OBES SURG DOI 10.1007/s11695-017-2870-8
HOW I DO IT
Laparoscopic Linear Stapled Running Enterotomy Closure in Roux-en-Y Gastric Bypass Using Absorbable Unidirectional Barbed Suture (Stratafix® 2/0) Ben Gys 1
&
Tobie Gys 1 & Michael Ruyssers 1 & Thierry Lafullarde 1
# Springer Science+Business Media, LLC 2017
Abstract Background Laparoscopic running enterotomy closure for linear stapled Roux-en-Y gastric bypass (RYGB) may be enhanced by using unidirectional barbed sutures (Stratafix™ 2/0, Ethicon) as it eliminates the need for knot tying and assistance from a third hand. Objectives The objective of this paper is to present our technique using unidirectional barbed sutures (Stratafix™ 2/0, Ethicon). Methods After stapling the gastrojejunostomy, we start the closure of the residual enterotomy unidirectional from left to right (single, full-thickness layer) which is cut without a knot. For the jejunojejunostomy, the residual enterotomy is closed perpendicular from top to bottom in order to avoid iatrogenic stricture formation (single, full-thickness layer). No backstitches are performed. Conclusions We feel strongly that this technique might enhance running enterotomy closure for linear stapled RYGB. Keywords Stratafix . Enterotomy . RYGB . Anastomosis . Laparoscopy . Knot . Barbed
Introduction As an alternative to multifilament sutures, we present the use of absorbable monofilament barbed sutures (Stratafix™ 2–0, Electronic supplementary material The online version of this article (doi:10.1007/s11695-017-2870-8) contains supplementary material, which is available to authorized users. * Ben Gys [email protected]
1
AZ Sint-Dimpna, J-.B. Stessensstraat 2,, 2440 Geel, Belgium
Ethicon) for running enterotomy closure after linear stapled gastrojejuno- and jejunojejunostomy.
Surgical Technique Patients are installed in dorsal minimal reverse Trendelenburg position. The operating surgeon is standing between the legs with a resident on the left side and a scrub nurse on the on the patient’s right side. Pneumoperitoneum is established using a 12mm trocar (Optiview™, Ethicon) placed on the midclavicular line in the left hypochondriac region about 5 cm below the xiphoid process. After careful inspection, another three bladed trocars are placed in the same sagittal plane: two 5-mm trocars in the left subcostal and right hypochondriac region and a 12-mm trocar in the right paramedian region. Liver retraction is established using a Nathanson hook (Mediflex®) fixed on an Omni-Tract® retractor (Integra®). If necessary, adhesiolysis is performed to allow access to the stomach and identification of a proximal mobile jejunal limb for pouch anastomosis. We always split the greater omentum to allow traction-free anastomosis. After marking the jejunum at the correct side to avoid torsion with a single intra-abdominal knotted stitch (using Vicryl® 2/0, Ethicon), a retro-gastric tunnel is dissected starting at the lesser curvature towards the left angle of His using a harmonic scalpel (Ultracision©, Ethicon). The stomach pouch (we aim for a volume of 15–30 ml) is created using a linear stapler (Echelon Endopath flex 60™, Ethicon) with blue cartridges (1.5-mm closed staple height) without the use of a transoral calibration tube. To avoid staple line rupture in thick scar tissue after previous (bariatric) surgery (e.g., gastric banding, vertical banded gastroplasty, fundoplication surgery…) we use gold cartridges (1.8-mm closed staple height) at the
OBES SURG
vertical staple line. We do not consistently perform staple line reinforcement. A stapled antegastric, antecolic gastrojejunostomy is created after gastrotomy at the horizontal staple line in the middle of the pouch using the harmonic scalpel (Ultracision©, Ethicon). Care is taken not to cross staple lines for optimal tissue vascularization. After placement of a single fullthickness reinforcement stitch at the right anastomotic corner (Vicryl® 2/0, Ethicon), we start the closure of the residual enterotomy unidirectional from left to right (single, running, full-thickness layer) which is cut without a knot (Video 1). No backstitches are performed. If necessary, small corrections are performed with extracorporeal knotted, non-absorbable stitches (Prolene® 2/0, Ethicon). A Roux limb of 100 cm is then measured up and a side-toside linear stapled jejunojejunostomy is created, again using the 60-mm-long linear stapler with a white cartridge (1.0-mm closed staple height). The residual enterotomy is closed perpendicular from top to bottom in order to avoid iatrogenic stricture formation (unidirectional, single running layer). No backstitches are performed and the suture is cut without a knot. After small bowel division, the mesenteric and Petersen’s defect are closed using a total of four separate extracorporeal knotted stitches of nonabsorbable suture (Prolene® 2/0, Ethicon). No intraoperative leak test is performed. Skin closure is performed using intradermal monofilament absorbable sutures. No drains are used routinely.
fastens the closure of the residual enterotomy at the stapled gastrojejunostomy and also significantly reduces the need for correction stitches. We did not encounter (intraluminal) bleeding, anastomotic stenosis, or gastric fistula (at 6 months follow-up). Use of barbed sutures may enhance laparoscopic running enterotomy closure in linear stapled RYGB by eliminating the need for knot tying and constant tension kept by a third hand. In our opinion, it is feasible, easy to use and requires minimal extra skills in comparison with the use of traditional multifilament sutures. Time benefit is plausible. Compliance with Ethical Standards Ethical Approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed Consent For this type of study formal consent is not required. Informed consent was obtained from all individual participants included in the study. Conflict of Interest The authors declare that they have no conflict of interest. Grants/Support None
References Discussion 1.
