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A 60-year-old female with a medical record of high blood pressure,T2DM treated with oral antidiabetics, dyslipidemia and a giant umbilical hernia. She suffered of super morbid obesity with a BMI of 56 Kg/m2. A laparoscopic sleeve gastrectomy plus an umbilical hernioplasty were uneventfully performed.
During the second year of follow up she went from 127 to 93 kg, which represents a BMI of 40 Kg/m2 and less than 50% EWL. She also had unsolved comorbidities. This patient had good adherence to the follow up program and to the nutritional supplement intake.
Revisional bariatric surgery was proposed, and during the preoperative workup a hiatal hernia, osteopenia and symptomatic bilateral inguinal hernias were found. She had correct glycated levels (6%).
Conversion into RYGBP will treat the hiatal hernia, not the insufficient weight loss and the comorbidities.
Conversion into BPD-DS will treat the insufficient weight loss and the comorbidities, but may worsen the osteopenia leading to severe complications such as pathological bone fractures and will leave the hiatal hernia untreated.
Conversion into a RYGBP with a long biliopancreatic limb will treat all the patient's current issues and can be performed by minimal invasive approach including the treatment of the inguinal hernias.
The patient was placed in the supine position with opened legs. The leading surgeon stood between the patient's legs with one asistant at each side. A total of 6 trocars were used. A 12 mm trocar was placed in a supraumbilical position for a 30° scope, three 12 mm trocars served as working channels for the leading surgeon at the epigastrium and on each flank, and the 5 mm trocar was placed in a more lateral position at the left flank. The last 12mm trocar was placed at the umbilicus and was used during the infraumbilical phase of the bypass.
The adhesions from the previous surgery were sectioned. The first maneuver was to build the gastric pouch. We use the second short vessel in the lesser curvature to perform the gastric transection. The assistant surgeons perform traction from the gastric remnant to expose the posterior gastric wall. This allows the leading surgeon to create a tunnel by means of blunt dissection.
The Gold Finger is a useful tool during this stage of the dissection. Taking down the fatty tissue removes all the redundant tissue and ensures effective accommodation between the stapler and the gastric wall to be sectioned. The Endo-GIA TriStapler™ is introduced through this tunnel.
Pulling down from the gastric pouch and the gastric remnant arranges the stomach into the mechanical suture achieving an effective section. We leave at least 1cm of the angle of His to avoid leaks. Then the anesthesiologist introduces the anvil of a circular mechanical suture through the patient's mouth, down into the oesophagus into the pouch.
The leading surgeon and the assistant maintain the tension and proper orientation. The cut setting of the hook is used for a small gastrotomy that enables the exteriorization of the tube attached to the anvil. The surgeons cut the string and extract the tube through the left hand 12mm trocar.
Now we change the scope to the 12mm umbilical trocar. The next step is to expose the major omentum for division. We open a window with the hook and then continue with the LigaSure™. This instrument can be used for blunt dissection and for tissue sealing and sectioning.
In the next maneuver the leading surgeon lifts the transverse colon and the assistants maintain exposure. The Treitz angle is identified. A 50cm ribbon is introduced to guide the measurement of the biliopancreatic limb. The gut is pulled up by the surgeon's nondominant hand while his other hand guides the ribbon over the bowel.
Once we reach 120 cm the small bowel is pulled up exposing the mesenterium and the hook is used to open a window. With the LigaSureTM we ensure that there is enough room to introduce the mechanical suture. As well as to guide the setting of the mechanical suture. The assistant surgeon grasps the mesenterium to pull the gut into the cartridge. This maneuver flattens the small bowel and makes it possible to verify that the surrounding organs are not involved in the mechanical suture.
The biliopancreatic limb is sectioned. One assistant surgeon grabs the stapler line from the alimentary limb while the contralateral assistant grasps the same loop distally. This enables the leading surgeon to perform an enterotomy parallel to the stapler line.
We enlarge the left flank 12mm wound to introduce the 25mm EEA DST device. Coordination is required. The gut lumen is exposed by the combined work between the leading surgeon and the assistant, making it possible to introduce the mechanical suture into the small bowel. The trocar is exteriorized while the assistant surgeon maintains the tension in the alimentary limb.
With the camera at the supraumbilical port, the leading surgeon attaches the trocar to the anvil and builds the gastro jejunal anastomosis. It is important to verify correct orientation before the mechanical suture is completely closed. The device is extracted through a protective bag to avoid wound infection
The enterotomy is closed with a mechanical suture. The stump is extracted in a protective bag. A 2-0 Vicryl knot is made between the pouch and the alimentary limb to release tension. Also between the alimentary limb and the gastric remnant to avoid torsion. A single 2-0 silk knot was made to close the crura anteriorly.
We change the camera into the 12 mm port located on the right flank. The leading surgeon stands on the patient's right hand side with one assistant on each side of the patient.
Once again the 50cm ribbon is introduced and used to measure 150cm from the gastrojejunal anastomosis. The cut setting of the hook is used to create a enterotomy in the antimesenteric border of the alimentary limb. For the biliopancreatic limb we create the enterotomy in the lateral border of the small bowel. This arrangement makes it easier to introduce the mechanical suture.
The assistant surgeon keeps the mechanical suture in the alimentary limb while the leading surgeon introduces the other arm into the mechanical suture inside the biliopancreatic limb. The jejuno jejunal anastomosis is finally created using a 60mm beige TriStapler™.
The enterotomy is closed with a Vicryl running suture. We make one knot at each edge. The inferior one will be used to improve exposure and securely close the entire defect. The assistant surgeon is in charge of maintaining tension in the running suture while the leading surgeon performs the maneuvers to close the enterotomy. All the sutures are tightened.
We close the mesenteric gap with a prolene running suture as we believe that it is less traumatic to the mesenterium. We advise not to go too deep in order to avoid vascular injuries. The last knot may involve an edge of small bowel to effectively seal the gap. Finally we tighten the knot, finishing the bariatric procedure. We left a drain for postoperative surveillance.
Now we continue with the inguinal hernia repair. In this case the patient had bilateral indirect groin hernias. The small bowel is reduced into the abdominal cavity. The peritoneum is incised with the hook and step by step access to the pre peritoneal space is gained.
The medial landmark is the umbilical ligament. The lateral landmark of the dissection is the iliac spine. Step by step the fatty tissue is separated from the peritoneum. The inguinal ligament is visualized from the pubis to the iliac spine. The LigaSure™ is a useful tool as it enables blunt dissection, tissue sealing and sectioning.
Pulling up from the peritoneum helps to identify the direction of the dissection towards the deep inguinal ring. The lipoma is identified and individualized from the sac by blunt dissection. The LigaSureTM is used when a correct plane is identified. Step by step the lipoma is pulled out from the inguinal canal.
The dissection has finished exposing all the weak points that will be reinforced from behind. A polypropylene titanium covered mesh is introduced and unfolded. It should cover from above the deep inguinal ring up to the pubis from below to above the inguinal ligament. We use a synthetic glue to securely fix the mesh. Using this approach we can avoid making knots or placing takers that might cause unexpected vascular or neural injuries.
The edges are fixed first to keep the mesh well unfolded. This is the final look of the mesh, covering all the defects from behind. Finally the peritoneal flap is also fixed with glue. The procedure was performed on both sides.
Surgery was performed completely by laparoscopic approach. It took 190 minutes and was uneventful. The patient started oral intake on the first postoperative day and left hospital two days after surgery.
