguyen NT, Goldman C, Rosenquist CJ, et al. Laparoscopic versus open gastric bypass: a randomized study of outcomes, quality of life, and costs. Ann Surg 2001; 234:279–289. Schauer PR, Ikramuddin S. Laparoscopic surgery for morbid obesity. Surg Clin North Am 2001;81:1145–1179. Schauer PR, Ikramuddin S, Gourash W, et al. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg 2000;232:515–529. Wittgrove AC, Clark GW. Laparoscopic gastric bypass, Roux-en-Y 500 patients: technique and results, with 3–60 month follow-up. Obes Surg 2000;10:233–239.