C. COPAESCU Sleeve resection

we are going to perform a sleeve rejection in a lady with a bmi of 41. okay thank you very much

so we are prepared to start when we will be in a direct connection with the participants to this

very important event let me know because I'm going to explain what I'm doing okay

sorry can you repeat so we are about to start and we are now waiting for a sign

from you okay you can start soon yeah okay we see you you need me to explain

a little bit will be a sleeve resection and we are now trying to enter under the left

lever lobe and with a cushy a retractor we okay but now we see just know you okay okay

okay here we are okay maybe I just placed a cushieri retractor below the left liver lobe

in order to elevate the liver and to have enough space

around the esogastric junction now we have six strokers placed in this abdomen

Do you want an external view of this procedure?

Okay, just...

It's okay.

No, it's okay, just an external view to see.

An external view, okay?

An external view just to see how the trockers are placed.

And I'm going to explain.

Please move a little bit the camera just to have the whole area.

I want a wider image here, please.

okay we have an optic trocha by the umbilicus then we have another optic

trocha above of the umbilicus 10 centimeters then we have another trocha

for the liver retractor 12 millimeter trocha on the right for the right hand

is a very safe procedure and it should be performed very fast please give me an internal view of the

of the uh patients okay do you have now the view on the stomach and i am starting now to

cut the left gastric vessels with the ligature atlas

I presume that you have a brilliant view of an HD camera that we hold it by my

aid thank you it's camera and I like it very much now I am just about to enter

in bursa omentalis. Here is the lesser sac opened. I started the procedure at the level

of the angle of the stomach, because here the adherences are less than in other parts,

below or upper part of the stomach as I am in the bursa mentalis now I am going

caudally to the piler we are cutting the vessels along the antrum and step by

step with the aid of this very efficient energy instrument we are cutting all the

vessels up to the pylorus the whole ant room is going to be freed from its

utterances you can see that now we have some gastropancreatic utterances that

are going to be dissected without injuring the vessels of feeding the

stomach and this will be done with the patient we can see behind the stomach

the pancreas it's a very nice view of her pancreas here and I am about to

reach the end of the dissection point here we have pylorus another step and

now I am ready for the distal section this is very interesting to see here

because we have some utterances of the stomach and I have to arrange a little

bit to deal with these utterances in order to remain only two layers of the

stomach because i'm going to cut with the stapler at this level so i don't need gastrogastric

adherences at this level otherwise misfiring will be uh awkward and we don't want this so this is

is something that I am doing usually preparing for the first firing now I am

going up to the angle of his the land the landmark of the upper dissect

dissection of the lateral aspect of the stomach the a does the third member of

the surgical team is going to grasp he's going to grasp now with the forceps the

greater curvature to grasp down a little bit the rock and now we are going up

angle of his step by step staying very close to the stomach now please clean up the camera

now we're going up are you still with us yes yes we can we can see and we appreciate a lot

we are moving forward very clear yeah they're clear images we are trying to deliver to you

a very good image as we have every day in our bariatric center. This is a bariatric center of

excellence, Delta Hospital in Bucharest. It's a brand new equipment and we are very proud of.

Now we are reaching up to the left cruz. We leave on the right side the spleen which cannot be

be injured and as the lateral part of the stomach is going to be rejected we

don't care about heating a little bit the gastric wall with the energy effect

of our forceps now we are moving up moving up we can see the spleen behind

and we have to step back one step and to cut this vessels which are feeding the

posterior aspect of the stomach and by this way we should free the upper part

of the gastric fundus in a very safe way we may see the spleen behind here we

have a very small space and i underline the great benefit of this instruments from covidian which

are very safe very efficient and easy to deal with in between the stomach and the spleen without

injuring any one of them now here is the left cruz I am cutting up the gastro

phrenic ligament and here here we have behind the esophagus here is the angle

of his and some more alliances are going to be treated here and as you can see I am NOT burning

the tissue very close to the esophagus who has a very sensible tissue and the vascularization I'm

trying to keep the line of the electrical section far from the esophagus

this will be the last point checking about hernia there is no hernia this is

the left cruise this is esophagus and from here start the stomach they do

anterior aspect of the stomach and we ask for our colleagues from the anesthesiologist anesthesiology

to introduce a bougie of 36 french okay the camera has been reintroduced through the umbilical

optical trocar and now I am about to fire the first cut of the stomach by

using do it TRS it's a stapler as you know covered with

buttress material from from the factory again a Covidian product now we have to

check if the remaining channel do have enough emptying space by appreciating the distance

from the lesser curvature to the steppled line both on the posterior aspect and the

anterior aspect of the stomach and of course we have to check if this device is going to

to be closed in a proper way as to obtain an adequate formating

of the stapers.

So my feeling is that the instrument

has been closed properly.

