Lack of Effective Surgical Team Communication During a Laparoscopic Roux-en-Y Gastric Bypass,Leading to a Severe Intraoperative Complication

Introduction

Laparoscopic gastric bypass surgical technique systematization makes it a very safe technique to perform nowadays. ¹ However, it is not exempt from intraoperative complications, given the complexity involved in the procedure's different steps. ² One of the key aspects for performing a safe procedure is combining technical expertise with nontechnical skills, such as communication and teamwork.^3–5 The use of a nasogastric tube is a technical element that can aid in the stomach's evacuation before making the reservoir and even help as a tutor for the gastrojejunal anastomosis. ⁶

Nevertheless, this step requires proper communication with the anesthesiology team to avoid unforeseen incidents during its manipulation, such as the incidental stapling with an endostapler (endo-GIA).^7–9 When this occurs, a useful resource is to perform a manual gastrojejunal anastomosis.^10,11 This will allow the extraction of the sectioned tube manually during laparoscopy through the gastrotomy made for the anastomosis, resolving the complication in the same laparoscopic procedure.^7–11

Materials and Methods

We describe a case that highlights the importance of combining both technical expertise and nontechnical skills to avoid intraoperative complications during bariatric surgery. A 48-year-old male presented with a body mass index of 37 kg/m² (weight 108.5 kg–height 171 cm) and medical history of arterial hypertension, dyslipidemia, allergic asthma, and gastroesophageal reflux disease (GERD). He had surgical history of L5-S1 arthrodesis, meniscus surgery, subcutaneous mastectomy, and umbilical hernioplasty. An elective laparoscopic gastric bypass was the procedure proposed after obtaining informed consent approved by the ethics committee.

Surgical access was achieved through a left subcostal Optiview trocar, two 12 mm trocars in the supraumbilical and right subcostal position, and two 5 mm trocars in both flanks. We started the procedure by identifying the ligament of Treitz and measuring 100 cm for the biliopancreatic limb and 200 cm for the alimentary limb. After the limb measurements, a mechanical jejunal–jejunal side-to-side anastomosis was done with a 45 mm cartridge. The jejunal enterotomy was closed with a barbed suture. After dissection of the His angle and the stapled gastric reservoir preparation, an incidental stapling of the nasogastric tube occurred due to inadequate communication with the anesthesiologist.

Inadequate interaction and effective communication between team members generated insufficient tube retrieval toward the esophagus and caused the tube to be included in the staple line. This severe complication was resolved by releasing the stapled probe in the gastric reservoir with a Bovie hook and removing the two segments of the tube: one in the gastric reservoir and the other in the gastric remanent. After tube extraction, the gastric remanent was closed using the stapled technique, and a manual gastrojejunal anastomosis was performed, using the hole made to release the probe. Anastomosis was checked for leaks with methylene blue that showed good results.

Results

Operative time was 140 minutes. In the postoperative period, a liquid diet was started at 24 hours, and the patient was discharged on the third day with good oral tolerance and restored digestive transit. In the 1-month postoperative control, the patient remains asymptomatic, tolerating a regular diet, and found to have a 13 kg weight loss. This clinical case highlights the importance of effective teamwork and a culture of safety during complex laparoscopic surgical procedures.^3–5

Conclusions

The lack of effective surgical team communication during a laparoscopic Roux-en-Y gastric bypass can be a cause of severe surgical complications that requires experience of the surgical team for its resolution. Our Supplementary Video S1 shows a way to solve incidental stapling of the nasogastric tube without altering the normal development of the surgical technique.