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A Double Stapled Technique for

Creation of the Entero-Enterostomy for


Laparoscopic Roux-en-Y Gastric Bypass
Randy S. Haluck, MD, FACS

oux-en-Y gastric bypass surgery for weight loss is a complex reconstructive procedure requiring creation of two
anastomoses, a gastro-jejunostomy and an entero-enterostomy. There are many techniques for constructing these
anastomoses and likely, as many variations as there are surgeons performing weight loss surgery.
In our practice, we perform the large majority of our Rouxen-Y gastric bypass laparoscopically (LRYGB) and construct
these anastomoses using linear stapled techniques. Technical
challenges and complications related to the entero-enterostomy are usually under-stated because early leaks at the gastrojejunostomy are the most morbid of the surgical consequences of the operation. Small bowel obstructions after
LRYGB is reported in 1.5% to 5% of patients and are reported
to occur as early as postoperative day 3.1,2 In one study,
40.5% of surgical explorations for SBO occurred within 6
months after the initial LRYGB.1
Laparoscopic techniques using surgical staplers for this anastomosis require special attention as there are limitations based
on instrumentation and dexterity related to the ability to orient
and align the bowel. Examples of this are 45 or 60 mm stapler
cartridges (in contrast to 75 and 100 mm cartridges for open
staplers) and assuring ant-mesenteric to antimesenteric bowel
approximation. It is also more challenging to align edges for
precise stapling without compromising the lumen of the anastomosis as required for common-channel closure.
We had routinely performed the entero-enterostomy using
a single stapled technique for creation of the common channel followed by transverse closure of the common channel
using the same staple load (Fig 1). The stapler was an Ethicon
ETS 45 (Cincinnati, OH) laparoscopic linear stapler with a 45
mm cartridge with 2.5 mm staples (white load). Seromuscular approximation/reinforcing sutures were placed on either
end of the common channel. The more distal suture was often
also regarded as an antiobstruction stitch after Brolin.3 In a
span of approximately 3 months we experienced three early

Department of Invasive and Bariatric Surgery, Penn State College of Medicine, Milton S. Hershey Medical Center, Hershey, PA.
Address reprint requests to Randy S. Haluck, MD, FACS, Chief of Minimally
Invasive and Bariatric Surgery, Penn State College of Medicine, Milton S.
Hershey Medical Center, C4628, 500 University Drive, Hershey, PA
17033. E-mail: rhaluck@hmc.psu.edu

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1524-153X/08/$-see front matter 2008 Elsevier Inc. All rights reserved.


doi:10.1053/j.optechgensurg.2008.10.007

postoperative bowel obstructions requiring surgical revision


on postoperative days 3, 13, and 3. Early bowel obstructions
such as these are certainly suggestive of a technical error or
suboptimal technique.
This experience caused us to examine our technique and
change to a double stapled (proximal and distal) stapler
firing technique to create the common channel as follows: A
stay suture is placed near the end of the bilopancreatic limb to
the alimentary limb on the antmesenteric surfaces (Fig 2).
Enterotomies are made using an ultrasonic dissector (Harmonic Scalpel, Ethicon) followed by the 45 mm linear stapler
inserted and fired to create one-half of the common channel
in the proximal direction. A second stay suture is then placed
distally just beyond the anticipated end of the distal common
channel. The anastomosis is then swung 180 to align the
bowel with the stapler entering through a fixed port. The
staple is inserted through the enterotomies and the second
half or distal common channel is created. The edges of the
common channel are grasped (or approximated with a staysuture) and aligned in this orientation for transverse closure
with the linear stapler. The stay sutures are left in place with
the distal suture also serving as an antiobstruction stitch.
There may be several reasons for a higher likelihood of obstruction at the anastomosis using the single-stapled technique
and ways the double-stapled technique avoids these. The first
concept however is that fewer postoperative adhesions occur in
laparoscopic versus open operations and we believe that the
bowel in the area of the anastomosis is less fixed and more
susceptible to twisting and kinking. It is very possible that the
common alimentary limb just distal to the anastomosis can fold
or kink (Fig 3). When this happens, the orifice into the common
alimentary limb is occluded causing the obstruction. It is also
possible that as proximal distention occurs, greater pressure is
exerted on the common limb, exacerbating the obstruction. This
is consistent with our intraoperative findings for the early obstructions noted. The single stapled technique creates a relatively small common channel, which may be compromised by
transverse closure. The double-stapled technique certainly creates a larger common channel orifice, which alone may reduce
the likelihood of compromise during closure of the common
channel or obstruction of the anastomosis if kinking, or adhesions occur (Fig 4). Furthermore, if the common limb does
kink, the orifice into that limb remains patent and all three limbs

Creation of the entero-enterostomy for LRYGB

Figure 1 Typical entero-enterostomy (jejunojenunostomy) showing the proximal alimentary limb (PA), the biliopancreatic limb (BP), and the distal common alimentary limb (CA). The anastomotic orifice from the single stapled
technique is indicated by the dashed lines. CC indicates the transverse stapled common channel closure. A small
common channel may be easily compromised during stapled transverse closure.

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R.S. Haluck

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Figure 2 Kinking of the anastomosis even with an antiobstruction suture in place causes occlusion of the orifice to the
common alimentary limb (CA). Distention of the proximal alimentary limb (PA) may further compress the distal
common alimentary limb. BP biliopancreatic limb.

Creation of the entero-enterostomy for LRYGB

Figure 3 Entero-enterostomy showing the proximal alimentary limb, the biliopancreatic limb, and the distal common
alimentary limb. Dashed lines show a larger orifice from the double-stapled technique that is less likely to be compromised during transverse stapled closure.

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R.S. Haluck

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Figure 4 Even with kinking of the common alimentary limb (CA), the orifice to the limb is preserved and the
anastomosis remains patent. There is also little dilation of the proximal alimentary limb (PA) and also greater separation
of the two limbs reducing compression on the common limb. CC indicates the transverse stapled common channel
closure. BP biliopancreatic limb.

remain open, preventing obstruction and avoiding the condition of proximal dilation compressing the distal bowel.
Since adopting this technique, we have performed over
600 LRYGB without an instance of an early postoperative
bowel obstruction as we had seen using the single stapled
technique. The technique is not particularly time consuming
and can be done without difficulty with an experienced or
novice assistant. Our mean operative time for the last 100
LRYGB cases from three surgeons at our institution using this
technique is 95.8 minutes.

Conclusion
Construction of the entero-enterostomy for LRYGB can be
technically challenging and result in early small bowel ob-

struction. A technique is presented that may make completion of the anastomosis easier and may be less susceptible to
early postoperative obstruction. The additional time to reorient the bowel and perform an additional stapler firing is
not prohibitive. Our results after adopting the double-stapled
technique are encouraging.

References
1. Husain S, Ahmed A, Johnson J, et al: Small-bowel obstruction after
laparoscopic Roux-en-Y Gastric Bypass: Etiology. Diagnosis, and Management. Arch Surg 142:988-993, 2007
2. Felsher J, Brodsky J, Brody F: Small bowel obstruction after laparoscopic
Roux-en-Y Gastric Bypass. Surgery 134:501-505, 2003
3. Brolin RE: The antiobstruction stitch in stapled Roux-en-Y enteroenterostomy. Am J Surg 169:355-357, 1995

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