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How Dr. Joya Does the Operation
When Dr.
Joya does the Gastric Bypass, Roux en-Y, he wants to make a very small pouch out
of the upper stomach, to restrict the amount of food which can be eaten. That pouch is separated from the rest of the stomach, which
is bypassed, by creating a new pathway into the intestines.
This pathway is called a “Roux en-Y” (named after the French surgeon, Dr.
Roux, who first described this reconstruction in the 1800's).
The bowel is cut, and reconstructed in a Y configuration, so that two
parts of the GI tract can feed into one.
Whether Dr.
Joya does the operation through an incision, or laparoscopically, the basic
methods, anatomy, and the results are the same, although the instruments differ.
Here’s how we do the operation laparoscopically:
Operating Ports
Laparoscopy
is done through “ports”, which are tubes that Dr. Joya passes instruments
through, to operate on the internal organs.
He place several of these in the abdominal wall, through tiny incisions.
Measuring the Stomach Pouch
 Dr.
Joya makes the upper stomach pouch very small, so that it will hold about one
tablespoon of liquid. To do this,
he passes a tube through the back of the mouth into the stomach (while you’re
asleep), and blows up a balloon on the end of the tube to a volume of 15
milliliters (one tablespoon). That
serves as a measure, as he cuts the stomach into upper and lower parts.
Drawing courtesy of
Ethicon Endosurgery, Inc.
Cutting the Stomach
With the
balloon tube serving as a guide, he places a special stapler across the stomach,
which makes several rows of staples on each side, and cuts between them. He then make additional cuts with the stapler, until the
stomach is completely divided. The
small upper pouch will be the new
stomach. The large lower part of
the stomach will no longer contain any food.
It still has all its blood vessels, and makes normal secretions, and
these can exit through its bottom connection, the pylorus, which is undisturbed.
Constructing the Roux Limb
 Dr.
Joya then cuts the small intestine a few inches below the stomach, and measure a
length of it, to be used as the “Roux limb”, which will attach to the new little
stomach. The bowel is connected side-to-side, to form the ‘Y’.
The upper
end of the Roux limb is passed behind the large intestine and the bypassed
stomach, because that is the most direct and shortest route to the little upper
stomach pouch.
Inserting the Stapler Anvil
 The
stomach pouch is so small, that suturing a connection would be very difficult,
especially by laparoscopy. From the
beginning, Dr. Joya devised a method of inserting part of the stapler, the
“anvil”, by passing it through the throat into the stomach pouch, pulling it
down into the pouch with a length of fine wire.
When the anvil is in place, he brings its stem through the side of the
pouch, to connect it to the body of the stapler.
Inserting the Stapler and
Connecting
 With
the anvil in place, Dr. Joya inserts the body of the stapler into the abdomen,
through one of the small port sites, and then slide it inside the bowel, to make
the connection. The stapler and
anvil are snapped together, and the stapler is screwed shut, then fired,
creating two circles of staples, with a hole through their middle, like a donut,
and uniting the stomach pouch to the upper end of the Roux limb.
After the
circular stapler is removed, the opened end of the bowel is re-closed with
another application of the linear stapler. This completes the construction
of the connection between the stomach and small bowel. The main part of
the operation is now over.
The final
result looks like this. Note that food enters the tiny stomach pouch, and
exits through a small hole into the small intestine, which has been moved up,
behind the lower stomach and large intestine, to be connected. The lower,
larger stomach pouch no longer receives any food, but still has a blood supply
and is able to secrete digestive juices, which can leave by the same route as
they always have, through the connection at the lower end (the "pylorus"), to
pass down the duodenum, to the Y-connection just a few inches downstream.
All the food and digestive juices still travel through about 25 feet of small
intestine, where absorption is essentially complete.
Here's
what the final operation looks like, when complete.
Testing and Tidying Up
Once all the
connections are made, Dr. Joya tests the upper one by inflating the stomach
pouch with air from above, and looking for air bubbles while the connection is
submerged under rinse water in the abdomen.
The abdomen is rinsed out and tidied up, a small drain tube is put in place, the
ports are removed, and the operation is over.
All drawings courtesy of Ethicon Endosurgery, Inc.
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