Supramesocolic Approach to Roux-en-Y Gastric Bypass when Standard Inframesocolic Approach Is Not Feasible

Abstract

The traditional approach to a Roux-en-Y gastric bypass is to construct the biliopancreatic and Roux limbs within the inframesocolic space. This requires reflecting the greater omentum, transverse colon, and mesocolon superiorly. This maneuver can be challenging in patients with a robust omentum, hepatomegaly, or significant omental adhesions. The inability to fully reflect the omentum superiorly prevents an appropriate view of the posterior transverse mesocolon and the inframesocolic space from being obtained. This can make it difficult to construct the biliopancreatic and Roux limbs. In order to circumvent the difficult situations described above, a supramesocolic approach to constructing the biliopancreatic and Roux limbs can be performed. This approach avoids the need to reflect the omentum and transverse colon. Key steps include entering the lesser sac by transecting the gastrocolic ligament and, next, an aperture in the transverse mesocolon made exposing the ligament of Treitz. The small bowel is then eviscerated into the supramesocolic space. The biliopancreatic and Roux limbs are then created in the usual fashion. All of the small bowel except the Roux limb is then returned through the mesocolon to the inframesocolic space. Peterson's space and the mesocolic defect are then closed using permanent suture. The remainder of the procedure is then performed in the usual fashion. No complications were reported immediately postoperatively or at a 12-month follow-up in all 3 cases. The supramesocolic approach to a Roux-en-Y Gastric Bypass is a safe and effective technique when an inframesocolic approach proves difficult.