The feasibility of hand-assisted laparoscopic aortic bypass using a low transverse incision

Background: Hand-assisted laparoscopy can be used to perform aortoiliac reconstructive procedures. This study aimed to evaluate the safety and feasibility of a hand-assisted aortofemoral bypass in patients with occlusive disease using a low abdominal transverse incision to reduce postoperative respiratory problems. Methods: In 18 patients, a modified Pfannenstiel incision was performed. A hand-assist device was inserted, and the aorta was exposed using transperitoneal laparoscopy. Tunneling was performed under laparoscopic control. The anastomosis was always performed proximally to the inferior mesenteric artery. In three patients, the proximal anastomosis had to be performed laparoscopically. The indication for surgery was occlusive disease in 16 patients and a combination of an aneurysm and aortoiliac occlusion in 2 patients. Results: Conversion was required in one patient (1/18). In 13 patients (13/18), the total operating time did not exceed 180 min, and 61% of the patients (11/18) could be discharged by postoperative day 5. None of the patients died perioperatively (0/18). Complications were observed in six patients (6/18). Only one of these patients had respiratory problems (1/18). The remaining five patients had local complications such as wound healing problems. The anastomosis was sutured laparoscopically in three patients (3/18). Conclusions: Hand-assisted laparoscopy can be performed safely using a low transverse abdominal incision. In our experience this laparoscopic access can reduce the incidence of postoperative respiratory problems and incision-related complications.     

Laparoscopic-assisted continent urinary diversion in obese patients

BACKGROUND AND PURPOSE: The Pfannenstiel incision provides good access to the bladder and bladder neck for major reconstructive surgery in the thin patient, whereas a midline incision is often necessary to get adequate exposure in the obese patient. We describe our experience using laparoscopic-assisted continent urinary diversion in conjunction with other bladder and bladder neck surgery in obese patients. PATIENTS AND METHODS: Three female patients (mean age 18; mean weight 175 pounds) with neurogenic bladder underwent Mitrofanoff appendicovesicostomy continent urinary diversion to the umbilicus and pubovaginal sling. An umbilical port for the telescope and two lateral ports were used. Once the appendix and right hemicolon had been completely mobilized up to the hepatic flexure, reconstruction was completed through a low Pfannenstiel incision. RESULTS: There were no laparoscopic complications. None of the laparoscopic port sites was visible postoperatively, as one was in the base of the umbilicus, and the other two had been incorporated into the Pfannenstiel incision. With a mean follow-up of 1 year, all patients were continent and catheterizing their umbilicus easily. Pfannenstiel incisions were well healed, and the patients were quite satisfied with their cosmesis. CONCLUSION: Laparoscopic-assisted Mitrofanoff appendicovesicostomy continent urinary diversion to the umbilicus can be performed in conjunction with a Pfannenstiel incision to complete major bladder and bladder neck surgery in the obese patient with good postoperative cosmesis. This procedure represents a nice compromise between a very lengthy bladder reconstructive procedure done purely laparoscopically and a midline incision with good exposure but suboptimal cosmesis.     

Totally Laparoscopic Distal Gastrectomy Using the Hand-Sewn Billroth-I Anastomotic Technique: Report of a Case

The development of more sophisticated instruments has enabled advanced laparoscopic surgery. We recently devised a totally laparoscopic method of performing Billroth-I hand-sewn anastomosis and established this technique in an animal training model. This report presents the case of a 50-year-old man in whom totally laparoscopic distal gastrectomy was successfully performed for gastric cancer, using the hand-sewn Billroth-I anastomotic technique. The patient was admitted with gastric cancer in the angle of the stomach and underwent laparoscopic distal gastrectomy with radical lymph node dissection. After the resected specimen was extracted through the small incision, a Billroth-I anastomosis was performed laparoscopically by the hand-sewn technique using the Albert-Leinbert method. The patient was discharged on the seventh postoperative day without any intra- or postoperative complications. Laparoscopic hand-sewn anastomosis was performed safely and allowed for quick recovery and good cosmesis in this patient. Received: February 4, 2002 / Accepted: September 3, 2002 Reprint requests to: S. Takiguchi     

Laparoscopically assisted ureterocystoplasty

OBJECTIVE: To assess the efficacy and safety of laparoscopically assisted ureterocystoplasty (LAU) in children. PATIENTS AND METHODS: From 1999 to 2001, five patients (mean age 7 years, range 3.5-13) from four centres underwent LAU with laparoscopic mobilization of the small kidney and upper ureter combined with ureterocystoplasty, with exposure of the bladder through a Pfannenstiel incision. The details and outcomes are reviewed. RESULTS: The LAU was successful in all five patients; there were no complications. A large midline incision was avoided and the LAU carried out through the better tolerated and less painful Pfannenstiel incision. CONCLUSION: LAU is an appealing technique that is safe with the added benefit of a reduced abdominal incision and acceptable operative duration. This represents the first published report of LAU.     