And anyway, I'm trying to check this

by closing the jaws of his instrument with another instrument and now I am forcing the tissue to

spill out all the the liquids that are inside also we can see that I started the sectioning

of the stomach at about three centimeters from the pylorus you can see and now i am firing

after about you could notice about 15 seconds of waiting until the liquids inside of the stomach

moved out from the inside of the stepped line so we presume now that the height of the tissue

is adequate with a blue cartridge I mean with staplers of 3.5 millimeters if we will use green

at this level for sure the formatting of the staplers will be better and much more easy for

the surgeon but we do expect much more bleeding sources to be observed on the stepper line now

after about one minute of waiting this first application of the stepper is performed we can

see that the external line was not formatted adequately but we still have medially too well

well-formated staplers and no bleeding on the stepper line.

Now, I am charging the second cartridge in my EndoGia Universal,

and I am asking Dr. Daniela Godoroja, the anesthesiologist,

to introduce the 36 French Bougie which is passing through the new channel up to

the pillars now again we are going to be concentrated to the fashioning of this

stomach to tailor a gastric tube with the equal contribution of the anterior and the posterior

part of the stomach because otherwise we will face the situation of a twist of the gastric

tube which is very narrow 36 French means 1.2 millimeters that will be a very very narrow

gastric tube so we may determine to the patient problem of food passage now I am

checking how the juice of this duet there was tears was we're closed and I

am now fighting I am sure that everything it's okay I feel this on my

left hand which is firing now the staple and for the second firing it's much more

easy because we are not crossing the edge of the stomach we for sure have to

cut only two layers of the stomach anterior and posterior now the camera is

reintroduced through the superior optic troca those placed above the umbilicus

about 10 centimeters and the cartridge is introduced through the right through

the troca placed on the left quadrant of the abdomen placed for the right hand of

the surgeon I would like to ask Florine my cameraman and the aid surgeon to

clean up the camera because i am not satisfied with the quality of the image that i'm going to

deliver to you do you agree marco oh yes but it's it's okay we we were appreciating your

procedure very clean actually this is one of the greatest advantages of laparoscopy and the hd to

to be very precise with the tissue

that we are going to cut, dissect, and so on.

Again, the same principle checking

that on the posterior aspect of the stomach

and on the anterior aspect of the stomach,

the contribution of the gastric world to the new gastric tube will be equal by

this we will obtain an uniform please check a little bit an uniform and nice

gastric tube very narrow gastric tube I just fired three staples I am about to

position now there is a here is a stapler not well formatted on the top

this is usually and again the new staple line should cross a little bit the

previous staple line in order to prevent the ischemic gap now all the time we are

checking on the posterior part of the stomach and we can see that

we have the same distance to lesser curvature on the posterior part where gastric fundus is

greater in size than on anterior part and on the other side this is the

anterior part I have to notice the advantage of this

buttress material because otherwise without this film on the stapled line

the bleeding will occur all the time so despite of the fact that we were checking very well about

the contribution of both parts of the stomach you can see that the posterior part of the stomach is

going to be retracted a little bit so the tendency of twisting around its longitudinal arcs it's real

for gastric sleeve and this is something very important to be noticed and I

discovered after an experience of more than 1,300 sleeves performed in this

center now we are about to finalize the cutting of the stomach again checking on

the posterior aspect of the stomach and here we have as you can see the posterior and now

the anterior part of the stomach now checking about the ischemic gap here crossing the previous

line the stepper line the previous separate line again rearranged in a proper position and firing

up to the top expecting that this was enough as it was for fulfilling the

gastric section on the top there is a small part of the tissue that I go that

is going to be oh this is not good another clip please and I'm gonna place

a clip there and this will be anyway an important landmark radiologically when

we will intend to see where the esogastric Junction is now will be here

one give me another one it is better to leave a little bit of

ear dog like here on the top in order to prevent cutting the esophagus and I will demonstrate

later on in a few minutes what I'm saying because you see there is a small part of tissue of five

millimeters far from from the esophagus here is esophagus and we still have here

few millimeters that we have to leave otherwise we will cut from the esophagus

who has no serosa and the muscular layer will be destroyed and the fistula may

occur now i am asking the anesthesiologist please remove the calibrating tube now we check if the

stomach stays in the position that we left the principal sign is to be able to see along the

stepper line the whole stepper line from the pylorus up to angle of his okay i am satisfied

now the anesthesiologist is going to introduce a nasogastric tube which is going to stay inside for

for the next 12 hours at least up to 24 hours now you you can see how the gastric tube passed

through the stomach and now i am pressing with my forceps on the duodenum and

And 100 cc of Medellin blue is going to be introduced in the gastric tube.

And now we are checking for any leak, any possible misfiring or defect of the stapling procedure.

now as we are sure that there is nothing to be worried about the staple line we are going to

explain the stomach and for this I would need an external view please please give me an external

view because I'm going I'm going show up how the stomach is removed okay now

there is no need to use a handle bag because it's perfectly closed and now

please again in intra-abdominal view because I'm going to close intra

abdominal view okay now I am closing the defect with a resorbable material this

is a PDS that is passed through the muscular wall with fascia closure this

This is also a Stuart's instrument that I'm happy with.

