Page 10 - Read Online

Page 2 of 7 Zhang et al. Mini-invasive Surg 2019;3:2 I http://dx.doi.org/10.20517/2574-1225.2018.64

The assisted procedures needed a mini-laparotomy incision of 60-70 mm in length made on the
[3]
epigastrium . But this procedure was not always easy to do, especially on patients with a small remnant
[4]
stomach or obese patients with thick abdominal walls . Anastomosis in such restricted space was usually
difficult. With the accumulation of laparoscopic surgery experience and the development of laparoscopic
devices, the gastrointestinal reconstruction now can be completed laparoscopically. Furthermore,
unnecessary manipulations and the incision made on the epigastrium can be avoided.

The ideal reconstruction should be not only for doctors but also for patients. Alimentary intake,
[5]
satisfactory nutritional status and easy performing should be all considered . The B-I anastomosis is
preferred by many doctors. It is said that the B-I anastomosis is simple and can provide a physiological
route for food digestion and absorb without the need for an intestinal bypass or blind loop. Until now,
various intracorporeal B-I anastomosis techniques were reported. In this article, we will review theses
reconstruction methods.

HAND-SEWN ANASTOMOSIS IN INTRACORPOREAL B-I RECONSTRUCTION
After the accumulation of operative experience, some experienced surgeons had also presented
intracorporeal hand-sewn techniques.

[6]
Takiguchi et al. firstly reported B-I intracorporeal hand-sewn anastomosis in 2003. In his study, the
Albert-Lembert method was used for the laparoscopic hand-sewing procedure and the anastomosis time
was 90 min. Due to the complexity of the procedure and large amount of time required for anastomosis, it
seemed that the hand-sewn anastomosis was not widely performed.

[7]
After almost 10 years, Matsuo et al. reported another study about hand-sewn B-I anastomosis. They
performed hand-sewn gastroduodenal anastomosis in 18 cases. The mean time of B-I anastomosis was
[7]
64.6 min. Matsuo et al. described that 3-0 absorbing thread was placed in the lesser curvature as a
supporting thread. A seromyotomy of the stomach was performed at the posterior wall. Both the remmant
stomach and the duodenum’s seromuscular layer were discontinuously sutured by extracorporeal knot-
typing method. The lumen was opened with the stomach and the duodenum in a fixed status. The thread
of the anchor suture was lifted upward to the abdominal wall. After that all layers of the stomach and
the duodenum at the posterior wall were continuously sutured. The authors believed that hand-sewn
anastomosis had some advantages. Hand-sewn sutures were not affected by the degree of freedom of the
duodenum. Because staplers were not used, the anastomosis area was soft and highly flexible. The hand-
sewn anastomosis was economical due to that less staplers were used.

CIRCULAR STAPLER USED IN INTRACORPOREAL B-I RECONSTRUCTION
In the open surgery, circular stapler is well applied as a standardized reconstruction method of
gastroduodenostomy. However, when it was attempted laparoscopically, the situation was often the
opposite.

[8]
Uyama et al. firstly described intracorporeal B-I reconstruction using a circular stapling device and
introduced one case in 1995. The method was defined by the same anatomic parameters as for the open
[9]
[10]
B-I. After that, Moriya et al. and Mayers and Orebaugh also reported B-I gastroduodenostomy with a
circular stapler device. Both techniques were complicated and difficult to operate, and especially at the left
subcostal area where an extended incision was needed. The extra incision spoiled the merit of minimally
invasive surgery.

There are 2 major difficulties when circular stapler is applied in laparoscopic gastroduodenostomy: the first
is the lack of a safe and fast intracorporeal purse-string suture technique and the second is the difficulty