Hand-assisted laparoscopic total gastrectomy for early gastric cancer

Laparoscopy-assisted distal gastrectomy has been applied to the treatment of early gastric cancer in Japan. However, there have been few reports on the laparoscopy-assisted total gastrectomy mainly because of the difficulty of the procedure. Here, we report a series of cases where hand-assisted laparoscopic total gastrectomies were performed successfully. The mobilization of the greater curvature was performed laparoscopically. About 7-cm mini-laparotomy was made at the epigastrium and duodenal transection was performed with linear stapler. After dissection of suprapyloric and anterosuperior lymph nodes was performed through the mini-laparotomy, dissection of lymph nodes along the celiac artery, and the left gastric artery was performed by hand-assisted laparoscopic surgery. Roux-en-Y reconstruction was performed through the mini-laparotomy. We successfully performed this procedure in 5 patients. The mean operating time and blood loss were 275 minutes and 177.5 mL, respectively. Hand-assisted laparoscopic total gastrectomy is suitable and feasible for early gastric cancer.     

Laparoscopic assisted reconstructive surgery

PURPOSE: We describe the use of laparoscopy to assist in performing complex pediatric reconstructive cases with the goals of improved cosmesis, and limited postoperative morbidity and adhesion formation. MATERIALS AND METHODS: Eight patients a mean age of 13.4 years underwent 8 laparoscopic assisted reconstructive procedures at our institution from June 1995 to February 1998. The group consisted of 5 patients with spina bifida, 1 with sacral agenesis, 1 with classic bladder exstrophy and 1 with bladder dysfunction secondary to posterior urethral valves. Information was obtained via personal communication and review of the hospital records. RESULTS: Eight successful laparoscopic assisted procedures were performed, including bladder augmentation and an appendiceal Mitrofanoff procedure in 4 cases as well as tapered ileal Mitrofanoff and Malone antegrade continence enema procedures in 1, and bladder augmentation, appendiceal Mitrofanoff and antegrade continence enema procedure, gastrocystoplasty removal, ileal augmentation and an appendiceal Mitrofanoff procedure, and an antegrade continence enema procedure in 1 each. The laparoscopic component of these operations included extensive mobilization of the right colon in all patients and complete appendiceal harvesting in 2. Reconstruction was then completed through a Pfannenstiel incision in 4 patients, previous low midline scar in 2 and a small midline incision in 2. Drains were placed via existing trocar sites and open incisions were carried through other sites whenever possible. Continent stomas were matured through a trocar site in all 8 cases. Final cosmesis was excellent. Operative time was comparable to that of similar open procedures and intraoperative blood loss was minimal. CONCLUSIONS: Laparoscopy may be used as a successful adjunct in complex pediatric reconstructive procedures to minimize disfiguring and morbid upper abdominal incisions, and decrease the risk of future adhesions.     

Hypergastrinemia following antral gastrocystoplasty

Antral gastrocystoplasty has been previously described as an effective method of bladder augmentation or replacement. Six dogs underwent gastrocystoplasty. Two bladders were augmented utilizing the gastric fundus, one antral augmentation was performed, and three total bladder replacements were created utilizing the antrum. Each dog was followed for at least twelve months or until death from peptic ulcer disease with periodic evaluation for urinary continence, serum gastrin level, serum electrolytes, urine culture, urine pH and the radiographic appearance of the urinary reservoir and upper tracts. All four dogs with antral gastrocystoplasties developed severe hypergastrinemia and two demonstrated gross ulcers. In contrast, the two dogs with fundic augmentation did not show elevation of serum gastrin levels or evidence of peptic ulcer disease. Severe hypergastrinemia can be expected following antral gastrocystoplasty and the resultant ulcer disease can be fatal.     

