Robotic Roux-en-Y Gastric Bypass (RYGB) for Treatment of Morbid Obesity

CHAPTER 1

My name is Hany Takla, I'm a general and bariatric surgeon and I'm the chair of surgery here at Mass General Brigham Wentworth-Douglass Hospital. So today we have - our first case is a gastric bypass. So it's a patient, young patient, she's 33, her BMI is 42. She does have some comorbidities including sleep apnea. She did have a previous history of a provoked DVT as well. So there's a plan to put the patient on prophylactic anticoagulation after surgery. So, typically for these procedures, there's, you know, there's a lot of things that go into it. The patients put a lot of effort, they work with the dieticians, psychologists as you all know, before surgery to sort of help them optimize their weight. And you know, if they have any comorbidities, et cetera, then they have to, you know, go through pulmonary clearance and cardiology if it's needed, et cetera. But this is our, you know, relatively healthy young patient. And you know, the reason we, you know, we elected to do a gastric bypass is just patient's choice. Typically my algorithm for gastric bypass versus sleeve gastrectomy for example is that for the gastric bypass, if a patient has diabetes or reflux disease, typically I would recommend a gastric bypass. So usually, you know, if the patient doesn't have advanced diabetes or reflux disease, then you know, sometimes the sleeve is just fine. However, this patient's sort of elected to have a gastric bypass. Now in terms of what you'll see in the procedure that we'll do today, there are different, you know, steps, obviously the port placement, which we'll go over during the case. But typically, I have a very standard port placement for any bariatric surgery that I do and also foregut procedures. So it's very similar port placement, as you'll see in the case. The second thing is you know, each of these procedures has certain steps that we have to go through. A gastric bypass is a surgery that, or a procedure that has a lot of technical steps and a lot of challenges. It has a lot of suturing, a lot of, you know, doing anastomoses and such. It's kind of a nice procedure for us to do for GI surgeons and also for trainees to go through 'cause it goes through different skills. But in any event, for the steps of the gastric bypass after port placement, basically the next step is to retract the left lobe of the liver because it sits on top of the stomach. So we have to retract it outta the way. There's several ways to do that, whether that's an Nathanson Retractor you'll see us using in these two cases or that case for the gastric bypass today. A barbed suture to retract the left lobe of the liver and the idea is to expose the GE junction or the junction between the esophagus and the stomach. That's an important landmark for creating the gastric pouch. So after that's done, we sort of try to clear that angle where we, you know, separate the esophagus from the left crus of the diaphragm, which is the phrenoesophageal ligament and define it and then we start creating the pouch. Typically, an adequate sized pouch should be about six centimeter from the GE junction. Vertically, that kind of creates a good sized pouch. So we measure that and then we start a perigastric dissection. There are some people that do a lesser curve dissection where we'd have to divide the lesser omentum. However, you know, I learned to - in training to do a perigastric dissection, preserve the vagus nerve, the vagus branches and the vessels and the blood supply to the pouch. That's a nice thing to do. And after we do that, we divide the pouch transversely and then size the pouch over a bougie and do basically a couple of vertical staple lines to complete creation of the pouch. The technique of creating the gastrojejunostomy - there are several ways of doing it. You can do a handsewn, you can do a stapled anastomosis. I learned also to do a handsewn anastomosis. Nothing wrong with stapled anastomosis. We also use an omega loop technique where you'll find us trying to find the ligament of Treitz and counting the biliopancreatic limb and then attaching that loop to the pouch first and then dividing the biliopancreatic limb There are some folks or some other techniques that you could basically create the jejunojejunostomy first. That makes things a little bit cumbersome I think, in my opinion because sometimes we may have trouble with the Roux limb breaching the pouch. But anyways, after we bring that loop of small intestine up to the pouch, we suture it with an absorbable suture to sort of create that second posterior layer of the anastomosis. And then after that's done, we then create the inner layer, do gastrotomy, enterotomy, create the inner layer, and then divide the biliopancreatic limb. After that, we do a leak test, which you'll see. It was interesting in that case then when we did the leak test in today's case, you know, there was, it looked like not necessarily a leak, but there was like a little bit of indocyanine green that we could see, which normally it was a little bit bright. So we sort of oversewed that. But anyways, after we divide the biliopancreatic limb, then we count about 120 or 130 centimeter of Roux limb and then create the jejunojejunostomy, which is a side-to-side anastomosis that's relatively easy to create. In some patients if the body mass index is much higher, meaning you know it's above 50, sometimes I'll elect to make the biliopancreatic limb a little bit longer, up to 100 centimeter. And the Roux limb also longer, up to 150 centimeters. So it varies a little bit based on the BMI, but for the most part, the very standard is to do 85-centimeter BP limb and about 120-, 130-centimeter Roux limb.

