Laparoscopic Roux-en-Y gastric bypass: Transoral or transgastric anvil placement?

Background: Laparoscopic techniques have been used to perform the Roux-en-Y gastric bypass (RYGBP). The gastrojejunostomy may be constructed using an end-to-end anastomosis (EEA) stapler. Most reports describe passing the EEA anvil transorally using an esophagogastroscope and a pull-wire technique. Method: We describe problems experienced using this technique and present an alternative method. Results: Esophageal injury may occur during laparoscopic RYGBP (LRYGBP) using the transoral anvil placement technique. When the anvil is retrieved into the gastric pouch, the anvil may become lodged at the cricopharngeus muscle. Dislodgment can be problematic and time-consuming. We present a case of mild esophageal injury which occurred during transoral anvil placement. The patient had transient postoperative dysphagia and recovered without sequelae. We present an alternative method in which the anvil is passed through a gastrotomy. Conclusion: Transgastric anvil placement alleviates the need for endoscopy, thereby saving time and resources. This technique eliminates the potential for esophageal injury. The transgastric anvil placement technique has proven reliable. The transgastric method may make the LRYGBP operation safer and easier to perform.