Seromuscular gastrocystoplasty in dogs

INTRODUCTION: The aim of this study was to investigate the feasibility of seromuscular gastrocystoplasty (SGCP) in an animal model and to compare it to conventional gastrocystoplasty (CGCP). MATERIALS AND METHODS: CGCP and SGCP (using gastric segments without mucosa) were each performed in 6 dogs. In both procedures, two-thirds of the dome of the bladder were excised and the gastric segment anastomosed to the bladder remnant. Cystography, cystomanometry, measurements of urine pH, and gross and microscopic pathological studies were carried out preoperatively, and postoperatively, at 6 and 12 weeks. RESULTS: All seromuscular gastric segments proved viable, and 6 weeks after the operation they were covered by a thin layer of transitional epithelium, which had gradually thickened by the end of the 12-week follow-up. There was no difference in bladder capacity and compliance between the two groups, however, fasting urinary pH values were higher (less acidic) in the SGCP group. CONCLUSIONS: Stripping off the mucosa of the gastric segment appears to stop hydrochloric acid secretion, thereby lessening the possible risk of ulceration, perforation, dysuria-haematuria, metaplasia and malignancy. The uroepithelium overgrowth of the seromuscular gastric segments might provide a more physiological neo-bladder than when using full-thickness gastrocystoplasty.     

Combination of hand-assisted and laparoscopic proctocolectomy (HALP): Technical aspects,learning curve and early postoperative results

BACKGROUND: Various techniques for laparoscopic proctocolectomy have been reported worldwide. We evaluated the technical aspects and early postoperative results of hand-assisted laparoscopic proctocolectomy (HALP) with construction of an ileal pouch-anal anastomosis through a Pfannenstiel incision. PATIENTS AND METHODS: Between June 2004 and May 2006, 20 patients (median age 28 years) underwent combined HALP at our institution. Preoperative diagnosis included ulcerative colitis (n = 16), indeterminate colitis (n = 1), familial adenomatous polyposis (n = 2), and carcinoma of the rectum associated with ulcerative colitis (n = 1). All patients were under immunosuppressive therapy. Laparoscopic mobilisation of rectum, sigmoid and descending colon was performed first. Subsequently, hand-assisted laparoscopic mobilization of the transverse and ascending colon as well as creation of an ileal J-pouch were performed through a Pfannenstiel incision. Ileal pouch-anal anastomosis was completed by transrectal stapling device and protected by a loop ileostomy. RESULTS: The ileal pouch-anal anastomosis could be achieved in 19 cases (95%). There was one conversion (5%) to open surgery with construction of an end-ileostomy. No intraoperative blood transfusions were necessary. The median operating time was 210 minutes (range 180 min to 330 min). It was longer for the first five procedures but then remained constant. Two patients (10%) developed anastomotic leakage, which could be treated conservatively. Mean length of hospital stay was 11 days (range 7-32 days). CONCLUSIONS: Combined HALP with construction of an ileal J-pouch-anal anastomosis can be performed safely and effectively. The Pfannenstiel incision proved to be advantageous for hand-assisted mobilisation of the transverse colon. Additionally, it was useful for the specimen removal and the J-pouch construction. Our new technique not only proved to be safe, but also resulted in a shortened total operation-time after a learning curve of about five procedures.     

Totally intracorporeal laparoscopic colorectal anastomosis using circular stapler

Background A number of surgical techniques for colorectal anastomosis have been described for laparoscopic left-sided colectomies. Due to the complexity of these procedures, open preparation of the proximal bowel for circular stapler anastomosis through a Pfannenstiel incision has become the gold standard. We report a new laparoscopic technique for totally intracorporeal colorectal circular anastomosis (TLCCA) using a circular stapler. Methods Preliminary experience using TLCCA in three patients scheduled for laparoscopic left colectomies (two) and sigmoidectomy (one). Results Side-to-end colorectal anastomosis through TLCCA was feasible in all patients scheduled for preliminary experience. Median time from anvil insertion into abdominal cavity to anastomosis was 14 (11–17) minutes. No postoperative complications were recorded. Conclusion Side-to-end anastomosis can be easily and safely performed using conventional circular stapler through TLCCA. TLCCA is performed using four laparoscopic ports without additional skin incision (except trocars incision) and allows the retrieval of surgical pieces through a specimen bag.     

