Gastric Sleeve to Bypass Revision

Hi, this is Dr. St. Laurent and today I will be presenting a gastric sleeve revision to a gastric bypass. Our patient is a 39 year old female undergoing a revision secondary to severe reflux from her previous gastric sleeve performed 3 years earlier. Our operation begins with a five millimeter optical trocar that's placed just below the left costal margin. Once we gain access into the abdominal cavity, we insulate with carbon dioxide to create a working space. Once this is accomplished, we can then insert our additional trocars into their standard positions. We utilize a five trocar technique, with one of our trocars being a liver retractor. Our operation begins by taking down some of the perigastric adhesions from the patient's prior operation. We utilize the ultrasonic shearss to take down these adhesions in order to control any bleeding. We then insert our liver retractor to provide countertraction on the liver. We then utilize the ultrasonic shears to begin taking down the perigastric adhesions of the stomach to the undersurface of the liver. We also utilize a hook electrocautery. Good countertraction is utilized during this process to separate these filmy adhesions. You can see from the patient's prior operation these adhesions can be quite extensive, but for the most part are fairly easy to take down. We continue the dissection superiorly until we are able to completely identify the diaphragm and the hiatus where the esophagus comes through the diaphragm. We continue to take down these adhesions systematically until we can completely separate the liver from the actual stomach. Here you can see the stomach has now been completely dissected free from the liver. At this point, we introduce our calibrating tube. We then begin our dissection for the small stomach pouch along the medial border of the stomach. We gain access into the retrogastric or posterior gastric space behind the actual sleeve. We then insert our first linear stapler to complete the small upper stomach pouch. Here the linear stapler is inserted and abutted up against the calibrating tube that is the proximal stomach. We inflate the calibrating tube to 20cc to create a small upper gastric pouch. Once the stapler's fired, you can see the completed stomach pouch. The calibrating tube is subsequently deflated and then removed. We then introduce the anvil of a 21 millimeter circular stapler. This is brought out through a small gastric opening in the lower border of the pouch. The introducing tubing is grasped and then removed from the abdominal cavity. The fixation sutures are subsequently divided, separating the introducing tubing from the actual anvil. Here you can see the completed pouch. The second part of our operation is forming the Roux limb. We identify the transverse colon as seen here at the superior aspect of the video. Below the transverse colon we can see the small bowel come into view in the beginning of the jejunum at the ligament of Treitz. We then follow the small bowel for a distance of 45 centimeters downstream. The small bowel is divided at this point to create a proximal biliary limb and a distal Roux limb or alimentary limb. Here we're breaking a small defect in the mesentery in order to introduce our linear stapler. This is subsequently fired, completing the two segments of our bowel. The mesentery is then divided using the harmonic scalpel. This provides additional length to the Roux limb so that it will reach the small upper stomach pouch previously created. We then follow the jejunum distally for a total distance of 80 centimeters. This portion of the small bowel is brought up to the proximal biliary limb. We then begin to create our anastomosis. Here we're putting in a small enterotomy in the actual Roux limb or alimentary limb. We also place a small opening in our biliary limb. Once this is completed, we can then insert our linear stapler into the bowel segments. Here the linear stapler is being advanced into the biliary limb and subsequently into the Roux limb. The stapler is subsequently fired creating the first part of the anastomosis. We then rotate the small bowel and fire the stapler in the opposite direction to create a nice, wide anastomosis. The stapler is then removed and the remaining enterotomy defect is initially closed with a stay suture of 2.0 silk. This is utilized as a stay suture in order to place a linear stapler across this area. Once the stay suture is in place, we can elevate it and then place a linear stapler across the defect. A tissue reinforcement strip is included in order to control any bleeding at the site. This tissue strip is subsequently divided and the redundant portion of small bowel removed. Here now you can see the distal anastomosis as it's completed. The mesentery defect in the two bowel segments is then closed, using a running suture of 2.0 silk. It's important to close this defect to prevent any internal herniation. This closure is performed in a running fashion, being careful not to injure any of the blood supply in the small intestine. Here a good countertraction is provided by my assistant to elevate the defect so that it can be more easily closed. This suture is run all the way down to the bottom to completely close the defect. Here we see complete closure of the defect. At this point we need to create a tension-free path for the Roux limb. We take the overlying omental fat pad that covers up the small intestine and divide it down to the level of the transverse colon as seen here. Here you can see the transverse colon at the lower border. We widen this path to easily bring the Roux limb up. Here we grasp the Roux limb and bring it up to the proximally located stomach. We open up the proximal Roux limb to introduce the handle of the 21 EEA stapler. The stapler handle is advanced through the lateral port, the introductory cone is removed, and the spike withdrawn. We then introduce the staple handle into the proximal bowel loop. We advance it approximately 5 centimeters until we reach healthy tissue. The spike of the stapler is then advanced along the antimesenteric border and it's made it to the approximately located anvil. We then close down the stapler, bringing the stomach into tight approximation with the small bowel or Roux limb. Once this is closed down, the stapler is fired, completing the actual circular anastomosis. Here you can see the stapler is now being open and withdrawn from the bowel segment. Here we reveal two complete tissue rings, signifying good anastomosis. The stapler handle is then thoroughly irrigated with saline and then it's subsequently removed from the side port along with the introducing cone. We then introduce our 15 millimeter trocar to complete the operation. The redundant portion of the small bowel overhanging the anastomosis is then divided using another firing of the linear stapler. The resected portion of the small bowel is then place in an Endo Catch retrieval bag and brought out through the left flank incision. This helps prevent any contamination of the subcutaneous tissue. We then continue by reinforcing our anastomosis using interrupted sutures of 2.0 silk. This helps take some of the tension off the anastomosis and reduces the risk of leak occurring. We place sutures on both the left and right lateral aspects of the anastomosis, as well as anteriorly. After completion of the Limberg sutures, we will then move forward with testing the anastomosis. Here the stomach and the Roux limb are identified. To test the anastomosis, we first clamp the Roux limb just distal to the anastomosis. We then place the anastomosis into a saline bath and perform an upper endoscopy. The upper endoscope examines the integrity of the staple line, and then we inflate the bowel segments to distend them. This will help us to determine if a leak is present. Once we've confirmed that there is no leak, all the remaining areas are aspirated and the scope is removed. We then remove our bowel clamp and proceed to reinforce the anastomosis with some fibrin sealant. Once this is accomplished, our liver retractor is removed and we begin abdominal closure. We use a suture needle passer and an absorbable O-micro suture to close the larger trocar defects. It's important to close these larger defects to prevent any herniation. The remaining 5 millimeter trocars do not require any closure as they're too small to have any herniation occur. We then remove the remaining air from the abdominal cavity, completing the operation. This postoperative course was unremarkable. She had an upper GI performed the day of surgery, which is normal. She was subsequently started on a clear liquid diet, postoperative day 1, and then eventually discharged home on the same day.