Few studies regarding the use of Stratafix® for enterotomy closure are available at this time. In a retrospective, small population study (50 patients) with 30 days of follow-up concerning one-anastomosis loop gastric bypass (fully hand sewn technique), Blanc et al. [1] reported no postoperative complications and good feasibility. Barbed suturing was performed bidirectionally with an interrupted Vicryl® 3/0 layer on top [2] [3]. In our own series [4], we can conclude that the use of Stratafix™ 2/0 (Ethicon) is feasible and safe. A significant decrease in postoperative intraluminal bleeding was encountered in patients when using barbed sutures, but this finding might be biased by the study design. Furthermore, the use of running unidirectional knotless barbed sutures significantly
2.
3.
4.
Blanc P, Lointier P, Breton C, et al. The hand-sewn anastomosis with an absorbable bidirectional monofilament barbed suture Stratafix™ during laparoscopic one anastomosis loop gastric bypass. Retrospective study in 50 patients. Obes Surg. 2015 Dec;25(12):2457–60. Kassir R, Blanc P, Breton C, et al. Laparoscopic Roux-en-Y gastric bypass with the absorbable bidirectional monofilament barbed suture Stratafix™: the hand-sewn technique. Obes Surg. 2015 Feb;25(2): 325–6. Kassir R, Breton C, Lointier P, et al. Laparoscopic Roux-en-Y gastric bypass with hand-sewn gastrojejunostomy using an absorbable bidirectional monofilament barbed suture: review of the literature and illustrative case video. Surg Obes Relat Dis. 2014 May-Jun;10(3): 560–1. Gys B, Gys T, Lafullarde T. The use of unidirectional knotless barbed suture for enterotomy closure in Roux-en-Y gastric bypass: a randomized comparative study. Obes Surg. 2017 Mar 9; doi:10.1007/s11695-017-2628-3.
HOW I DO IT
Laparoscopic Linear Stapled Running Enterotomy Closure in Roux-en-Y Gastric Bypass Using Absorbable Unidirectional Barbed Suture (Stratafix® 2/0) Ben Gys 1
&
Tobie Gys 1 & Michael Ruyssers 1 & Thierry Lafullarde 1
# Springer Science+Business Media, LLC 2017
Abstract Background Laparoscopic running enterotomy closure for linear stapled Roux-en-Y gastric bypass (RYGB) may be enhanced by using unidirectional barbed sutures (Stratafix™ 2/0, Ethicon) as it eliminates the need for knot tying and assistance from a third hand. Objectives The objective of this paper is to present our technique using unidirectional barbed sutures (Stratafix™ 2/0, Ethicon). Methods After stapling the gastrojejunostomy, we start the closure of the residual enterotomy unidirectional from left to right (single, full-thickness layer) which is cut without a knot. For the jejunojejunostomy, the residual enterotomy is closed perpendicular from top to bottom in order to avoid iatrogenic stricture formation (single, full-thickness layer). No backstitches are performed. Conclusions We feel strongly that this technique might enhance running enterotomy closure for linear stapled RYGB. Keywords Stratafix . Enterotomy . RYGB . Anastomosis . Laparoscopy . Knot . Barbed
Introduction As an alternative to multifilament sutures, we present the use of absorbable monofilament barbed sutures (Stratafix™ 2–0, Electronic supplementary material The online version of this article (doi:10.1007/s11695-017-2870-8) contains supplementary material, which is available to authorized users. * Ben Gys [email protected]
1
AZ Sint-Dimpna, J-.B. Stessensstraat 2,, 2440 Geel, Belgium
Ethicon) for running enterotomy closure after linear stapled gastrojejuno- and jejunojejunostomy.