CHAPTER 2

Alright, so for these cases, usually what I'll do is I'll do a Veress needle entry at the Palmer's point and then go in with an Optiview. So Palmer's point, this is the costal margin here. So just kind of go a little bit below that. I'll take local. So typically, I'll measure a handbreadth from the costal margin. Kind of this is where I want my camera port to be and I'll go a little bit below that. For the gastric bypass, it's nice to go a little bit lower than the sleeve because you have the jejunojejunostomy to deal with. So you don't want to be too high. So if I was doing a sleeve gastrectomy, I'll go with the camera here. If I was doing a gastric bypass, I'll just go a little bit below that. I typically use two right hands and one left hand. Some people use two left hands. But it depends on what approach you use or what you're used to doing. So I learned this in residency to just attach the insufflation to the Veress needle rather than doing a water test. That's kind of the way I learned to do it. I'll sense the layers of the fascia. And then I'll look at the pressure and make sure that, you know, it's not a very high pressure. So 15 is a little high. Just trying to come back a little bit. Still too high. All right, so - okay, one more try. So now the pressure is 10, so that's a good pressure. So I probably was in the posterior rectus sheath. Let's give it a little bit of time. If I'm not getting very good insufflation, then I'll basically skip that and go actually with Optiview. I'll take local. Just to make sure that I'm not, you know, somewhere that I don't want to be. So that's an eight-millimeter port. The camera port. The Bovie working? We put it up to like four or something? Yes. Thank you. It's not working well. All right, can I get the knife? Okay, I'll take an eight. And can we turn the room lights off? So now I'm gonna try to go in this with a 30-degree scope, just making sure I focus on the center. Let's go in. So I see fascia. I'm gonna slow down a little bit. It's kind of - I see rectus right here. Little too deep. There we go. So now posterior sheath is there. So now I'm in, that's probably falciform. There we go. Pressure's three. There we go, our intra-abdominal. And it looks like I wasn't even there. So it looks like the Veress needle was basically in the posterior sheath. I wasn't even intra-abdominal. Just take a look, make sure we didn't cause any injuries going in. That's the spleen, stomach, liver. All right, so I'm gonna put my 12 here. So I usually do a handbreadth between ports. So this is the eight-millimeter camera port. So I usually use two 12 ports. So a handbreadth from the eight port and then that's a 12-millimeter port 'cause that gives you a good angle for the vertical line of the pouch. The vertical staple line. That's why I use a 12 port on this side. Some people use only one 12 port on the other side. But I find that it's easier, gives you a better access and better angle for the pouch. And these 12-millimeter ports, the reality is it's called 12 millimeter, but it's actually 15 outer diameter because it's metal. So that's why I actually close all these 12-millimeter ports. Come back just a little. Okay. A little closer. All right. And then I'll usually do an eight-millimeter lateral port. The reason I use that configuration is because I trained in laparoscopy to have the assistant port, the most lateral port like that one. So I just kind of simulated my port placement laparoscopic. So I usually used to use that lateral most port for the assistant, the retract, et cetera. So that's where my fourth arm will go. So that's basically my assistant arm. So that's an eight millimeter? Yes. Do a 12 port on the opposite side. That is for the stapler also. Also a handbreadth from this one. So about maybe this one. That's for the creating the JJ and the transverse fire of the staple line. Maybe go a little more lateral. Also looking around in the pelvis, make sure there are no adhesions. If there is, sometimes you might have to take adhesions down. Laparoscopic before we dock. Some people do them robotic too. I'll take a grasper. So same thing because it's a 12 port, so we want to close it because again the outer diameter is 15, really. So you don't want someone to have a port site hernia, especially early on. All right and I'll take the sponge. So now we're gonna put a sponge and a stitch to retract the liver just before we dock the robot so that, 'cause we're gonna need those. All right, Elena, can we do a reverse T? Now we need to basically really see the hiatus, that's why we put the patient in reverse Trendelenburg and I think, you know, usually my cue is when I see the hiatus really well, just to make sure that we have access to that 'cause you need to really see the GE junction for these procedures. So I don't have like a set number or degree to do reverse. Can we do a little more? So I can see the stomach very well. I can see the left lobe of the liver. It's the spleen up here. So I think that should be a good view. Alright, we can bring the robot in.

CHAPTER 3

Dock the remain arms.

