A 52 year old female allergic to atropine with a previous history of high blood pressure and OSA treated with CPAP suffers from a morbid obesity with a BMI of 46 Kg/m2. Two years ago she underwent a POSE procedure in a private center which was unsuccessful. She only lost 6kg and then regained and developed gastro esophageal reflux.
Preoperative workup was performed with an upper endoscopy that revealed a normal mucosa and some sutures from the previous POSE procedure, most of them in the gastric fundus. These sutures are uneffective as the gastric volume is almost normal as you can see in the gastrografin test.
The Clotest was negative. The abdominal ultrasound showed liver steatosis and no cholelithiasis.
Conversion into a roux-en-Y gastric bypass was performed with the patient under general anesthesia and placed in supine position with open legs. The surgeon stood between the legs with one assistant on each side of the patient.
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 surgery.
Luckily there are only few additions from the previous procedure. One assistant surgeon performs traction from the liver surface and the other performs traction from the stomach to improve exposure. As the plane is clear we use the hook to take down these adhesions.
We perform the required dissection to identify the landmarks and build the pouch. Here the surgeon looks for the left crura and the angle of His. The surgeon's left hand achieves extra tension and exposure to identify the avascular plane. The hook may also be used to effectively perform blunt dissection. Once the limit between the esophagogastric junction and the crura is identified the goldfinger is used to perform blunt dissection.
To perform traction against the crura and the stomach a retrogastric tunnel is built that serves as a landmark during the creation of the pouch. The assistant surgeons pulls up the stomach by bringing it close to the lesser curvature, at the height of the second short vessel we mobilize the gastric wall.
Once again we found adhesions and fused planes. The LigaSureTM was used for blunt dissection, sealing and cutting.
Step by step the dissection progress as the gastric wall gets lifted and a retrogastric tunnel is built to achieve this maneuver the camera must be one of the surgeon's instruments. The left hand keeps the gastric wall lifted while the right hand performs blunt dissection. Once the tunnel is created the left hand makes progress.
With these movements the surgeons mobilizes the posterior gastric wall until the dissection performed at the angle of His is communicated. The goldfinger is used to check the dissection, it looks like there is a lot of fat pad that must be mobilized prior to building the pouch.
We used the LigaSureTM to achieve this step of the procedure. Seal and cut is used when a vessel is visible. Otherwise, blunt dissection is effective. As you can see, this a very versatile surgical tool. Now we leave a laparoscopic debakey inside the retrogastric tunnel and the mechanical suture is introduced through the epigastric trocar, guided by the debakey it has better access to to the stomach.
With the stapler closed we verify that the knots from the POSE are away. Once again the goldfinger is used to check the retrogastric dissection, this makes it possible to make the next mechanical suture, purple cartridges are safe in this thickened tissue. Now we confirm the remnant tissue to be sectioned, one last firing is enough.
Surgery took 140 minutes and was uneventful. Drainage was left for postoperative surveillance. The patient was discharged two days after the procedure with no complications.
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