Autoaugmentation gastrocystoplasty: further studies of the sheep model

OBJECTIVE: To report our experience with autoaugmentation gastrocystoplasty (AAGC, reported to result in an inconsistent augmentation effect in children) in a sheep model, specifically addressing issues of surgical techniques and postoperative bladder drainage that may affect the augmentation result, as many factors have been implicated in the poor outcome. MATERIALS AND METHODS: Ten 6-month-old male lambs had a suprapubic catheter placed by an open laparotomy. Intraoperative urodynamics were evaluated before and after detrusorotomy for autoaugmentation and after completing AAGC. The bladder was drained with no distension for 1 week after surgery and the urodynamic evaluation repeated on control and experimental animals 6 months after surgery. The animals were then killed and the bladders evaluated for gastric flap survival and histological changes in the native bladder and augmentation segments. The results were analysed using a one-sided Student's t-test. RESULTS: The median (range) native bladder volume at leak-point pressure was 110 (40-490) mL. Intraoperative bladder volumes after completing AAGC confirmed adequate augmentation segments in all animals. The urodynamic evaluation at 6 months after AAGC showed increases in bladder volumes in nine of 10 animals (0-1336 mL), significantly greater than the increase in volume in the control sheep (median 337.5 vs 115.3 mL; P < 0.05). The bladder compliance (volume/pressure at leak capacity) 6 months after AAGC was slightly better but not significantly higher than in controls (median 17.3 vs 10.8 mL/cmH(2)O; P > 0.05). The median (range) ratio of surviving gastric flap to native bladder circumferences was 34.5 (31-53)%. Histology showed scarring of the submucosal layer in one of 10 augmentation segments and normal urothelium in all bladders. CONCLUSION: AAGC produces reliable bladder augmentation and excellent bladder compliance in a sheep model of a non-neurogenic bladder. The gastric flap survived well and there was no bladder wall separation with simple postoperative catheter drainage.     

Restorative proctectomy after emergency laparoscopic colectomy for ulcerative colitis: a case-matched study

OBJECTIVE: The aim of the study was to evaluate feasibility and safety of restorative proctectomy with ileal pouch anal anastomosis (IPAA) through a Pfannenstiel incision after prior laparoscopic colectomy. METHODS: Seventeen patients who underwent restorative proctectomy after laparoscopic emergency colectomy for ulcerative colitis (UC) were prospectively evaluated. Results were compared with results of a group of 21 case matched patients that had restorative proctectomy and IPAA via a midline incision in the same period. RESULTS: Median operation time was longer, although not significantly, in patients who had a restorative proctectomy through a pfannenstiel (186 min) compared to a restorative proctectomy through a midline incision (158 min). Procedure related complications were comparable between the groups, respectively, 1 of 17 patients in the pfannenstiel group and 3 of 21 patients in the median laparotomy group. Median hospital stay in the pfannenstiel group was 10 days and in the midline group 12 days. CONCLUSIONS: After laparoscopic assisted emergency colectomy for ulcerative colitis, restorative proctectomy is feasible and can be performed safely through a Pfannenstiel incision.     

Hand-assisted laparoscopic radical nephrectomy: the experience of the inexperienced

PURPOSE: We retrospectively examined the experience of novice laparoscopic surgeons performing hand-assisted laparoscopic radical nephrectomy. The purpose was to determine if urologists with minimal laparoscopic training could perform hand-assisted laparoscopic nephrectomies in a safe and efficient manner. MATERIALS AND METHODS: The first six hand-assisted laparoscopic radical nephrectomies performed by four different urology residents at the Chicago Lakeside VA hospital were reviewed. The residents included three chief urology residents and one postgraduate year 3 urology resident. None of the residents had taken any laparoscopic course, and all had limited exposure to the hand-assisted technique. In all cases, the residents performed the entire operation. The patients were evaluated for operative time, tumor size, body mass index, and ASA score. RESULTS: All six procedures were completed without conversion to the open technique. The average operating time was 215.8 minutes, and the time from incision to organ removal averaged 140.8 minutes. The average estimated blood loss was 166 mL. Complications included an intraoperative diaphragmatic injury (recognized and repaired laparoscopically) and one postoperative ileus. CONCLUSION: Hand-assisted laparoscopic radical nephrectomy can be performed safely and efficiently by urologists with minimal laparoscopic experience.     

全腔镜下吻合技术在腹腔镜胃癌根治术中的应用

目的 探讨全腔镜下吻合技术在腹腔镜胃癌根治术中的安全性及可行性.方法 回顾分析2012年7月-2013年7月吉林大学第二医院胃肠外科实施腹腔镜胃癌根治术全腔镜下吻合（36例,全腔镜吻合组）与小切口辅助吻合（47例, 小切口辅助组）患者的临床资料,并对两组临床资料进行对比分析.结果 83例患者均成功实施手术,无一例中转开腹.小切口辅助组切口长度为（7.1±0.9） cm,全腔镜吻合组为（2.6±0.4） cm.小切口辅助组吻合时间为（70.9±9.0） min,全腔镜吻合组为（29.1±4.9） min.术后小切口辅助组中度疼痛者6例,余41例为重度疼痛;全腔镜吻合组中度疼痛者29例,余7例为重度疼痛.小切口辅助组术后发生吻合口瘘1例,全腔镜吻合组未出现吻合口瘘及吻合口出血等并发症.结论 全腔镜下吻合技术在腹腔镜胃癌根治术中安全、可行,与小切口辅助吻合相比具有手术时间短和疼痛感减轻等优势.     