CHAPTER 4

All right. Okay, so now usually keep the sponge in the left upper quadrant. This kind of helps if there's you know, you get into bleeding, and it helps actually sometimes with retraction too. You can see the spleen is pretty close here. I've been using this V-Loc to do the liver hammock stitch or the venous stitch for some time now. It's been working well for me. So that's what I've been using. So I'm just gonna use the sponge to see it like a big left lobe here. Big spleen. I'm just gonna tuck this there. There's a good exposure to the hiatus there, I think. You know it's always good landmark to see. The patient didn't have a hiatal hernia on her upper GI. I'm gonna try to retract that left lobe of the liver, so I'll see like where it wants to lie on the abdominal wall and sort of take that first bite there. And this suture just kind of helps kind of retract the liver out of the way a little bit. It's not necessarily to push it, I mean but some people it's mainly, I guess mainly pushing the liver. Not really... You don't have to really pull it too tight, it's just to kind of let the liver rest on it and then also use the Nathanson retractor for probably the first three years in my practice since 2015 and I switched to the suture about 2017. That's a little tricky here because left lobe of the liver is big. And also this suture and the diaphragm is a little tricky too 'cause you don't want it to be too deep and you don't want it to be too superficial 'cause the heart is actually right there. I see the diaphragm fibers here, so maybe I'll just take a little bit higher. And just enough to get, see the needle through the fibers. The patient doesn't have a hiatal hernia, so I don't have to be very aggressive with this. Just need to see the GE junction, hold it in place, and then the next bite, falciform is big and it's in my way, I'll just take a bite of it and then attach the other bite to the abdominal wall basically. The first load will be blue, guys. It doesn't have to be too tight just to kind of lift the liver up out of the way. Interesting that the spleen is enlarged. Little bit unexpected. Again, I'll park this, it's actually nice that I could just do this. Just park the sponge and lift up the left lobe of the liver. So the first step is actually to define the GE junction. You can see that's the hiatus, the esophagus here, the fundus is there. So the tip of the spleen. So we have to be careful with that when we're creating the pouch. And so I'll usually we will retract the fundus sort of down towards me. I just dissect the phrenoesophageal ligament, which is right about there. And since the patient doesn't have a hiatal hernia, so I don't need to take all of these attachments down just enough to leave room for my final stapler. I know all, some of that dissection posteriorly as well, but I think it's - kind of gets you started here. There's kind of a lymph node there. I dunno if you see it, but there's a lymph node here. The nice thing about the robotic energy is that you can actually see the spread of the energy as it's happening. So you can basically stop if you think it's too much spread. So I think I'm gonna go with my stapler just away from these vessels right here. Some are there. Once I see that retrogastric fat, then I think I'm in a good place. I just want to move that spleen out of my way 'cause it's really in the way. All right, I'll just leave these vessels alone and kind of make sure I come out with my stapler here in that window. So second step I guess is - started creating the pouch. Just felt I could do a little bit more dissect here. When I'm lifting the stomach, I'm not, you know, you're really pulling the spleen too much. So anyways, the pouch length ideally in about six centimeters or so. They give you a good volume for the pouch. So we think that - so fat bed here, fundus is here. That's kind of where GE junction would be.

