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Minigastric Bypass video with Technical points.
MINI GASTRIC BYPASS TECHNICAL POINTS
IMRAN ABBAS MD,Laparoscopic Bariatric Surgeon,Dubai.
SurgicalTeam & Their Position:
Surgeon(B/W legs),First Assisstant Camera holder(patient right side),Second Assisstant(patient left side).
Instruments:
New version Laparoscope with at least two moniters,0 degree &30 degree lens,two atraumatic graspers,one single action grasper short arms,Needle holder,one suction irrigation,energy source hormonic 7+ or ligasure.
Patient position:
supine,open arms,semisitting(45 degree),semilithotomy,semiflexed knees(pillos under both knees) and fixed with bed.
Patient must wear antithrombotic socks during surgery.
2gm cepazoline and 5000 units heparin(sc) just before starting the surgery.
Port position:
1st port 10mm(optical port) just left lateral to mid line,about 12cm(males) 15cm(female) from xiphoid process.
2nd port 12mm, 10 cm left lateral and parallel to first port.
3rd port 12mm, right of patient 10cm superolateral to 1st port.
4th port 5mm, left anterior axillary line of patient just 2cm beneath costal margin.
5th port: 5mm, in epigastrum.
1st step;
A general intraabdominal view,any intestinal adhesion or any other incidental pathology.
Retract liver with the help of left hand grasper and fix endoclinch grasper by grasping right crus.
2nd step:
Decompress the stomach by an orogastric tube that must be sizer(38F) and after decompressing,orogastric tube must be retract till esophagus.
3rd step:
Grasp most upper portion of omentum by endoclinch grasper from 5th port and retract below.
4th step:
Grasp the gastric fundus by left hand grasper(single action) when mobile arm of single action is below and retract fundus below and medially.
5th step:
Meticulous dissection of HIS angle,becarful to esophagus and upper short gastric vessel and put a mesh gauze after dissection at HIS site.
6th step:
Watch carefuly small intestine just by manupulating the omentum medially to rule out intestinal adhesion.
7th step:
Grasp the gastrohepatic ligament just at the incisura angularis and retract it superiorly at the same time assisstant grasp stomach about 10cm below to incisura angularis and retract below and lateral.dissect by hormonic along with horizental portion of incisura angularis just with two bites you will be in lesser sac,if posterior adhesions present than change your hand and grasp hormonic by left hand and stomach by right hand superiorly & lateraly and assisstant will be off,and start dissection by harmonic,than you will be in leser sac,dissect gently so much that a stapler arm can easily enter.
8th step:
1st stapler 45mm green in male & redo and Golden in female,by left hand horizently,becarful do not fold stomach and confirm orogastric tube is not in stomach.
9th step:
Insert Orogastric tube(sizer) 38F.
10th step:
Staple verticaly attach to sizer,dissect posterior adhesions while assisstant tenting the stomach,becareful splenic artery,and also left gastric artry when dissecting for 3rd stapler.
11th step:
Last stapler, dissect posterior side while assisstant is tenting the stomach,till you reach the gauze that you placed in HIS angle dissection site,blue arm of stapler below and assisstant retract mentum below and surgeon grasp the fundus and retract below,just see the blue arm in HIS angle site,just lateral to esophageal gastric junction fat pad(1cm lateral to EG juntion).
12th step:
See the stapler line on bothside and put a gauze in between two pouches.
13th step:
Perforate the gastric pouch for anastomosis,preference posteriorly,just below the transverse stapler line, perforate by hormonic fix arm while anesthesia assisstant holding sizer in gastric pouch with a little pressure,if more vasculature is present at posterior side,you can use anterior side.
14th step:
with the help of camera holder when he is watching just LUQ mobilize omentum superomedially by your left hand and than assisstant enter verticaly and hold the colon mesentry and exlore Trietz ligament.Measure small intestintine while mobilizing it superolaterally till 200cm(It depends on patient BMI,I prefer 180 cm).
15 th step:
Check the loop reach easily to gastric pouch and than perforate while holding by left hand.
16 th step:
Enter the stapler blue 45mm, while blue arm is below,enter blue arm gently in intestine and pull down the gastric pouch,becareful do not push intestine above forcefully it will perforate bowl.
17 th step:
Enter in gastric foramen metalic arm of stapler and when stapling becareful stapler line a little toward gastric mesentry by this way there will be no chance of ischemia.
18 th step:
Stitching the defect with PDS 0-2 continously,seromuscular of small intestine and full thickness of stomach.
19th step:
Air leak test,hold gentely the both afferent & effent arm of bowl 10 cm beyond gastrojejunostomy.