Histological changes following two-step flap gastrocystoplasty in rats.

INTRODUCTION: A gastric segment used to increase bladder capacity can undergo considerable changes over time, as can all intestinal segments implanted in the urinary tract and in contact with urine. This experimental study reports the differences between the histological alterations observed in the gastric patch transposed in the bladder both with its own pedicle and after deafferentation from the stomach. MATERIALS AND METHODS: A group of 30 young male Sprague-Dawley rats underwent gastrocystoplasty. Survivors were divided into 3 groups: gastrocystoplasty alone (8 rats); gastrocystoplasty with vascular deafferentation at 15 days (7 rats), and at 2 months (8 rats). 5 rats were used as controls. Urinary pH was evaluated during a 6-month follow-up. RESULTS: Histology showed that early devascularization hindered the fusion of the two mucosae in the junctional area but reduced papillary hyperplasia (p = 0.013) of the gastric mucosa. No changes were observed in urinary pH after patch devascularization. CONCLUSIONS: Vascular deafferentation creates a gastric flap on the bladder which, even if it does not prevent urinary acidification, reduces the frequency of histologically detected changes susceptible for transformation into neoplasms.     

Hand-assisted laparoscopic radical cystoprostatectomy and urethrectomy with ileal conduit construction

Introduction Hand-assisted laparoscopy was first performed in the 1990s by inserting the surgeon’s finger or hand through a small tight wound. Although leakage of gas from the incision initially limited the usefulness of the technique, the hand-assisted procedures have advanced extensively since the introduction of the hand-assisted laparoscopy port. Laparoscopic procedure has only rarely been applied to radical cystoprostatectomy. Favorable reports for laparoscopic radical prostatectomy encouraged us to attempt a cystoprostatectomy under hand-assisted laparoscopy. Patient The patient was a 70-year-old male with an invasive bladder tumor and no distant metastasis. Informed consent for undergoing hand-assisted laparoscopic radical cystoprostatectomy and ileal conduit construction was obtained. Methods and results The bladder was dissected free and extracted whole through the incision for the hand port. The bilateral ureters and a loop of small intestine were withdrawn through the same incision. An ileal segment was isolated and small intestine continuity was recovered. Each ureter was anastomosed to one extreme of the ileal segment that was then reintroduced into the abdomen. The stoma was constructed through the right side port without additional incision. No intraoperative complications were observed. Recuperation was unusually quick and painless, and few postoperative analgesics were needed. Conclusions Hand-assisted laparoscopic cystoprostatectomy and urinary diversion could provide the advantage of decreased postoperative morbidity without the long operation time and technical difficulty of a strictly laparoscopic procedure.     

腹腔镜膀胱癌根治加回肠膀胱术

目的:总结腹腔镜下膀胱癌根治加回肠膀胱术的手术方法及临床疗效。方法:2003年6月～2007年5月共行25例腹腔镜下根治性全膀胱切除、双侧盆腔淋巴结清扫加回肠膀胱术,患者平均年龄68岁,全膀胱切除和盆腔淋巴结清扫均在腹腔镜下完成,标本自下腹部小切口取出后,体外切取末端回肠10～15cm,近端闭合并与双侧输尿管吻合,远端造口于右下腹壁。结果:所有手术均顺利完成,手术时间210～320min,平均270min。术中出血220～1000ml,平均460ml。平均每例清扫淋巴结数10个,淋巴结阳性率16.2%,手术切缘均阴性。术后3～5天肠道功能恢复,1例因粘连性肠梗阻于术后1周再行手术探查松解粘连。术后2～3周拔除单J管,无肠漏及尿漏并发症发生。随访2～30个月,1例死于原发病转移,无腹壁造口狭窄发生,3例术后B超或造影显示单侧轻度肾积水和轻度输尿管扩张。结论:腹腔镜膀胱癌根治术具有创伤小,恢复快等优点,但手术难度较大,手术技术要求较高。回肠膀胱术手术操作相对简单,并发症少,可作为腹腔镜膀胱癌根治术后尿流改道可选方式之一。     

