BACKGROUND
Laparoscopic Roux-en-Y gastric bypass requires formation of a gastrojejunostomy that is often fashioned using a circular stapler. Accurate placement of the anvil whilst avoiding trauma to the stomach is essential. We describe a technique that facilitates smooth delivery of the anvil head into the stomach using a Goldfinger™ (Ethicon, UK).
TECHNIQUE
A gastrotomy is created above the mid-point of the transverse staple line in (what will become) the gastric pouch using a harmonic scalpel or alternative energy source (Fig. 1). A 25-Fr anvil is introduced into the abdomen using the stapler handle via a dilated port site; use of a 25-Fr stapler ensures adequate closure of the pouch gastrotomy. The anvil and its spike are connected within the abdomen having first tied a short extracorporeal loop of 2/0 polypropylene to the anvil spike (Fig. 2). A small lateral gastrotomy is created and the Goldfinger™ delivered through the stomach (Fig. 3). The anvil is connected to the Goldfinger™ using the polypropylene loop and the Goldfinger™ straightened and pulled back through the stomach to deliver the anvil through the staple line (Fig. 4). The polypropylene loop can be used as a useful retractor whilst the remainder of the gastric pouch is fashioned.
Figure 1.
Staple line gastrotomy fashioned with harmonic scalpel.
Figure 2.
Spike with 2/0 polypropylene suture re-attached to anvil.
Figure 3.
Goldfinger™ passed through staple line and lateral gastrotomies.
Figure 4.
Traction on in-line Goldfinger™ starts delivery of anvil through staple line.
DISCUSSION
This method provides smooth delivery of the anvil head and prevents the tip of the anvil spike from traumatising the rugal folds of the stomach.