A novel approach for Roux limb construction via the lesser sac

Exposure of the ligament of Treitz for Roux limb construction during laparoscopic gastric bypass requires either division or displacement of the omentum. Factors compromising this exposure include: (1) a bulky omentum, (2) hepatomegaly, (3) adhesions between the omentum and lower abdominal wall or pelvic contents and (4) inability to identify the transverse colon because of overlying adipose tissue. The lesser sac approach is an alternative method for Roux limb construction during laparoscopic gastric bypass when access to the inframesocolic abdomen is difficult. In this technique the lesser sac is entered through the gastrocolic ligament. The transverse mesocolon is then opened and the ligament of Treitz is identified. The jejunum is pulled into the lesser sac and the Roux limb is constructed. The jejunojejunostomy is reduced into the inframesocolic compartment, the mesenteric defects are closed, and the remaining portion of the procedure is completed. This technique provides an alternative method for completion of a laparoscopic gastric bypass in patients who would otherwise require more extensive surgery.