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Gastric bypass using barbed suture (with video)

Article in Journal of Visceral Surgery November 2014

DOI: 10.1016/j.jviscsurg.2014.09.011

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Radwan Kassir Pierre Blanc

Universit Jean Monnet Clinique mutualiste saint tienne
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Surgery for Obesity and Related Diseases ] (2014) 0000
4
5
6 Surgeon-at-work
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Laparoscopic Roux-en-Y gastric bypass with hand-sewn
10 gastrojejunostomy using an absorbable bidirectional monolament
11
12 Q4 barbed suture: review of the literature and illustrative case video
13
Q1 R. Kassira,*, C. Bretona, P. Lointierb, P. Blanca
14 a
Department of Digestive Surgery, Clinique chirurgicale mutualiste, Saint Etienne, France
15 Q5 b
Department of Digestive Surgery, Clinique de la Chtaigneraie, 63110 Beaumont
16 Received January 19, 2014; accepted January 25, 2014
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Keywords: Gastric bypass; Stratax; V-LOC; Vicryl; Gastrojejunostomy
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22 56
23 The laparoscopic Roux-en-Y gastric bypass (LRYGB) is a the Roux limb is sutured in a continuous fashion to the 57
24 technically demanding procedure. With the advent of the staple-line at the caudal end of the pouch, beginning on the58
25 laparoscopic approach for RYGB, many techniques have vertical staple-line just above the horizontal staple-line and
59
26 evolved. There is no consensus on the optimal gastrojejunos- proceeds toward the lesser curvature. This suture-line serves
60
27 tomy anastomotic (GJA) technique. The hand-sewn technique as the rst posterior layer and prevents any tension on the 61
28 with absorbable bidirectional monolament barbed suture anastomosis. 62
29 Stratax (Ethicon Endosurgery, Inc., Cincinnati, OH, USA) The monopolar hook is used to create a gastrotomy against63
30 appears to be ideal for GJA using a double loop technique. the gastric tube at the tip of the gastric pouch anterior to the
64
31 suture line and to create the enterotomy on the antimesenteric
65
32 Operating procedure border. Once a smaller tube can pass through, a second 66
33 posterior suture-line is created between both openings using67
The procedure consists of a 100-cm biliopancreatic limb, absorbable suture as 30 Vicryl (Ethicon) (interrupted suture-
34 a 150-cm Roux limb passed in antecolic fashion, a lesser 68
35 line, 3 stitches). We tighten the tissue closure after each pass
69
curvature based vertically oriented gastric pouch created of the needle through the tissue. The gastric tube is advanced
36 around a 36-Fr bougie with an antegastric hand-sewn 70
37 into the Roux limb and the anterior layer is created in a 71
gastrojejunostomy around the gastric tube. continuous fashion with the Stratax on the left corner to the
38 We used 4 12-mm bladeless ports (Applied Medical, Inc., 72
39 Q6 right corner of the anastomosis. The anterior layer may also73
city, state) and 1 5-mm bladeless port. The rst port was be completed in a continuous double-layered fashion with the
40 placed on the midline, 18 cm under the xiphoid. The second 74
41 Stratax from left to right and from right to left. No knot is
75
port was inserted in the left midclavicular line, the third port needed at the end of the anastomosis. We cut it, leaving at
42 was inserted in the right midclavicular line, and the fourth 76
43 least a 1-cm tail outside the bowel. 77
port was inserted in the left hypochondriac immediately The anastomosis is tested at the end by placing a bowel
44 below the subcostal region with the 5-mm port (which was 78
45 clamp on the Roux limb and insufating the pouch and 79
inserted on the left of the xiphoid). anastomosis with 60 mL methylene blue under pressure.
46 Using the Stratax (Ethicon) absorbable bidirectional 80
47 monolament barbed suture, the antimesenteric border of 81
48 Discussion 82
49 *
Correspondence: Radwan Kassir, Department of Digestive Surgery, 83
50 CHU Hospital, Jean Monnet University, Avenue Albert Raimond 42270 LRYGB in our trial was performed by 2 experienced 84
51 Saint Etienne, France. surgeons. The 3 GJA techniques (hand-sewn, linear-stapled, Q7 85
52 E-mail: Radwankassir42@hotmail.fr and circular-stapled) can be used safely with a low 86
53 http://dx.doi.org/10.1016/j.soard.2014.01.029 87
54 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved. 88
55
 2 R. Kassir et al. / Surgery for Obesity and Related Diseases ] (2014) 0000

