Patients with hiatal hernia, GERD, Barrett’s esophagus and osteoporosis must be selected for other techniques such as a Roux-n-Y gastric bypass. A minimal invasive approach performed by experienced surgeons is feasible and safe.
This video focuses on the main steps and some suggestions to perform a laparoscopic biliopancreatic diversion with duodenal switch.
The patient was placed in the supine position with open legs. The leading surgeon stood between the legs and two assistant surgeons stood one on each side of the patient.
A total of six trocars were used: a 12-mm trocar in a supraumbilical position for a 30º scope, two 5-mm trocars located at the epigastrium and at the left flank, and three 12-mm trocars, one at each flank and the last one at the umbilicus.
There were some adhesions from the stomach to the liver, due to the previous sleeve. The scissors were used to take them down, avoid injuries from the energy device and clarify the planes. The surgeon mobilized enough stomach to guide the placement of the anvil shaft and perform the post pyloric dissection.
The assistant surgeon performed traction from the liver to achieve a correct exposure. The duodenum was then prepared using blunt dissection to create a tunnel behind its posterior wall. The landmark was just after the pylorus. The goldfinger is a useful tool for this maneuver. It curves around the duodenum creating a pathway to introduce a mechanical suture and produce a post pyloric section.
The gastric stump was mobilized to improve the maneuvers during the setting of the anvil. the anesthesiologist introduced a tube with the anvil attached through the mouth. It would later be extracted through the stapler line. A mesenteric gap was created to allow the antecolic placement of the alimentary loop.
Now the surgeons changed their positions. The leading surgeon and the camera stood to the left of the patient and the assistant stood between the legs. The terminal ileum was located. Using a 50cm ribbon, the surgeons measured 100 cm from the ileocecal valve and created a knot. This was the landmark to create the jejuno-jejunal anastomosis.
A useful trick is to place a clip distal to the knot that will help to maintain the orientation during the creation of the anastomosis. The surgeons then measured 150cm in a Treitz angle. It is important to focus during this phase of the procedure and perform the maneuvers in a systematic manner to avoid confusions with the bowel.
The gut was prepared for section. The portion located at the right of the screen would become the alimentary loop and the other one would be the biliopancreatic loop. An enterotomy was performed using a hook, and an EndoGiaTM Tri-Stapler was used to create the anastomosis. The enterotomy was closed with a Vicryl running suture.
The alimentary loop was grabbed and an enterotomy was performed to introduce the circular stapler by enlarging the trocar wound at the right flank. This is the most technically demanding maneuver of the procedure, as the surgeons must be in coordination and work simultaneously to achieve it.
An end-to-end mechanical circular anastomosis was performed. It is important to guide the orientation by performing traction of the stomach or the small bowel when required. The small bowel was sealed by firing a mechanical suture. A couple of knots were made to release tension and maintain the orientation of the anastomosis.
A drain was placed for surveillance of the duodenal-jejunal anastomosis and the duodenal stump.