CHAPTER 5

So about six centimeters. So this instrument, the tip up grasper from here to there is about six centimeter and it usually coincides with the second crossing vein is where you want your transverse staple line to be. That's about six centimeters. So that's first crossing vein, second crossing vein, third crossing vein. So I'm gonna go somewhere here. So right where that is or just slightly below. And I'm gonna basically hold the lesser omentum and start dividing it. I usually do a perigastric dissection. I think it's nicer. It preserves the nerves as much as possible and... Also that's kind of, I trained to do it this way. It's kind of a, with the tip up grasper, I usually just point it down a little bit. So, kind of almost having my wrist down and lifting it up. So that shows you posteriorly and you kind of go hand over hand just like you do with laparoscopic. Just spread. I'm kind of with my left hand I'm spreading and laying on the lesser omentum. And then once I see an opportunity to hold tissue, then I'll hold it. If I see a small vessel or something, then I'll... It's always nice to do a, you know, as limited dissection as you can see. So you don't devascularize the corners of the pouch. Okay, lifting it up, I see a vessel here. Was it? And then I'll keep rolling the stomach over. So maybe like this - hand it to my other hand and lift it. And I'm lifting it up in the air. And sort of hand over hand. Boom. Can I see a vessel here? I see a vessel posteriorly there as well. So it might be a good idea to try to... Other hand. Alright, keep doing this until I see that I'm in the lesser sac. Elena, is the bougie in the stomach? Or is it in her mouth? Suction? In her stomach. What's that? Can you guys pull it back? Is it in her mouth or in her stomach? Pull it back? Yeah, the bougie. Yeah, keep going. Pull it back, back, back. Yeah, you can leave it there for now. The OG still in also? Can you guys take the OG out and the bougie, if you pull it back, that'd be great. There you go. It was kind of skewing my view of the stuff. Thank you. Thank you. Good call, good call. Dr. Shabra, my fellow just pointed that out. It's always good to check what's in the mouth, what's in the esophagus 'cause as you can see, it kind of - once that's out, it sort of made my dissection a little easier. That's a splenic artery in the back there. So there I think it's free. And the lesser sac right there. So it is important because you can see here, this is the splenic artery. So if you don't do a good job with this dissection, that's kind of risky. My patient has a thin stomach, big spleen. So, you gotta take your time to, you know, to do this step properly. And you gotta see this free stomach, nothing, no attachments behind. I'll take the blue load in number one. She's got nice anatomy, yeah. All right, so I'm, again, I'm gonna leave my vessel sealer there so I can see and just put the stapler in the window. And just kind of feed... Feed the stomach on the stapler until it's about, you know, 50 millimeters or so. 50, 55 millimeter 'cause that's gonna be the transverse pouch staple line. And I see that there's a vessel here, right? So my anastomosis is gonna be anterior, so I want to leave myself a little room for the anastomosis away from that vessel. That's why I'm saying it's basically at or just below the second crossing vein. All right, can we advance the bougie, guys? Slowly. Okay, go in a little more, a little more. Okay, okay, that's good. So I can see the bougie going down. So I'm just gonna turn my hand a little bit so that I create a little bit of room on the anterior surface of the pouch so that I can do an anti-colic anti-gastric anastomosis 'cause I do my anastomosis anteriorly. So below the second crossing vein, there's a vessel here that you know, will be in our way when we're doing the anastomosis, but it's small. And you can see I turned my hand to close the stapler this way. And I'm gonna fire this. So the second load will be white. Okay, I will take the fenestrated. So typically the length of the pouch is about maybe 12 millimeters. So that's two firings of the stapler. I mean they always say if you do more than two firings and you have a longer pouch, typically, you know, we kind of leave the bougie in to keep the pouch straight as much as possible. You can see the splenic artery in the back there. So there. I get my right hand here to lift up the fundus because we don't want a lot of fundus back there. And basically I wanna find my way from here to the left crus so I can almost see it through here. Have to remember that we were seeing the spleen was really close to the stomach there. So I'm just gonna be very careful with that dissection. So I just leave my vessel sealer here and basically look for it where it wants to come out 'cause that's where I think the left crus of the diaphragm is. I'll just straighten the pouch again, pull. Just kind of look for it. I can see where that lymph node was. Somewhere here. So I'll go back and try to define that path more, but at this point you can actually fire the second stapler and then try to figure this out later. On the second fire. I see a little oozing here. You can see the left crus there, right here. You can see my point of dissection almost there. Right there. So that's kind of my trajectory we're on. I'll take the white load in number three. I'll just do those two fires and if you wanna do the second layer, I'll bring the loop up. All right, I'll usually use the angle side posteriorly 'cause it's easier to work with because it's thin. You can see the bougie there. I can see where the trajectory of where I want to be is. That's to the right. Right there. Now what I usually do is actually I'll get this hand out. and what I usually do is I like to have like a wider based pouch just for the anastomosis. So I'll kind of do the base a little bit wider and then go towards the bougie a little bit more. You don't have to really hug the bougie. This is a actually a 40 French bougie. It's actually pretty big, but my trajectory is just lateral to the fat pad, and see it's kind of a wide base pouch. You can have a kind of a streak. So I'll close this. I'll take the vessel sealer bit. I see a stapler here, so I'm gonna take that out so it doesn't cause any issues with the next fire. I'm gonna again find the path for my next fire, which I think is right here. All right, come back. I was kind of finding where the stapler is gonna come out. All right, I'll take the white load. Robert, can I get ready to give that IV ICG in a minute? I usually check the blood supply of the pouch. I mean for revisions it's very important for this. You know, most of the time you can tell and for the most part, pouches have good blood supply but still I think it's a reassuring thing to do. Can you advance the white load in? Put that fat outta the jaws. Perch just a little more. So it would actually do it in one fire. Make sure I don't have spleen or liver. Can close it. All right, you can go ahead and give that ICG. 7.5 cc, correct? Yeah, actually 7.5 milligrams, three cc. Sorry what? 7.5 milligrams, 3 cc. 3 cc? Yeah. All right, I'll take the scissors maybe. Right, now take those sutures, the 3-0 and the 4-0. You can bring the sutures in. Again, GE junction's here. So right about there, six centimeter. That's good blood supply. This is sensitive mode. And I'll look at the GE junction. There we go.

