Approach to Marginal Ulceration Following RYGB Surgery: Laparoscopic Excision of the Marginal Ulcer and Retrocolic, Retrogastric Rerouting of the Roux Limb with Truncal Vagotomy and Hiatal Hernia Repair

1. Anesthesia

• General anesthesia achieved in the operating room.

2. Patient Positioning

• Patient positioned supine with pressure points padded and foot support at end of bed to allow deep reverse Trendelenburg.

3. Endoscopy/Port Placement

4. Lysis of Adhesions and Hiatal Dissection

• Mobilization of liver.
• Hiatal dissection.

5. Vagotomy

• Identify and divide posterior vagus nerve.
• Identify and divide anterior vagus nerve.

6. Hiatal Hernia Repair

• Identify GE junction.
• Placement of sutures.

7. Division of Roux Limb

8. Partial Gastretomy/Resection of Ulcer

1. Remove adhesions and mesentery.
2. Dissection of stomach.
3. Division of gastric remnant.
4. Dissection of remnant off of pouch.
5. Dissection of remnant/pouch/roux limb confluence (resection of ulcer).
6. Completion of remnant dissection.

9. Rerouting of Roux limb

1. Oversew staple line of remnant.
2. Mobilize jejunal mesentery.
3. Evaluation of Jejunal anastomosis.
4. Evaluation of Jejunal common channel.
5. Division of attachments of Roux limb to mesocolon.
6. Identification of ligament of Treitz/creation of mesocolonic window.
7. Passage of Jejunum through transverse mesocolon.

10. New GJ Anastomosis

1. First layer of anastomosis (posterior outer layer).
2. Second and third layers of anastomosis (posterior and anterior inner layers).
3. Fourth layer of anastomosis (anterior outer layer).

11. Endoscopy for Testing of Anastomosis

12. Reducing the Jejunum and Closing Petersen's Defect

13. Revision of JJ Anastomosis

14. Retrieving the Specimen from the Abdominal Cavity

15. Closure

• Close mesenteric defects.
• Remove specimen.
• Close port sites.