The laparoscopic linear stapled anastomosis has been criticized for its inability to determine the size of the opening for the gastrojejunostomy or the jejunojejunostomy. The circular stapled EEA has a reported 25% stricture occurrence in reported series. We examined various techniques for the gastrojejunal anastomosis varying from circular stapled, linear stapled with triangulation and linear stapled combined with hand suturing while performing laparoscopic RYGB.
METHODS: 41 patients underwent laparoscopic RYGB with 5 trocars. Three patients underwent circular stapled anastomosis, seven patients underwent triangulated linear stapled anastomosis with an endoscopic 45 mm linear stapler and thirty-one patients underwent combined linear stapled with hand sewn closure of the remaining enterotomy. A porcine model of the RYGB was performed and casts were made from jejunojejunostomy to determine the size of the anastomotic opening.
RESULTS: The circular 21 mm EEA stapler requires trocar dilatation and closure. The triangulated stapled anastomosis had three obstructions (2 at the gastrojejunal site, 1 at the jejunojejunal site) requiring modification of the anastomosis. The combined linear stapled with hand-sewn closure of the remaining enterotomy did not have any complications of obstruction or leakage. Patients returned to work within 8-14 days and weight loss is comparable to the open RYGB. The porcine casts of the stapled anastomosis are described in the table below.
CONCLUSIONS: Combined laparoscopic 45 mm linear stapled anastomosis with hand-sewing is the safest and quickest method of performing laparoscopic gastrointestinal anastomosis. The porcine casts reveal that a completely stapled anastomosis without suturing will decrease the opening of the anastomosis by 27%. The triangulated anastomosis is dependent on the thickness of the bowel. In morbidly obese patients, the jejunum is greatly thickened resulting in a smaller length in the linear stapled anastomosis. Laparoscopic RYGB is easily performed with linear stapling and suturing.
Porcine Side to Side Linear Stapled Anastmosis
Suture/Staple 1.77 cm 980.5 mm2
Stapled 1.51 cm 718.2 mm2