Surgical Technique Patients are installed in dorsal minimal reverse Trendelenburg position. The operating surgeon is standing between the legs with a resident on the left side and a scrub nurse on the on the patient’s right side. Pneumoperitoneum is established using a 12mm trocar (Optiview™, Ethicon) placed on the midclavicular line in the left hypochondriac region about 5 cm below the xiphoid process. After careful inspection, another three bladed trocars are placed in the same sagittal plane: two 5-mm trocars in the left subcostal and right hypochondriac region and a 12-mm trocar in the right paramedian region. Liver retraction is established using a Nathanson hook (Mediflex®) fixed on an Omni-Tract® retractor (Integra®). If necessary, adhesiolysis is performed to allow access to the stomach and identification of a proximal mobile jejunal limb for pouch anastomosis. We always split the greater omentum to allow traction-free anastomosis. After marking the jejunum at the correct side to avoid torsion with a single intra-abdominal knotted stitch (using Vicryl® 2/0, Ethicon), a retro-gastric tunnel is dissected starting at the lesser curvature towards the left angle of His using a harmonic scalpel (Ultracision©, Ethicon). The stomach pouch (we aim for a volume of 15–30 ml) is created using a linear stapler (Echelon Endopath flex 60™, Ethicon) with blue cartridges (1.5-mm closed staple height) without the use of a transoral calibration tube. To avoid staple line rupture in thick scar tissue after previous (bariatric) surgery (e.g., gastric banding, vertical banded gastroplasty, fundoplication surgery…) we use gold cartridges (1.8-mm closed staple height) at the
OBES SURG
vertical staple line. We do not consistently perform staple line reinforcement. A stapled antegastric, antecolic gastrojejunostomy is created after gastrotomy at the horizontal staple line in the middle of the pouch using the harmonic scalpel (Ultracision©, Ethicon). Care is taken not to cross staple lines for optimal tissue vascularization. After placement of a single fullthickness reinforcement stitch at the right anastomotic corner (Vicryl® 2/0, Ethicon), we start the closure of the residual enterotomy unidirectional from left to right (single, running, full-thickness layer) which is cut without a knot (Video 1). No backstitches are performed. If necessary, small corrections are performed with extracorporeal knotted, non-absorbable stitches (Prolene® 2/0, Ethicon). A Roux limb of 100 cm is then measured up and a side-toside linear stapled jejunojejunostomy is created, again using the 60-mm-long linear stapler with a white cartridge (1.0-mm closed staple height). The residual enterotomy is closed perpendicular from top to bottom in order to avoid iatrogenic stricture formation (unidirectional, single running layer). No backstitches are performed and the suture is cut without a knot. After small bowel division, the mesenteric and Petersen’s defect are closed using a total of four separate extracorporeal knotted stitches of nonabsorbable suture (Prolene® 2/0, Ethicon). No intraoperative leak test is performed. Skin closure is performed using intradermal monofilament absorbable sutures. No drains are used routinely.
fastens the closure of the residual enterotomy at the stapled gastrojejunostomy and also significantly reduces the need for correction stitches. We did not encounter (intraluminal) bleeding, anastomotic stenosis, or gastric fistula (at 6 months follow-up). Use of barbed sutures may enhance laparoscopic running enterotomy closure in linear stapled RYGB by eliminating the need for knot tying and constant tension kept by a third hand. In our opinion, it is feasible, easy to use and requires minimal extra skills in comparison with the use of traditional multifilament sutures. Time benefit is plausible. Compliance with Ethical Standards Ethical Approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed Consent For this type of study formal consent is not required. Informed consent was obtained from all individual participants included in the study. Conflict of Interest The authors declare that they have no conflict of interest. Grants/Support None
References Discussion 1.
Few studies regarding the use of Stratafix® for enterotomy closure are available at this time. In a retrospective, small population study (50 patients) with 30 days of follow-up concerning one-anastomosis loop gastric bypass (fully hand sewn technique), Blanc et al. [1] reported no postoperative complications and good feasibility. Barbed suturing was performed bidirectionally with an interrupted Vicryl® 3/0 layer on top [2] [3]. In our own series [4], we can conclude that the use of Stratafix™ 2/0 (Ethicon) is feasible and safe. A significant decrease in postoperative intraluminal bleeding was encountered in patients when using barbed sutures, but this finding might be biased by the study design. Furthermore, the use of running unidirectional knotless barbed sutures significantly
2.
3.
4.
Blanc P, Lointier P, Breton C, et al. The hand-sewn anastomosis with an absorbable bidirectional monofilament barbed suture Stratafix™ during laparoscopic one anastomosis loop gastric bypass. Retrospective study in 50 patients. Obes Surg. 2015 Dec;25(12):2457–60. Kassir R, Blanc P, Breton C, et al. Laparoscopic Roux-en-Y gastric bypass with the absorbable bidirectional monofilament barbed suture Stratafix™: the hand-sewn technique. Obes Surg. 2015 Feb;25(2): 325–6. Kassir R, Breton C, Lointier P, et al. Laparoscopic Roux-en-Y gastric bypass with hand-sewn gastrojejunostomy using an absorbable bidirectional monofilament barbed suture: review of the literature and illustrative case video. Surg Obes Relat Dis. 2014 May-Jun;10(3): 560–1. Gys B, Gys T, Lafullarde T. The use of unidirectional knotless barbed suture for enterotomy closure in Roux-en-Y gastric bypass: a randomized comparative study. Obes Surg. 2017 Mar 9; doi:10.1007/s11695-017-2628-3.
