Sleeve Gastrectomy Flashcards
What does SADI stand for?
Single anastomosis duodenal-ileostomy
What does DS stand for?
duodenal switch
The esophagus passes through the diaphragm at?
esophageal hiatus
Where is the gastroesophageal junction found?
terminal end of the esopahagus
What controls the passage of food from the esophagus into the stomach?
Lower esophageal sphincter (LES)
What is the cardia?
The first portion of the stomach and contains the cardiac sphincter.
What does the cardiac sphincter open into?
The fundus
what is the fundus of the stomach
upper most portion of the stomach. Adjacent to the cardia.
Where is the lining of the stomach the thinnest?
The fundus
What is the pyloric region?
most distal part of the stomach contains the pyloric antrum, pyloric canal, and pyloric sphincter
What else is the pyloric sphincter called?
pylorus
What is the thickest part of the stomach
pyloric region
What is the lesser curve
boundary of the stomach that forms a short concave curve on the right side of the stomach. From the esophagus to the duodenum.
What is the greater curve
curve on the left side of the stomach. It is much longer than the lesser curve. Runs from esophagus to duodenum
What are landmarks surgeons use during bariatric surgery? -5
Angle of his
incisura angulari
pyloric antrum
pyloric canal
pyloric sphincter
Angle of his
at the junction of the end of the esophagus and the borders of the cardia and fundus on the superior side
How do surgeons use the angle of his during a procedure
Landmark - to ensure the entire fundus is resected during a sleeve gastrectomy or bypass
Incisura angularis
a notch on the inferior portion of the lesser curve, near the pylorus region.
How is the incusura angularis used during a procedure
landmark during stapling. Getting too close to the incisura may cause stricture, or narrowing that makes it difficult for chyme to pass.
what is the purpose of the Pyloric antrum
It holds food until it is ready to pass into the duodenum. Found in the pyloric region
Pyloric canal
most distal portion of the stomach and includes the pyloric sphincter.
Pyloric sphincter
a ring of tissue that controls when and how stomach contents move into the duodenum
The splenic artery
perfuses the spleen. Branches off the celiac trunk
Short gastric arteries
perfuse the upper portion and greater curve of the stomach. Branch off the splenic artery
R & L gastroepiploic arteries
perfuse the greater curve of the stomach and the greater omentum. L branches off the splenic artery, R branches off the gastroduodenal artery
Left gastric artery
perfuses the lower esophagus via esophageal artery - branches off the celiac trunk and perfuses the lesser curve of the stomach and lower intestines
Right gastric artery
branches off the proper hepatic artery, but variations can occur.
3 sections of the small intestines
duodenum, jejunum, ileum
Duodenum
First section of the s. intestines (25-28cm in length = shortest section). digestive enzymes from the pancreas and bile from the gallbladder enter from the ampulla of vater.
It surrounds the head of the pancreas.
Where does the duodenum end
Ligament of treitz
Jejunum
Second section of the small intestines (2.5 meters long) . Primary section for nutrient absorption. Specialized vili for the absorption of sugars, amino acids, and fatty foods.
Where does the jejunum begin
ligament of treitz
Ileum
third and final section of the s. intestines. secondary section for nutrient absorption. It contains vili used for digesting mainly vitamins, minerals, carbohydrates, fats, and proteins.
What is the ligament of treitz
A suspensory muscle of the duodenum and is used as a landmark in gastric bypass procedures.
How can you tell when it moved from the jejunum to the ileum?
There is no well defines transition, but the ileum’s lumen is typically smaller and has thinner walls.
