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Bariatric Times • September 2011
Surgical Pearls DISTAL ROUX LIMB COMMON LIMB ROUX LIMB
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DISTAL
COMMON LIMB
BILIOPANCREATIC LIMB
BILIOPANCREATIC LIMB
FIGURE 1. Typical end-to-side stapled enteroenterostomy as was employed in my series of open RYGB. After completion of the anastomosis, the transsected mesentery of the biliopancreatic limb was sewn to the mesentery of the adjacent common limb using interrupted 3-0 silk sutures.
ROUX LIMB ROUX LIMB
BILIOPANCREATIC LIMB
BILIOPANCREATIC LIMB
DISTAL COMMON LIMB
FIGURE 3A. Seromuscular suture of 3-0 silk placed between the common limb immediately distal to the anastomosis and the cut end of the biliopancreatic limb.
DISTAL
FIGURE 2. Mechanical obstruction of the common limb immediately distal to the anastomosis resulted from the everted staple line folding forward (arrow) with adherence to the staple line of the biliopancreatic limb.
COMMON LIMB
FIGURE 3B. Tying the antiobstruction suture prevents the everted linear staple line from folding forward on itself, thereby averting anastomotic obstruction by this mechanism.
FIGURE 4. Large internal hernia defect at the jejunojejunostomy that contains a portion of the BP limb at seven o'clock (arrow). Two sutures that were used in closure of the mesenteric defect at during the primary operation are visible at 11 o'clock (arrow).
FIGURE 5. Closure of the hernia defect was performed using interrupted 2-0 silk sutures placed between the cut edge of the mesentery of the BP limb and the mesentery of the Roux limb. The antiobstruction stitch that was placed at the primary operation is not visible.