CHAPTER 6

Oh actually I'll need the vessel sealer. So these are the sutures that I'll use to make the anastomosis. So this is a 90-day absorbable V-Loc. Can we pull back number four just a little? The other suture is the one that I use for the outer layer and it's 3-0. This one is 12 inches today and it's 180 days absorbable. So I'm just gonna anchor the angle of the pouch here before I bring the... So I use an omega loop technique and I'll show you, but it's basically bringing a loop of small intestine and attaching it to the pouch. So this is just an anchoring suture right now. And I like to split the omentum. I know some people don't. I mean this is not a very high BMI patient. So you can argue not to split it. There. I'm just gonna park it here somewhere. And then I'll try to look for the transverse colon. And this is a step where I would, you know, split the omentum. So I'm just gonna look for the great omentum down here, just gently kind of trying to push it up. Just kind of laying it on the stomach. And we'll start splitting the omentum until we get to the transverse colon just to kind of clear the path for the Roux limb to come up, would be less tension. I mean obviously if there's too much tension, there's other ways to get the Roux limb up like retrocolic and other things that could be done. I see this vessel here, so I'm just gonna take my time so it doesn't cause an issue. Come on. Lemme see if transverse colon is coming up. Stop at the gastrocolic ligament. That's where it is. And now I'm gonna try to find the ligament of Treitz. Find the transverse colon which is right here. Sort of gently lift it up. Hand over hands. Now I need to find the ligament of Treitz. So I'm gonna use my vessel sealer to grab the mesentery of the transverse colon gently so I can actually use my other two blunt hands to find the ligament of Treitz, which is right here. It's kind of right there. So now the important part is to avoid a ruin all, and kind of have to make sure that you, or at least the omega loop technique, you have to make sure you put the biliopancreatic limb on this side of the screen and the Roux limb on this side of the screen. So it requires a little bit of a rotational movement. So you can see, ligament Treitz is here. So I'm gonna basically do this. So now the biliopancreatic limb is gonna be this, and Roux limb is gonna be this. I'm gonna do the counting, I usually do 85 centimeters from the ligament Treitz. So again, this is six centimeter from here to here. So let's say about here is about five centimeter. So it's 5, 10, 15, 20, 25, 30, 35, 40, 45, I'm gonna let go of the transverse colon. And park it here. It's 45, so 50, 55, 60, 65, 70, 75, 80, 85. So about there is where I want to do my anastomosis. So again, biliopancreatic limb is on this side of the screen, patient's left side. So this side. And Roux limb is gonna be on that side. So if you trace this back, it should take you to the ligament of Treitz. So I'm gonna hold this small intestine like right here and then start to do that second posterior layer of the anastomosis with that V-Loc. So I'm gonna use that V-Loc that I parked back there in the corner to do that posterior second layer. So I wanna... So this is antimesenteric border, mesenteric border, so I'll do it a little bit posterior so that when you do the gastrotomy and enterotomy and roll the small intestine anteriorly, you have room actually to do the anastomosis on the anterior surface of the bowel. So I'll just, I won't cinch it yet, I'll just anchor it. There. I was telling Dr. Shabra, that, almost like vascular surgery, we like parachute this in, so... And he's gonna show you the second layer posteriorly There. After I do that, I'm gonna just kind of cinch that down, bring the small intestinal a little closer. Then after I'm done with that, now it's a little easier to do it. So I'll let the bowel go and sort of hold the pouch, raise it, and then Dr. Shaber is gonna show you by basically taking bites of the staple line, the small dowel. Kind of pulling it through. Cinching it down. Good. He is kind of pulling the V-Loc lateral so that - to straighten out the anastomotic line and then is just basically suturing the staple line to the antimesenteric border of the loop that we brought up. There's a lot of, you know, efficiencies to learn. You know, this is a long suture, which we're not used to. We're used to shorter sutures, but that's what we have. So with shorter sutures, it's easy to kind of pull it through. But it kind of sets it up where you want really these sutures to be spaced out properly from each other. And now he's cinching it down and then he's ready for the next one. So try to take the staple line more than the stomach. Less stomach, more staple. Okay. Yep, nice. You can always push on the bowel with your left hand a little bit. There you go. That's good. Perfect. I think it's locked. I think you're good. Just pull it, pull the needle out of the loop, that's all. And just get it out of the tip of, do you guys have a a six inch? 3-0, all right. Yes. So let me give them this back. That's okay. And then can you take the needle out? 'Cause we use a suture cut needle holder. Sometimes it's a little, you know, easier not to use that at the beginning when they're first starting these. Especially also like other things like hernia repairs and things like that. But you know, if it is, that happens worse comes to worse, then you could, you know, basically start another one. So I'll basically start like a little bit before where that happened, so here somewhere. There. And we can basically just go like this. And same thing, staple line. This will be a little easier 'cause it's short. So maybe a couple more bites. One here, one here. Nice, rotate your hand. That's good. Great. And maybe lock the next one. Nice. Nice. So now we're kind of done with the posterior second layer. Gastrotomy and enterotomy. Good job. That's good. It happens to the best of us. Okay, so I'm gonna take the scissors. So this is the second layer. I'm just gonna use it to sort of tent the pouch up a little bit so we can create the gastrotomy and enterotomy. So I like to do the gastrotomy about two centimeters. So the open jaws of the fenestrated is about two centimeters. So I guess from here to there. There's that vessel here I'm dreading. Rob, can you advance the bougie please? Just slowly. Well that's where we restarted the... The second suture? Okay. Second suture and then also I think that's where I was saying, you know, try to stay on the staple line. More, a little more. Yeah, that's good. And if we can put it on suction. All right. So two centimeters about here to up there. I'm gonna want to leave a little lip of pouch posteriorly. So I'm just gonna mark it from there to there somewhere. I'm gonna use cut on six. Just open all the layers and I see a vessel here, so I'm gonna use coag for it. There and I see the bougie. All right, Elena, can you take it off suction and just pull it back a little bit? Sure. Thank you. Yeah, that's good. Thank you. You're welcome, should I get back on the suction? No, you can leave it just there. Okay, there. That's a pretty good sized gastrotomy there. So about two centimeter, full thickness. Now mirror image in the small bowel, same thing. Two centimeters from about here to here. Also this is kind of... Doing the enterotomy, you have to be a little careful 'cause... It's easy to back wall the small intestine, especially if it was under a little tension because the small bowel gets like flattened out. One of the only leaks that we had in my fellowship was a back wall. And just kind of went through the back wall. We didn't know until later. So there, pretty good enterotomy. All right, and I'll take the needle holder. So now I'm gonna suture the inner layer. Which we will use the 4-0 for. So just like any handsewn anastomosis, just running suture. Start at the corner. So here's usually full-thickness bite, you can see seromuscular and mucosa out to in. And then on the small bowel, go in to out. So that actually my knot or my loop is actually on the outside, not the inside. So again, in to out at the corner. And go in through the loop. This is a 4-0, 12-inch 90-day absorbable suture, barbed suture. So I'll go back out to in, taking a small bite of the mucosa and mostly seromuscular, but just a small bite of the mucosa. Just kind of cinch this down a little bit. So with this, it's nice to, you know, if you put a little bit of tension on the suture down so you can see mucosa and seromusculaar layers. So I can see it. Now I'm getting it and then seromuscular on the bowel and mucosa. And these are, it's kind of an important layer. So just kind of take your time, don't rush through this. So again, mucosa, seromuscular, I can see it. There. Okay, suture down. I'm kind of almost at the corner. So I'm just gonna change a little bit where I'll take it in two bites so I can actually have a good grasp of the corner. Can see it there. I'm gonna show myself a little bit bit intraluminal, so I know where I'm going. Corner. There. Hold this up. And go in through serosa. Now this is always kind of, you know, how much do you pull to cinch down? And kind of comes in with some, doing it that way for a while and just kind of a more visual cues and how tight these, to pull on these sutures. And as we can do less mucosa, that's usually helpful, kind of less strictures and... I'm still not at a point to use forehand. I'm still gonna do this one, last one probably, and then I'm gonna try to switch forehand after this. So now I'm inside on the small bowel. So I'm gonna go inside to outside on the pouch. So that's mucosa there. And maybe I'll do one more. And I'll go - see this vessel? So I'm gonna try to go around it, but I'll go in to out. Yeah, yeah, so I'm gonna go... No, I'm still in. So this one I did in to out on the... Now I'm gonna go out to in actually at that vessel so that, you know, it doesn't bleed. So same thing, we'll lift this up. There. Now I switched to the inner row, kind of forehand, as you can see, I sort of transitioned from inside to the outside, so it can be easy. And then before I kind of finished that closure, I'm actually gonna pass the bougie through so that when I'm doing the inner row, it doesn't purse string the anastomosis too much and cause a stricture. So I'm just gonna take one more bite and ask to pass the bougie. All right Rob, can we push the bougie in slowly, please? Keep going, keep going. Now I passed the bougie through the anastomosis so I know that one, I'm not back walling it, and then two, that I'm not untightening these sutures with this inner layer or the second outer layer, that I'm not purse stringing it too much. The last case we used a scope for this because it was a little difficult to get the bougie down. So that's also another option. Another way is to do these stapled linear anastomosis too, that's another option, which actually saves a little bit of time. It really depends on how you trained. I think - my personal experience is that handsewn anastomosis is a little bit less prone to strictures. That being said, I've had my own strictures, I know, but - I believe it's maybe a little less ischemic or something. I don't know. I got this last part. So after that, I locked it, and I'm actually gonna go back a a few bites just to, you know, these barbed sutures could potentially unravel. So it's not a bad idea to... Even though after locking it to go back a few throws and even when closing the peritoneum or fascia in hernias, I do the same. Get this. I'm done with this part. And then use the same exact V-Loc to go back on a second, anterior layer. And we are gonna get ready to do that leak test in a minute. I like seromuscular bites, doesn't have to be too deep. That's going a little tricky. So I sort of telescope the scope a little bit so I can actually see. All right, so I'll give you those back and I'll take the other sutures and the ruler.

