Aust. zyxwvutsrqpo N.Z. J. Surg. zyxwvutsrqpo 1985, zyxwvutsrq 55, 403-404 403 zy -~-~~-___.__ ______ ~. SURGICAL TECHNIQUES zyxw A SIMPLIFIED TECHNIQUE FOR CONSTRUCTION OF A GASTRIC POUCH FOR MORBID OBESITY SURGERY A. M. VAN &J A simple method for the construction of the gastric pouch used as a step in surgery for the morbidly obese is described. Key words: morbid obesity, gastric bypass, gastric partition. Introduction The construction of the small 30-60ml gastric pouch in the surgical procedure for the management of the morbidly obese patient provides a technical challenge. In these patients access to the upper stom- ach through the depths of encroaching fatty tissues is difficult. A variety of approaches to expose the upper stomach and form the gastric pouch with the place- ment of the usual double-row of staples across the stomach have been described. These have included mobilization of the entire greater curvature of the stomach, or a more limited mobilization including the fundus and ligation of only the uppermost gastro- splenic vessels. These measures are time- consuming and are considered in some instances to cause relative ischaemia of the pouch once the staples have been applied, and result in pouch per- f~ration.~ In these obese patients these dissections require manipulations in close proximity to the spleen which are not without added hazard and the risk of splenic trauma. However, without these measures to adequately mobilize the upper stomach the accurate placement of parallel double staple-lines is difficult. Method A technique is described to facilitate the accurate placement of the required double staple-line without the more extensive mobilization of the stomach and the associated problems. Once the abdomen is opened through an upper midline incision and suit- able retractors are positioned, the left side of the oesophagogastric junction is identified. Blind finger Correspondence: Dr A. M. van Rij, Department of Surgely. University of Otago Medical School. Private Bag. Dunedin, New Zealand. Accepted for publication 20 December 1984. dissection is camed out from the angle of the oesophagus and fundus across the bare area of the stomach, taking care to avoid the posterior vagus, to the lesser curvature approximately 3 cm below the oesophagogastric junction immediately distal to the commonly observed larger venous branches (Fig. I a). A large bore (12 mm, i.d.) heavy plastic tube is pressed over the index finger protruding through the lesser omentum immediately adjacent to the lesser curvature (Fig. Ib). The tube is guided along the track behind the stomach and held secure. At the opposite end the anvils of two TA-90 staplers are firmly fixed together into the lumen of the tube. Further traction on the tube is used to guide the staplers into position across the stomach. Pins are placed across the open ends of the staplers to main- tain control of the stomach within the aperture of the staplers. The pouch is readily modified to size by traction on the anterior stomach wall prior to appos- ing the proximal stapler. With the position of the proximal stapler confirmed the distal device is placed up against it and ensures a parallel application of the second staple-line. The staplers are fired and re- moved. Stay sutures at each end secure the proximal staple-line and facilitate exposure by drawing the pouch into the operating field. FurtheF steps for gas- tric bypass or gastrogastrostomy follow. Gastro- plasty, with the appropriate staples removed from the cartridges prior to starting, is also readily accom- plished whether it is to be done at the lesser or greater curvature. Discussion This technique is quicker in that it avoids the time- consuming mobilization of the greater curvature of the fundus of the stomach. The hazard of relative pouch ischaemia and of manipulations around the spleen in the depths of excessive fat are minimized.