BMI classes
Class 1 - 30-35
Class 2- 35-39.9
class 3 - 40 and above
How do you get BMI
Weight in KG divided by height (In meters) squared
What is BMI
a measurement used as a screening tool to evaluate recommended body weight relative to body height
4 treatment options
lifestyle changes
medications
endoscopic procedures
bariatric surgery
2 types of endoscopic procedures
intra-gastric balloon & endoscopic sleeve gastroplastys
4 types of bariatric surgery
Gastric Sleeve
Gastric bypass
Duodenal switch (DS)
Single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI or SADI_S)
Gastric sleeve - Reversible or not? Purpose of the procedure
not reversible - nutrient absorption decreased through decreased stomach size
Gastric bypass -what is the purpose and is it reversible?
reversible - nutrient absorption decreased through reconfiguration of digestive system and decreased size of stomach
Duodenal switch
partially reversible - nutrient absorption decreased through reconfiguration of digestive system and decreased size of stomach
Single anastomosis duodenal-ileal bypass w/ sleeve gastrectomy SADI_S
partially reversible, nutrient decreased through reconfiguration of digestive system and decreased size of the stomach
Restrictive procedures
gastroplasty
balloon
lap band
sleeve
Restrictive and malabsorptive
bypass
DS
SADI
Reversible
Gastroplasty
Balloon
Lap band
partially reversible
bypass
SADI
DS
Non-reversible
Sleeve
Malabsorptive - what does it mean?
decreases the absorbable surface area of the intestines. They typically reroute the digestive track limiting the amount of time and surface area that nutrients are able to be absorbed
Sleeve gastrectomy - Patient positioning & Prep
Supine
arms on arm boards
secure patient with footboards and straps above and below knees
sterilely prep abdomen
36 Fr. orogastric tube placed - bougie
patient placed in 45 degrees reverse trend
Procedure steps for a sleeve gastrectomy
- Identification of the superior landmark and dissection of the greater curvature
- Gastrectomy
- Closure
Step for identification of the superior landmark and dissection of the greater curvature
- dissect L crus from angle of his. = to visualize gastroesophageal junction and ensure fundus will be fully resected.
- Identify location 6cm from pylorus to start omental dissection
- Dissect greater omentum from greater curvature w/ vessel sealer
- continue to use VSE for dissection from spleen
- free stomach from greater omentum
Steps for the gastrectomy
- Ensure orogastric tube placement at pylorus and lesser curve
- use SureForm stapler 60 at port 2 with green reload with cartridge side positioned posteriorly
- Position stapler 6cm from pylorus being careful not to narrow incisura angularis
- Orient and fire stapler parallel to orogastric tube.
- As the stapler nears the fundus, orient the stapler at the left crus to ensure full resection of the fundus
- Complete gastrectomy
Steps for Closure
Reapproximate the greater omentum to the staple line using single interrupted 2-0 silk suture
After undocking, remove the excised stomach through the 12mm stapler port incision
close the anterior rectus sheath of the 12mm stapler port site.
Staple line reinforcement
a process used by surgeons in the hopes of preventing leaks - Suturing, buttressing
What is buttressing?
Its a material added to the staples and reload that’s absorbed by the patient. The added material is meant to reinforce the tissue being stapled.
How is buttressing used?
Its secured to the cartridge and anvil with adhesive strips or sutures
Roux-en-Y bypass - digestive pathways
A- food enters the new pouch and travels through the gastrojejunostomy down the roux limb
B - stomach & pancreatic enzymes travel down the duodenum
c - Food and the secretions mix for the first time in the biliopancreatic limb
Roux-en-Y procedure steps
- Creation of gastric pouch
- gastrojejunostomy
- Jejunojejunostomy
- closure of defects and final reconstruction
What is the purpose of Creation of the gastric pouch
this makes the stomach smaller so the patient can’t consume large amounts of food. - Restrictive
Gastrojejunostomy
create an enterotomy in the small bowel and the gastric pouch. Then suturing the jejunal enterotomy to the gastric pouch to create an anastomosis that allows food to travel from the stomach into the small intestines
Creation of the jejunojejunostomy
create a defect in the small bowel mesentery just distal to the GJ and transecting the jejunum. Then create an enterotomy in both the roux limb and the biliopancreatic limb. Then suture the two jejunal enterotomies together.
Closure of defects
close the defect created during the procedure to the mesentery. Also close peterson’s defect.
