Dr. Matthew St. Laurent Explains the Duodenal Switch Procedure

This is Dr. Matthew St. Laurent, and today I will be presenting a laparoscopic loop duodenal switch. A modification of the BPD with duodenal switch. Our operation begins with a 5-millimeter optical trocar on the left side. This is used to insufflate the abdominal cavity with carbon dioxide to create a working space. Once this is accomplished, we introduce our trocars in their standard positions. We utilize a five-trocar technique, similar to that of a sleeve gastrectomy. Here we introduce the Nathanson liver retractor to elevate the left lobe of the liver, in order to expose the upper portion of the stomach. Our operation begins by identifying the ileocecal valve. We then follow the ileum upstream, 250 to 300 centimeters. This loop of the small bowel is what will be used to anastomose to the duodenum. Once we identify this loop, we tack it to the upper portion of the greater omentum. This is to easily identify it later on during the case. A simple tacking suture is utilized to hold the loop of bowel in this position for later identification. Once this is accomplished, we can then proceed with the sleeve gastrectomy. We start our dissection at the lower portion of the stomach. We utilize ultrasonic shears to begin taking down the epiploic vessels along the lateral surface of the stomach. Here, you can see we gain access into the retrogastric space. We begin working our way upstream, taking down these short gastric vessels along the lateral surface of the stomach. We utilize the ultrasonic shears to help divide the blood vessels and control bleeding during the course of the case. We continue to work our way upstream, taking down these soft adhesions between the posterior aspect of the stomach and the pancreas. Taking down these adhesions is important to help completely mobilize the stomach so that a complete sleeve gastrectomy can be performed. We continue to work our way upstream until we identify the spleen in the right portion of your screen. We then take down the attachments between the stomach and the spleen, being careful not to cause any bleeding in this area. We continue to work our way superiorly, fully exposing the left portion of the diaphragm. We then take down the phrenoesophageal attachments, to fully mobilize the esophagus circumferentially around the diaphragm. In this particular individual, a moderate size hiatal hernia was preoperatively diagnosed. Here, we begin to dissect in the retroesophageal space, and the left portion of the diaphragmatic edge can be identified. We then rotate the stomach over, and then open up the right side of the omental window. We work our way towards the right crus of the diaphragm, again taking down the phrenoesophageal attachments, to freely mobilize the esophagus away from the diaphragmatic edge. Here you can see in the picture, the instrument on the left is holding the right crus of the diaphragm, as the phrenoesophageal attachments are being taken down. We continue to dissect in the posterior space until we've obtained a retrogastric window all the way to the opposite side. At this point, we can insert an articulating bending instrument to help elevate the esophagus and provide good countertraction. This allows a more thorough dissection of the posterior space. Here, you can see the posterior vagus nerve come into view. It's important during this dissection to preserve this nerve and not to injure it. We continue to take down the loose areolar tissue in the posterior space until both of the columns of the diaphragm are well-exposed. Here, we have now completely dissected the esophagus and stomach away from the diaphragm. We can see the right crus of the diaphragm, the aorta, and the left crus of the diaphragm. Once these columns have been completely dissected free, we can then perform a posterior repair of the diaphragm to reapproximate the diaphragmatic edges. We utilize a nonabsorbable suture in a figure-of-eight pattern to bring the posterior columns together. Oftentimes, multiple sutures are utilized to reapproximate the diaphragmatic edges and close the diaphragmatic defect. It's important to close the defect to prevent migration of the gastric pouch into the chest cavity. We want to locate at least 3 to 4 centimeters of the esophagus, below the actual diaphragm. This allows the lower esophageal sphincter to function more optimally. It's important not to close the defect too tightly, otherwise the patient will have difficulty swallowing in the postoperative period. Too tight of a closure could also result in more reflux. Once the diaphragmatic defect has been completely closed, we can then direct our attention to completing the lower dissection of the stomach. We again use the ultrasonic shears to take down the epiploic vessels along the lateral border of the stomach. We continue in this downstream fashion, taking down the loose areolar tissue, and completely freeing up the distal stomach. We continue the dissection just distal to the stomach, to incorporate at least 4 to 5 centimeters of the duodenum. Here, you can see that the distal stomach has now been completely mobilized, and we have continued to this dissection, at least 4 centimeters beyond the pylorus. We then insert an articulating bending instrument to freely mobilize the first portion of the duodenum. Here, you can identify the pylorus, and approximately 4 