CHAPTER 7

So now we're done with the GJ, so now we're gonna divide this. So this is the biliopancreatic limb, Roux limb, so now we're gonna divide the biliopancreatic limb and then do the JJ. But before we do that, after we divide, we gotta test the anastomosis and I usually use a ICG leak test for that. So it's 20 cc of water or saline mixed with the rest of the ICG that we didn't use, and then we followed by 20 cc of air just to make sure it's liquid and airtight. All right, I'll take the vessel sealer, okay? I'm gonna divide the biliopancreatic limb. So I'll lift it up and see what the trajectory of the vertical staple line is so that we don't create a long candy cane. And I think maybe here should be good. All right and I'll take the stapler, white load. So right where that window is. I will just align my stapler with the vertical pouch staple line so I don't have a long candy cane. Something like that. All right.

CHAPTER 8

All right, Elena, can we take the bougie off suction and pull it back, please? Yes. Now we're gonna do the leak test. So I'm asking them to pull the bougie back until it's in the pouch. Keep going, keep going. A little more, a little more. Okay, that's good. Now if we can do that leak test. Okay. Okay. Okay. All right, you can put it on suction. I think it's just thin. All right, you can take it off suction and take it all the way up. It's not a leak per say, but it's kind of like thin serosa I guess. Usually the ICG is very - much more sensitive than methylene blue or air. Actually, I could probably use an Ethibond. Or yeah, maybe - that's okay. If you have the Vicryl, I'll use it. All right, happy now again. All right, I'll give you this back and I'll take the scissors.

