24.08.2020 | Multimedia Article | Ausgabe 11/2020
Supramesocolic Approach to Roux-en-Y Gastric Bypass when
Standard Inframesocolic Approach Is Not Feasible
- Nicholas Dugan, Abdelrahman Nimeri
The traditional approach to a Roux-en-Y gastric bypass is to
construct the biliopancreatic and Roux limbs within the inframesocolic space.
This requires reflecting the greater omentum, transverse colon, and mesocolon
superiorly. This maneuver can be challenging in patients with a robust omentum,
hepatomegaly, or significant omental adhesions. The inability to fully reflect
the omentum superiorly prevents an appropriate view of the posterior transverse
mesocolon and the inframesocolic space from being obtained. This can make it
difficult to construct the biliopancreatic and Roux limbs. In order to
circumvent the difficult situations described above, a supramesocolic approach
to constructing the biliopancreatic and Roux limbs can be performed. This
approach avoids the need to reflect the omentum and transverse colon.
Key steps include entering the lesser sac by transecting the
gastrocolic ligament and, next, an aperture in the transverse mesocolon made
exposing the ligament of Treitz. The small bowel is then eviscerated into the
supramesocolic space. The biliopancreatic and Roux limbs are then created in the
usual fashion. All of the small bowel except the Roux limb is then returned
through the mesocolon to the inframesocolic space. Peterson’s space and the
mesocolic defect are then closed using permanent suture. The remainder of the
procedure is then performed in the usual fashion.
No complications were reported immediately postoperatively or at a
12-month follow-up in all 3 cases.
The supramesocolic approach to a Roux-en-Y Gastric Bypass is a safe
and effective technique when an inframesocolic approach proves difficult.