What are the steps of a laparoscopic Roux en Y procedure?

Steps of Laparoscopic Roux-en-Y Gastric Bypass

The laparoscopic Roux-en-Y gastric bypass procedure involves the construction of a small (20 mL) proximal gastric pouch, which empties into a segment of jejunum that is anastomosed to the pouch as a Roux-en-Y limb. 1 This procedure accounts for 70% of bariatric operations performed in the United States and is highly effective for weight loss, achieving 25-30% loss of initial weight and 50-65% loss of excess weight.

Preoperative Preparation

• Patient selection based on BMI criteria (≥40 kg/m² or ≥35 kg/m² with obesity-related comorbidities)
• Comprehensive preoperative assessment including nutritional evaluation
• Optimization of comorbidities
• Prophylactic antibiotics and DVT prophylaxis

Key Surgical Steps

1. Port Placement and Initial Access

• Establish pneumoperitoneum (typically at umbilicus)
• Place 5-6 laparoscopic ports in upper abdomen
• Perform diagnostic laparoscopy to assess anatomy

2. Creation of Gastric Pouch

• Divide the peritoneum and fat at the angle of His
• Create a window at the lesser curvature near the gastroesophageal junction
• Use a linear stapler to create a small proximal gastric pouch (approximately 20 mL)
• Completely separate the pouch from the remainder of the stomach

3. Jejunal Division and Roux Limb Creation

• Identify and measure jejunum 30-50 cm from the ligament of Treitz
• Divide jejunum with a linear stapler
• Create a Roux limb (alimentary limb) of 75-150 cm length

4. Gastrojejunostomy Creation

• Bring the Roux limb up to the gastric pouch
• Create an anastomosis between the gastric pouch and Roux limb using either:
  • Circular stapler technique (totally intra-abdominal approach)
  • Linear stapler technique
  • Hand-sewn technique
• Ensure a small anastomotic opening (1-1.5 cm)

5. Jejunojejunostomy Creation

• Create an anastomosis between the proximal biliopancreatic limb and the Roux limb
• Position this approximately 75-150 cm distal to the gastrojejunostomy
• Use linear staplers or hand-sewn technique

6. Closure of Mesenteric Defects

• Close Peterson's space (between mesentery of Roux limb and transverse mesocolon)
• Close the jejunojejunostomy mesenteric defect
• Use non-absorbable sutures to prevent internal hernias

7. Leak Testing and Hemostasis

• Perform intraoperative leak test of gastrojejunal anastomosis
• Ensure complete hemostasis
• Place drains if indicated (not routine in all centers)

8. Port Closure

• Remove instruments and ports under direct visualization
• Close fascial defects >10 mm
• Close skin incisions

Technical Considerations and Pitfalls

• Anastomotic Technique: The gastrojejunostomy can be performed using circular staplers, linear staplers, or hand-sewn techniques. The circular stapler approach provides a consistent small opening but requires careful intra-abdominal manipulation 2.

• Roux Limb Positioning: The Roux limb can be positioned in either an antecolic or retrocolic fashion. Antecolic positioning is associated with lower rates of internal hernias compared to retrocolic positioning 1.

• Mesenteric Defect Closure: Failure to close mesenteric defects can lead to internal hernias, which are a common cause of small bowel obstruction after RYGB. The most common sites are Petersen's space and the jejunojejunostomy mesenteric defect 1.

• Leak Prevention: Careful technique and intraoperative leak testing are essential to minimize the risk of anastomotic leaks, which can lead to peritonitis and sepsis.

Postoperative Care

• Early mobilization
• Progressive diet advancement
• Vitamin and mineral supplementation
• Regular follow-up to monitor weight loss and nutritional status
• Monitoring for potential complications

This procedure has evolved significantly since its early laparoscopic applications in the 1990s 3, 4, 5 and remains one of the most effective surgical treatments for severe obesity, with significant improvements in weight-related comorbidities and quality of life 6.