CHAPTER 9

All right, so now I'm gonna count the small intestine and I usually do either 120, 130 centimeter. Sometimes I'll go up to 150 depending on the patient's BMI. But for this lady, I believe BMI is kind of low 40s, so we can probably do 130. So I'm gonna count it and then Dr. Shabra will sort of help with the JJ part. So this is about 10 centimeter and that's why I have the ruler. Just roughly. And it's kind of a clockwise direction of rotating the bowel. So this is 10, it's about 20, rotating it, it's about 30. About 40. About 50. 60. 70. 80. 90. 100. 110. 20. 30. So there's probably very good. So now I'm gonna do an enterotomy. So this is the Roux limb, this is the common channel, this is the biliopancreatic limb. I'm gonna do an enterotomy in the Roux limb to connect it to the biliopancreatic limb. So it's almost like an end-to-side anastomosis, but it's really side-to-side. So this is animesenteric boarder. Just gonna use cut to make an enterotomy. Just a little bit of cut in the peritoneum here to let the BP limb sort of... So we're gonna also pick an area on the antimesenteric border on the BP limb and just a little bit distal to the staple line. Just make an enterotomy there. All right, we'll take the fenestrated in three and the stapler in the other one. So easiest thing is to hold this part up and then put it in the BP, hold it, and then bring this back and feed this into the... Look down a little bit. There you go and bring that camera back just a little. So if you hold the BP limb with the tip up, need to make it a little bit bigger. So just dilate it with the tip up a little bit. Try to nose it in a little bit. There you go. And then if you pull the BP limb this direction, just a little. There you go, that's nice, nice, nice. Hold it and then move it, move the stapler this way a little bit. That's good. Yep and then hold it. That's good, now grab this part with the tip up and keep it there for now. And then so, grab the bowel with the stapler. So close the stapler. There we go and keep it that way and then get your tip up. And then move this common channel up towards it. That's good, you can leave it there. Yeah, you don't need to pull it up more. And then if you grab the common channel with the tip up grasper. So this part right here, and then hold it here. Okay and then park it. And then try to, using this, feed it to the tip of the stapler. So hold it from here maybe. There you go, it's good. Now let go of the tip up. And then hold this. Yeah, feed it on the stapler. Feed it, feed it, feed it. Cool and then use the tip up to grab this, the BP limb. And then pull it up on the stapler. And then remember to push your stapler in just gently, gently, gently, gently. A little more. That's good. Grab it. Remember that clockwise rotation. Yeah, cinch up the BP limb a little more and push the stapler in. Perfect, push it in a little more. That's good. That's good. Now hold the, yeah, there you go. That's good. Now hold both of the bowel ends this way so that, but just gently and then with the tip up too. Alright now now we can fire when ready. All right, just give it a minute. And this patient's gonna be on Lovenox according to Kendall. It is gonna be on anticoagulation, this lady too, for some reason. I think she had a history of DVT. Yeah, go for it. Now when you're getting the stapler out, you don't want to open it all the way. Just gently enough to get it out so you don't make the enterotomy bigger. Say what? Anything I can do to keep the mucosa from poking out? No, I think you can just basically nose the stapler in and out. That will help it a little bit. Okay and then drop the BP limb. Just drop it. There you go, that's good. Straighten out your hand. All right, now I'll take the fenestrated in one and the needle holder in three. All right, so let me help you out with that part and maybe I can have you close the common enterotomy with the V-Loc. Nice job dude, that was good. So now you gotta close that common enterotomy. Usually I'll put this just a stay stitch, that will help sort of expose the common channel so we can close it. So just beyond the anastomosis here, I'll just do a simple suture here to there. Could you use the suture as the anti-kink suture? Yeah, you could, but it's just sometimes it changes the orientation of it a little bit and I just rather not use it and just use the mesenteric defect closure stitched to do that. So what about use this for the mesenteric closure? Yeah you could, but I like to start from the bottom to the top because if you start from the top to the bottom, it becomes harder to see the actual end of where the defect is. You know when you're closing an iliocolic anastomosis, you know if you don't start at the corner, then it closes it on you, you can't see it. So this is basically seromuscular. So I'll just start here, trying to dunk this mucosa. So I'll start in to out, leave the loop. And then go on the other side, seromuscular, mucosa. And then we'll go through the loop. And then go to the other side. So we'll see when I cinch this, then it helps sort of dunk that corner and it also helps get rid of the loop, so it's not showing. I'm just kind of finishing that closure. Yes, gonna do one more. And is there anything to look at? I'll go back a second there. This is kind of the second layer Lembert sutures, just doing seromuscular. I also do this anastomosis like double stapled. Some people do tri-stapled, which is always okay too. And we are gonna start closing the space behind the JJ. So I'll use that same Ethibond suture right here and sort of just drag this anastomosis a little bit towards the left upper quadrant. That usually will help expose the mesenteric defect behind the JJ, which I'll show you in a minute. And because this patient doesn't have a lot of mesenteric fat, not - probably a good idea to close the sort of Petersen too. So there's kind of the space behind the JJ. So I'm doing mesentery. Of... Mesentery of the Roux limb to the mesentery of the BP limb. I caught the bowel a little bit here. So I just wanna make sure. We will be a little bit cumbersome. So some people prefer to use V-Loc for these or barbed suture for this, but a couple of people that had, you know, bowel obstruction from something like that. So that's why I switched to using Ethibond, works well. Again, just kind of closing mesentery. All right, now as I get closer to the anastomosis, I want it to hold up too much like that. So I'm gonna relax on my grip and see where it wants to land naturally so it doesn't have a kink going into the anastomosis, the Roux limb, that's kind of where it wants to land. So that this Roux limb goes into the anastomosis without any kinks or narrowing. So that's where I'll suture a little bit of serosa to the mesentery of the biliopancreatic limb so it doesn't... So sometimes people do the Brolin's stitch, so from the BP limb to the Roux limb. So this kind of serves a similar purpose. So maybe from here, serosa to mesentery of BP limb. Now I'll actually catch the serosa of the BP limb as well to the mesentery here. So it just kind of pulls it down a little bit. Now I'll finish it. Okay. So now I'm gonna take a look at the Petersen or sort of Petersen. So this patient again has like very thin peritoneum and see we can close it as well right there. So probably better to close it. I've had a couple of people that had a little bit of narrowing of their... Their colon from like tight closures of this. So I don't routinely close them for everybody, but I think it's a good idea if you... See and we can take maybe a little bit of colon serosa there. Don't need it to go too crazy with it. Wanna do the scope, doctor? So now we're done with all this. I have to take a look, make sure everything is hemostatic and then I have to do an endoscopy. We'll take this liver stitch out. All right, lemme get these sutures.