Patient positioning for Roux-en-Y bypass
Supine
Arms on arm boards
secure w/footboards & straps at the thighs
40 Fr. orogastric tube placed w/ suction
Veress needle through palmers point - insufflate to 15mmHg
20 degree reverse trend
What is the reference point used for port placement during a roux-en-Y
22 cm from xiphoid process to midline. -ensure the point is superior to the umbilicus
Where do you place the endoscope port? and which port is it in?
Left lateral, 1.5 cm away from reference point - port 2
Where do you place port 1? What instrument is used?
2 cm cranial and 8cm to the right of reference point - 12 mm stapler port
Where do you place port 3? Roux-en-y
left lateral 8 cm away
Where do you place port 4 - roux-en-y
left lateral 8 cm away
Any accessory item used for the roux-en-y procedure
Nathanson liver retractor - high epigastric position
Creation of the gastric pouch - explain this process
incise between 2nd & 3rd. branches of L gastric artery.
Incise lesser omentum and enter lesser sac - free stomach from adhesions
Staple perpendicular to esophagus and lesser curve for first fire
dissect tunnel to angle of His to visualize L crus
reload stapler and fire parallel along bougie to complete
Gastrojejunostomy - explain this process
create a rent using VSE through omentum to transverse colon
measure 100cm from ligament of Treitz and pull up to pouch - using graptor
Place a 2-0 silk suture b/w gastric pouch and antimesenteric side of Roux limb jejunum to hold in place
After the 2-0 silk suture is in place to keep the roux limb attached to the pouch, what happens
Retract bougie
create gastrostomy in the corner of the pouch
Create an enterotomy in the jejunum where roux limb sits naturally
create side-by-side gastrojejunsotomy w/ SureForm
The size of the gastrojejunostomy will decrease 2-2.3 cm after closure
How do you close the gastrojejunostomy
with double-layer closure with the inner-layer being a 2-0 vicryl
cinch the suture by pushing the tissue down
invert outer layer closure by suturing perpendicular to inner layer closure
Jejunojejunsotomy - explain this process
Transect the jejunal loop after stay suture
Inspect for leaks
Measure 100 cm of Roux limb bowel
bring biliopancreatic limb down to this point
After brininging the bilipancreatic limb down, what happens (JJ cont.)
Create enterotomies in the Roux and biliopancreatic limbs
place enterotomies on the side the anastomosis will lay naturally
Create side by side jejunojejunostomy utilizing the full lenght of the white reload.
How do you close the JJ?
Use double-layer closure using 2-0 vicryl
Place single interrupted suture w/ 2-0 silk suture in crotch of jejunojejunostomy
invert outer-layer by running suture perpendicular
tension on the tails can be used to provide exposure during outer layer closure
Closure for Roux-en-Y Bypass
Retract jejunojejunostomy to expose mesenteric defect
Close mesenteric defect w/ 2-0 silk
reflect roux limb to left and transect colon cranially
expose ligament of treitz
close peterson’s defect
Close 12mm stapler port
Disgestive pathway - SADI-S
A- food enters new sleeve and passes through pylorus b4 travelling t/r the duodenal ileostomy
B - Bile and pancreatic enzymes travel through duodenum and jejunum before they mix with chyme
C- chyme and enzymes meet and will mix for the first time at the duodenal ileostomy
SADI-S Procedure steps
Bowel measurement from ileum vs ligament of Treitz
Duodenal dissection
One anastomosis
sleeve gastrectomy
Digestive pathway of Duodenal switch
A - food enters new sleeve and passes through pylorus before travelling through duodenal ileostomy
B- bile & pancreatic enzymes travle through the duodenum and jejunum
C - chyme and enzymes mix for the first time at the ileo-ileostomy
DS - procedure steps
Measure small bowel from ileum vs. ligament of Treitz
Duodenal dissection
Two anastomoses - duodeno-ileostomy & ileo-ileostomy
sleeve gastrectomy