89 complication rate [1]. The use of a hand-sewn gastro- Conclusion 128

90 jejunostomy appears to be as safe as mechanical sutures [2]. 129
With regard to unidirectional absorbable (V-Loc, Covi- All bariatric surgeons should know how to do a hand-
91 130
dien, Manseld, MA), Costantino et al. [3] demonstrated sewn gastrojejunostomy, because the mechanical sutures are
92 131
that the use of unidirectional absorbable 3/0 suture (V-Loc not always feasible, especially in cases of revision surgery.
93 132
180, Covidien) shortens the total operative time in terms of Video 1 demonstrates that the use of Stratax can be
94 133
a gastrojejunal or jejunojejunal anastomosis [3]. The knot- incorporated in LRYGB. Stratax appears to be efcient,
95 134
less anastomosis was less expensive than a knot-tying safe, and reproducible, but additional studies are needed to
96 135
anastomosis [4]. In general surgery, V-Loc is used to close evaluate long-term results.
97 136
98 the peritoneum during transabdominal preperitoneal poly- 137
99 propylene procedures [5]. The free tail of the barbed suture Appendix 138
100 could result in intestinal obstruction [6]. The use of V-Loc 139
101 instead of traditional suture has had similar 30-day out- Supplementary data 140
102 comes [7]. Supplementary data associated with this article can be found 141
103 With regard to bidirectional absorbable, the French medi- in the online version at doi:10.1016/j.soard.2014.01.029. 142
104 cal bylaws has not yet approved the use of barbed suture in 143
105 obesity surgery but nevertheless the use of Stratax pro- References 144
106 vides benets that simplify the suturing technique. The total 145
107 cost of material was signicantly less than that for creation [1] Bendewald FP, Choi JN, Blythe LS, Selzer DJ, Ditslear JH, Mattar SG. 146
108 of the GJA using a V-Loc unidirectional absorbable suture, Comparison of hand-sewn, linear-stapled, and circular-stapled gastro- 147
109 because of the use of 2 V-Loc, 1 posterior and 1 anterior. jejunostomy in laparoscopic Roux-en-Y gastric bypass. Obes Surg 148
2011;21:16715.
110 The other advantages of the use of Stratax are short 149
[2] De Blasi V, Facy O, Goergen M, Poulain V, De Magistris L, Azagra
111 learning curve, shortened operative time, knotless techni- JS. Barbed versus usual suture for closure of the gastrojejunal 150
112 que, assistance is not required to maintain suture tension, anastomosis in laparoscopic gastric bypass: a comparative trial. Obes 151
113 and the suture does not slip. The nature of Stratax obviates Surg 2013;23:603. 152
114 the need for repeated tightening along its length. The suture [3] Costantino F, Dente M, Perrin P, Sarhan FA, Keller P. Barbed 153
unidirectional V-Loc 180 suture in laparoscopic Roux-en-Y gastric
115 is monolament and purple, making it easily handled within 154
bypass: a study comparing unidirectional barbed monolament and
116 the abdomen. With a hand-sewn suture, the risk of bleeding multilament absorbable suture. Surg Endosc 2013;27:384651. 155
117 is signicantly lower than that for creation of the GJA using [4] Milone M, Di Minno MN, Galloro G, et al. Safety and efcacy of 156
118 mechanical sutures. The use of absorbable suture decreases barbed suture for gastrointestinal suture : a prospective and randomized 157
119 the risk of ulcer than that for creation of the GJA using study on obese patients undergoing gastric bypass. J Laparoendosc 158
Adv Surg Tech A 2013;23:7569.
120 no-absorbable sutures. We believed that Stratax promotes 159
[5] Takayama S, Nakai N, Shiozaki M, Ogawa R, Sakamoto M,
121 a narrow anastomosis, which may increase the effective- Takeyama H. Use of barbed suture for peritoneal closure in trans- 160
122 ness of gastric bypass and decrease the risk of dumping abdominal preperitoneal hernia repair. World J Gastrointest Surg 2012; 161
123 syndrome. In our trial, no complications occurred because 4:1779. 162
124 of the suture, including GJA stenosis, leaks, or intestinal [6] Donellan NM, Mansuria SM. Small bowel obstruction resulting from 163
laparoscopic vaginal cuff closure with a barbed suture. J Minim
125 obstruction at the tail of Stratax. The barbed suture should 164
Invasive Gynecol 2011;18:52830.
126 allow for a greater distribution of tensile strength along the [7] Tyner RP, Clifton GT, Fenton SJ. Hand-sewn gastrojejunostomy using 165
127 GJA and increase the surface area of adhesion between the knotless unidirectional barbed absorbable suture during laparoscopic 166
Q8 tissues [7]. gastric bypass. Surg Endosc 2013;27:13606.

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