CHAPTER 10

So now Dr. Shabra is doing the endoscopy. Just going through the esophagus. All looks good. GE junction, can see the pouch. Can see the staple line there. That's the anastomosis. We'll try to both... Alright, that's good. Beautiful. That's candy cane there. Okay, that's the candy cane side, that's the Roux limb side. It's occluded, right? Yep. Perfect, perfect. Okay, and suction it. Okay, good. And come back and look at the pouch itself. Clean it. That's good. Have no bleeding in there. Okay, cool. Awesome. Come back a little. Come back a little bit, that's good. Now go back and empty the air out. Alright, looks good. Ready to take it out? Yeah, go ahead. Uh, can you suction it? Yup. Okay, good. Okay. All right, that's good. All right, we can undock I guess.

CHAPTER 11

All right, so now everything is done, we'll do a TAP block and then basically close the ports. We had those Vicryl sutures placed already at the beginning. So after we're done with the TAP block, we're gonna tie them down, close the skin. So now we're doing this TAP block, it's a mixture of marcaine, lidocaine, and saline. It gives a mixture of about 60 cc. We don't have access to Exparel, so we just use our own mixture here. Sorry. So we're just injecting it in the TA plane to do the block. So we have 30 cc basically on each side. So that's... It's a good mix. All right. That's good.

CHAPTER 12

So overall, the case went really well. I think we didn't really have a whole lot of unexpected findings. The spleen for that patient was a little bit bigger than normal, but you know, that kind of, you know, was okay because we also didn't have a hiatal hernia to deal with. Also, in terms of hiatal hernias for gastric bypass, I usually am a little bit less aggressive for looking for it. I usually, you know, study these patients before surgery with an upper GI at least, even if they don't have any symptoms. If the patient is going to have a sleeve gastrectomy, I think we gotta be more aggressive with looking for these hiatal hernias because it is one of the reasons why, I mean, part of the reason why we do that is because the sleeve gastrectomy is a reflexogenic procedure, the gastric bypass is not. And if it's a small hiatal hernia the gastric bypass, probably won't cause any issues. But if there's a small hiatal hernia and you do the sleeve, they might have a sleeve migration, which is important to know. During the case, I think, you know, key points is, you know, efficiencies with suturing. So you'll see the fellow sort of doing the posterior layer. He did a great job with that 'cause we were just doing another case before this, a gastric bypass as well. One of the issues is using that suture cut needle holder, sometimes it can cut the suture, which actually happened in this case. You know, not a big deal. Sometimes you can just sort of rearrange yourself, use another suture. But for people that are starting to train and doing these procedures robotically, I don't recommend using a suture cut needle holder because of it can inadvertently cut the suture and that can sort of slow you down and decrease your efficiency and things like that. And in terms of when we were doing the leak test, we saw, we didn't see a leak but we saw a little area of bright ICG. So ICG is when you do the leak test with it, it's very known that it's very sensitive. So even if there are leaks that, you know, you may have not seen with methylene blue or air, you actually might see it with the indocyanine green. So we saw that bright area, it wasn't necessarily a leak, but we sort of decided to oversaw it with Vicryl, which was nice. And we also did an endoscopy and looked at the end and everything looked pretty good. So overall the case went really well and I think these are kind of the learning points or things that happened during the case that I think people should learn from.