Sample Type / Medical Specialty: Bariatrics

Sample Name: Laparoscopic Gastric Bypass - 1

Description: Morbid obesity. Laparoscopic Roux-en-Y gastric bypass, antecolic, a
ntegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Morbid obesity.
POSTOPERATIVE DIAGNOSIS: Morbid obesity.
PROCEDURE: Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25
-mm EEA anastamosis, esophagogastroduodenoscopy.
ANESTHESIA: General with endotracheal intubation.
INDICATIONS FOR PROCEDURE: This is a 50-year-old male who has been overweight fo
r many years and has tried multiple different weight loss diets and programs. Th
e patient has now begun to have comorbidities related to the obesity. The patien
t has attended our bariatric seminar and met with our dietician and psychologist
. The patient has read through our comprehensive handout and understands the ris
ks and benefits of bypass surgery as evidenced by the signing of our consent for
m.
PROCEDURE IN DETAIL: The risks and benefits were explained to the patient. Conse
nt was obtained. The patient was taken to the operating room and placed supine o
n the operating room table. General anesthesia was administered with endotrachea
l intubation. A Foley catheter was placed for bladder decompression. All pressur
e points were carefully padded, and sequential compression devices were placed o
n the legs. The abdomen was prepped and draped in standard, sterile, surgical fa
shion. Marcaine was injected into the umbilicus.
A small incision was made, and a Veress needle was introduced into the abdomen.
CO2 insufflation was done to a maximum pressure of 15 mmHg. Then a 12-mm VersaSt
ep port was placed in the umbilicus. Laparoscopic examination showed no injuries
from entry. I then placed a 5-mm port in the left side just subcostal and just
anterior to the mid-axillary line. A few centimeters below and medial to that, I
placed a 15-mm port. On the right side just subcostal and anterior to the mid-a
xillary line, I placed another 5-mm port. Another 5-mm port was placed just to t
he right of the midline and just subxiphoid, and a few centimeters below that, a
12-mm VersaStep port was placed.
We began by identifying the colon and lifting the transverse colon up and thereb
y identifying the ligament of Treitz. I ran the small bowel down approximately 4
0 cm. I divided the small bowel with a white load GIA stapler. I then divided ac
ross the mesentery utilizing a LigaSure device all the way down to its base. I t
hen ran the distal bowel down 100 cm, and at 100 cm I made a hole in the Roux li
mb and a hole in the duodenogastric limb. I placed a 45 white load stapler into
the abdomen and put 1 side of the white load stapler in the duodenogastric limb
and 1 side in the Roux limb. I fired the stapler, thereby creating a side-to-sid
e anastomosis. I reapproximated the defect with interrupted Surgidac sutures and
then stapled across it with a white load GIA stapler.
I then did a Brolin anti-obstruction stitch with an interrupted Surgidac suture.
I then closed the mesenteric defect with interrupted Surgidac sutures. I then d
ivided the omentum all the way down to the transverse colon in order to create a
pathway to place the Roux limb antecolic, antegastric.
I then placed the patient in reverse Trendelenburg position and placed a liver r
etractor. I first identified the angle of His and made sure that it was clearly

visible. I then had Anesthesia drop a balloon into the stomach and blow it up to
30 cc. Below that, I then cleared the mesentery at the lesser curve and got beh
ind the stomach into the lesser space. I then fired a blue load stapler transver
sely across the stomach, after checking with Anesthesia that everything had been
removed from the stomach. I then made a hole into the stomach at the mid portio
n of the superior staple line. I then made an incision on the greater curve and
made a gastrotomy. I then brought a 25 EEA anvil with a stitch attached to it in
to the abdominal cavity. I placed an angulating grasper into the gastrotomy abov
e my staple line and had it come out through the gastrotomy at the greater curve
. I grabbed the anvil and pulled it through the greater curve gastrotomy and had
the stem come out through the superior staple line so that the stem was now com
ing out through the base of my soon-to-be gastric pouch.
I then completed my pouch by firing 60 blue loads with SeamGuard cephalad up and
through the angle of His. After creating the pouch, I then closed the gastrotom
y on the greater curve by firing across it with blue load stapler. Once this had
been done, I brought up the Roux limb. I cut a hole in the antimesenteric porti
on of the Roux limb and passed a 25 EEA stapler into the abdomen through the 15mm port site and had it go in through the enterotomy. I had a spike come out on
the antimesenteric portion of the small bowel. I removed the spike and joined th
e stapler with the anvil and fired the stapler, thereby creating the anastomosis
, and then removed the EEA stapler. I divided the end of the redundant portion o
f the Roux limb that had the enterotomy utilizing a white load stapler and remov
ed that through the 15-mm port site. I then had a pretty straight shot from the
pouch into the small bowel. I put additional 3-0 Vicryl sutures in the corners i
n order to take off any tension and further secure the wound. I then put a bowel
clamp on the bowel. I went above and performed an esophagogastroduodenoscopy.
I placed a scope into the mouth and down through the esophagus with ease. I pass
ed it into the stomach pouch. I distended up the pouch with air. There was no ai
r leak seen laparoscopically. I was able to pass the scope easily across the ana
stomosis. No bleeding was seen. I then withdrew the scope and scrubbed back into
the case. I closed the 15-mm port site with interrupted 0 Vicryl suture utilizi
ng Carter-Thomason. I then put a 10-flat Jackson-Pratt through the left upper qu
adrant incision and sutured that in place using nylon.
I then closed the skin of all incisions with a running Monocryl. Prior to closin
g, I irrigated the 15-mm port site with dilute Betadine. Sponge, instrument, and
needle counts were correct at the end of the case. The patient tolerated the pr
ocedure well without any complications.
Keywords: bariatrics, morbid obesity, roux-en-y, gastric bypass, antecolic, ante
gastric, anastamosis, esophagogastroduodenoscopy, eea, surgidac sutures, roux li
mb, port, stapler, laparoscopic, intubation,