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A 62-year-old male patient with a history of high blood pressure (treated with two drugs), a coronary angioplasty due to ischemic heart disease (twice), and an open cholecystectomy. He suffered from morbid obesity with a BMI of 50.9 Kg/m2 (140 kg). A vertical banded gastroplasty (VBG) was performed in another hospital 20 years ago with a good outcome (50.9% excess weight loss).
He was referred to our hospital due to severe gastro esophageal reflux and a progressive intolerance to oral intake.
Further investigation was performed by means of a gastroscopy that excluded esophageal lesions and revealed a stenosis 50 cm from the dentate arcade. Upper GI series revealed a hiatal hernia with reflux and delayed gastric emptying.
The patient was advised to undergo surgical treatment with conversion of the VBG into a Roux-en-Y gastric bypass.
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 supra umbilical position for 30º scope, three 12-mm trocars as working channels, a more lateral 5-mm trocar at the left flank, and finally a 12-mm trocar at the umbilicus, which is used during the inframesocolic phase of the by-pass.
This video focuses on the dissection of the stomach and the creation of the pouch.
The greater omentum and the transverse colon were tractioned to the abdominal wall by adhesions. The LigaSure™ was used to take them down. The stomach presented several adhesions too, which were resected using the scissors. The pylorus and the gastric body were fused to the liver.
The assistant surgeon performed lateral traction of the stomach. The liver was carefully handled. Scissors were used to open a window in an avascular plane. Suction was used for blunt dissection and to advance with the individualization. There was bleeding and the energy device was used to improve hemostasis.
An incidental lesion of the liver occurred due to the thigh adhesions. Dissection strategies varied during the surgery, depending on the adhesions or bleeding. Scissors were used to release the fused tissues and to prevent unexpected injuries due to the energy devices.
At this stage the liver was free and exposure was improved by performing traction with an EndoClinch. Step by step the lesser curvature and the right crus were identified. Now that the greater curvature had been dissected, the assistant surgeon performed traction from the gastrosplenic ligament to expose the avascular plane.
This is another critical phase of the surgery: it is important to be very careful and avoid lesions in the short vessels. The working space is small and control of hemostasis is difficult.
Dissection of the lesser curvature progressed. There were many adhesions from the previous surgery. The goal was to identify the second short vessel which is the anatomical landmark to initiate the creation of the pouch.
A tunnel was made at the posterior gastric wall. The surgeons must work in coordination to perform the right maneuvers. The Goldfinger was used to advance and guide the placement of the mechanical suture.
Purple TriStaplers were used in this case due to thickened tissues from the previous gastroplasty. After the first fire, exposure improves and makes it possible to finish the dissection of the posterior wall. The mechanical suture was fired, excluding the previous stapler line.
Traction of the fundus exposed the limits to fire the mechanical suture and complete the pouch. The Goldfinger was used to verify that the lateral dissection was complete and prevent spleen injuries.
The mechanical suture was placed away from the angle of His. The anesthesiologist moved the anvil shaft from the mouth to the pouch through a gastrostomy performed by the surgeon.
A Roux-en-Y gastric bypass was completed with a 50-cm biliopancreatic limb and a jejuno-jejunal anastomosis 150 cm from the alimentary limb.
The surgery lasted 210 minutes, and there were no post-operative complications. 48 hours later, an upper GI excluded leaks and oral intake was initiated. The latest follow-up took place 1 month after the procedure, and the patient remains asymptomatic.