centimeters beyond the pylorus where our resection will take place. Once this has been accomplished, we then begin resection of the stomach for our sleeve gastrectomy. We begin our resection approximately 1 to 2 centimeters, proximal to the pylorus. We perform our first two firings of the stapler without a calibrating tube in place. This helps prevent any kinking or twisting of the distal stomach during the resection. We also make sure not to narrow the incisure, the sharp angulation of the stomach right at its lower border. Once our third firing of the stapler has been placed on the stomach and clamped down, we can then place our calibrating tube. We utilize a 42-French bougie calibrating tube, which is passed into the distal stomach. The calibrating tube is utilized to help form the appropriate size pouch. It also helps prevent narrowing of the pouch along the course of the resection. Once the tube is in place, we can then fire our third stapler. At this point, subsequent firings of the Endo GIA are used to complete the resection. Along the vertical portion of the sleeve, we hug the calibrating tube a little bit tighter to provide good restriction for the patient in the postoperative period. We continue our resection up to the junction of the esophagus and stomach. Here, you can see approximately 4 centimeters of the esophagus is located below the diaphragm. We make sure, with our final stapler, not to place any of the staples on the actual esophagus, as this can increase the risk of the patient developing a leak. Once the resection is complete, we divide the tissue reinforcement strip, and then the specimen is removed from the abdominal cavity. Once the specimen is extracted, we then reintroduce our trocar. The gastric staple line is then examined for hemostasis, and then the bougie calibrating tube is removed. Here, we can see the pylorus, and now we proceed with resecting the duodenum just distal to the pylorus. Once the duodenum has been divided, we can then begin our duodeno-ileal anastomosis. The loop of ileum is re-identified, and the fixation suture is divided. The loop of small bowel is then brought up to the duodenum, where the anastomosis will be completed. We perform a hand-sewn, two-layer anastomosis. We start with the posterior row of running 2-0 silk suture. We run this along the entire width of the actual duodenum to create a wide opening. This helps prevent strictures at this level. We start at the superior aspect of the duodenum, and work our way down, incorporating the entire ileal loop. Once the posterior layer is complete, we then create enterotomies in both the duodenum and the ileum distally. We then begin the formation of the inner row of sutures. For the inner row of the anastomosis, we utilize an absorbable suture of 3-0 vicryl. We run the suture from top to bottom, along the entire length of the anastomosis to be created. Once the posterior inner row is complete, we then start forming the anterior inner row. We again utilize an absorbable 3-0 vicryl suture to complete the anterior row. Here you can see the anterior row is now being completed. At this point, our final layer is performed. We utilize a nonabsorbable suture to perform an anterior outer row of sutures. We utilize a nonabsorbable 2-0 silk suture to close the outer layer. This is also performed in running fashion. Again, we work our way from the top portion of the anastomosis to the lower portion. Here, you can see completion of the two-layer closure of the anastomosis. The anastomosis itself is wide and limits the risk of a stricture. Once the anastomosis is complete, we then proceed with an upper endoscopy to evaluate the staple line, as well as the anastomosis. We clamp the afferent limb and proceed with the upper endoscopy. Here, we are placing the anastomosis under a saline bath, as the endoscope is advanced, both through the efferent and the afferent limbs. We use the air insufflation test to examine the staple line and make sure there is not a leak. Once we've confirmed that there's no leak, the clamp is removed, and the abdominal irrigation is withdrawn from the abdominal cavity. We make sure to examine the entire staple line along its length to make sure that there's good hemostasis. At this point, we reinforce the anastomosis with a fibrin sealant. This helps reduce the risk of a patient developing a postoperative leak. This is complete, we then insert a Jackson Pratt drain, and bring it along the lower border of the stomach and up to the apex of the spleen. It's useful for helping to remove any of the left over abdominal irrigation during the operation. It also helps to check for a leak in the early postoperative period. Once the drain is in place, we begin our abdominal closure. We remove our larger trocars and proceed to close the fascial defects using a suture needle passer in an 0 vicryl absorbable suture. This helps reduce the risk of the patient developing a postoperative hernia. The remaining trocars are small and have little risk of a postoperative hernia occurring. As a result, no closure is required. At this point, the remaining air in the abdominal cavity is aspirated, and the abdominal operation is complete. The patient's postoperative course was unremarkable. She had an upper GI the same day of surgery which was normal. She was subsequently started on a clear liquid diet on postoperative day one, and eventually discharged home.