Laparoscopically assisted total or distal gastrectomy with lymph node dissection for early gastric cancer

BACKGROUND: A secure lymphadenectomy in a laparoscopically assisted gastrectomy performed for gastric cancer is required because of the high prevalence of lymph node metastasis. A surgical technique for laparoscopic gastrectomy with lymph node dissection and reconstruction using a conventional circular stapler is reported. METHODS: Forty-nine laparoscopically assisted gastrectomies with lymphadenectomy (47 distal and two total gastrectomies) were performed using devices for retraction of the stomach and laparoscopic ligation of arteries, which were developed to ensure secure dissection of lymph nodes. Reconstruction by Billroth I or intestinal interposition using a conventional circular stapler was performed through a small incision through which the specimen was removed. When submucosal invasion was suspected (n = 16), the lymph nodes along with the common hepatic artery were also dissected through the same incision. RESULTS: The operations were performed without serious complication. None was converted to laparotomy, and there were no deaths. Metastatic lymph nodes were seen in perigastric nodes and nodes along the left gastric artery in five cases. In five of the 49 patients the macroscopic diagnosis of depth of invasion was underestimated. CONCLUSION: A technique of laparoscopic gastrectomy with lymph node dissection for early invasive gastric cancer is described. A definitive answer concerning the appropriate level of lymph node dissection and the role of laparoscopic gastrectomy in the treatment of more advanced gastric cancer remains to be defined.     

Hand-assisted laparoscopic abdominal aortic aneurysm repair.

Hand-assisted laparoscopic aneurysm resection enables the surgeon to use his tactile senses while performing a laparoscopic aneurysm repair. Even more complex procedures that involve suprarenal clamping of the aorta can be performed by using this laparoscopically assisted approach. Twenty-nine laparoscopic patients were compared with a control group of 19 patients who were operated on conventionally. Transperitoneal hand-assisted laparoscopic aneurysm resection with a tube graft or a bifurcated graft was performed. The anastomosis was sutured with conventional instruments using the mini-incision as an access. The time for laparoscopy did not exceed 40 minutes. The incidence of complications did not vary between groups. The mean operating time was 135 minutes in the conventional group versus 180 minutes in the minimal invasive group. Intensive care stay and postoperative hospital stay were significantly shorter after the laparoscopic procedure. An oral diet was resumed significantly earlier, and the time until complete recovery was shortened in the miniaccess group. Hand-assisted laparoscopic aneurysm resection can be performed safely with operating times almost as expeditiously as in open surgery. Because it can be offered to the majority of patients with aortic disease, the technique described has distinct advantages over a total laparoscopic approach and a less steep learning curve.     

Taking Posterior Rectus Sheath Laparoscopically to Reinforce the Gastrojejunostomy in Laparoscopic Roux-en-Y Gastric Bypass

Background: The Roux-en-Y gastric bypass (RYGBP) is now performed laparoscopically widely with low morbidity and mortality. However, in some cases long-term adequate weight loss is not satisfied because of dilatation of the gastrojejunostomy. Therefore, a prosthetic material and bio-membranes have been used to prevent dilatation. In this study, we used posterior rectus sheath by laparoscopy, to evaluate feasibility and safety of the procedure. Methods: 20 Yorkshire pigs, under general anesthesia, had a standard laparoscopic RYGBP. In addition, 10 had their gastrojejunostomy anastomosis wrapped with 2x10 cm posterior rectus sheath. Clinical and operative outcome after operation were compared with the control group of laparoscopic RYGBP cases. Results: The median weight of the pigs was 46.1 kg (range 42-51) in the posterior rectus sheath-applied group and 45.2 kg (range 42-49) in the control group. All gastrojejunostomies in the posterior rectus sheath-applied group were successfully reinforced laparoscopically. Both groups loss weight compared with their normal growth weight, but there was no significant difference in the median weight loss between the two groups. Two pigs in the posterior rectus sheath-applied group developed a stenosis at the gastrojejunostomy anastomosis following RYGBP. All pigs in the posterior rectus sheath-applied group were found to develop hypertrophic smooth muscle and connective tissue scarring at the gastrojejunostomy on histologic examination. Conclusion: Laparoscopic application of posterior rectus sheath around the gastrojejunostomy in laparoscopic RYGBP is feasible and safe. The sheath-applied group developed stenosis and connective tissue scarring. Additional research is needed to evaluate effectiveness in preventing dilation of the anastomosis.