And now, after this crossing stitch,

I am now reintroducing the trocar.

And I am prepared now to check the bleeding sources inside.

Good morning, Professor.

Good morning.

My name is Umberto Grande.

I have some questions for you.

Please.

Good morning.

My name is Umberto Grandi, and I just want to tell you that there are so many people attending this Congress and especially so many young surgeons that have been able to see your procedure that it looks like it has been simple, but it's not.

I'm really sure that your experience gave us this opportunity to see such a wonderful procedure.

Thank you.

No problem.

the the question is do you reserve this procedure to which kind of patient I mean this is 42 of BMI

this patient and what about malabsorptive procedures what are you performing and in

which kind of patients malabsorptive procedures if you refer to BPD or BPD DS in our center

dedicated for the patients who are classified here with BMI over 50 but

anyway being a suffers supper obese as a first step of the procedure we do

perform initially a gastric sleeve and after one year or two years we do a

perform the second step, which is BPD-DS.

This is our routine attitude,

and this is adding much more safe for very difficult and very complicated patients.

So part of the patients who are candidates for gastric sleeve

will remain with a sleeve resection because it's efficient as a solid procedure and these are

patients with BMI under 40 for other patients is necessary in about 50% of the cases to switch to

the next step in the next three in the next five years which neck which second

step is BPD DS or gastric bypass this is our attitude perfect professor this

now because we have so many young surgeons attending the audience and so I

I just wanted to ask your ideas about that.

Okay, I welcome and I'm happy that they are present here to watch this procedure.

Now, it is very interesting to say from my experience

that an important number of the patients developed in the first postoperative day complications like bleeding.

and despite of using any kind of buttress materials I noticed that that

bleedings occurred so I was worried about this complication and we addressed

to our team question what to do and the answer was probably as we end any

procedure without any bleeding as you can see there is no blooding active

bleeding source on the stepper line at this moment probably in the very

afternoon of the day of surgery the blood pressure increases so much as a bleeding

source will occur and this will be the explanation for the post-operative bleeding complication and

what we started to do two years ago and we do routinely the same we rise up with the help of

neosynephrine we rise up the blood pressure inside of the procedure during

the same anesthesia and we check the stepper line at higher level of the

blood pressure if you check it at 100 millimeters of HD is G this is no

reason to worry about but if we check at 170 now we have 170 we can see that a

bleeding source is going to come here please stay with me then you will see

that about rising up the blood pressure other sources will be observed sometimes

the checking of the stepper line is longer than the procedure itself actually

the procedure was about 20 minutes up to now but now I am very very patient I'm

very delicate with all the possible bleeding sources because they will bleed

in the afternoon and we have to reoperate the patient without without a

pleasure of course we don't intend this to reoperate the same patient we want to

reopen to operate another patients not the same one many times now you see we

have now the blood pressure of 180 and I suppose this will be the final test you

see still we have here a bleeding source and I'm gonna close with a medium-large

titanium clips and I'm controlling the bleeding before occurring post-operative

bleeding complication and with this procedure I can tell you that in the

last three years we had a significant decrease of the bleeding complications

in the first post-operative days which is very very important we may discharge

the patients after two hospital days now okay I'm gonna place intraperitoneal

drainage tube of 14 French this is going to be introduced here and placed

laterally to the stepper line the fire okay again we check about the stepper

line we do not oversee you routinely the stepper line because this is going to

reduce the blood sources the the blood going to the and going feeding up the stepper line i want

another clip here please a medium large clip okay i think i need something to clean up the space

like in open surgery we may clean up here please go up please go up and check

if anything is going to this is a great advantage of laparoscopic surgery because we have a lot of

eyes checking about the quality of the procedure in our or and hopefully in the room where you

attend this very important event so again checking checking checking if any

bleeding source is going to be active again up up up up possible here I am

noticed by my aide nobody will accept even a small bleeding source to remain

active and just immediately after the operation drugs being active of

decreasing the blood pressure are introduced because obesity is associated

with increased blood pressure as all you know now as the procedure is finished I

I am removing the elevator from below of the liver lobe.

This flexible liver retractor is retracted.

Now we are checking any access in order to verify if any bleeding is active on that side.

destroyed these brokers from covidian and from other companies without a metal blade are very

safe from this point of view sorry yes okay yes please it's not a little bleeding on the spleen

no just to see yes no okay it's it's a it was something that we were worried about at one point

when when my aide pulled down the stomach and there is a risk of injuring the spleen

superficially and if this occur placing sponge of paco seal will be enough but this is an injector

This is not a bleeding source.

You can see very well.

Yes?

Okay.

It was something that was attracting me a few minutes ago, and I checked.

I take the opportunity of again checking the bleeding line.

Sorry for being so, so patient with these sources.

I don't want any complication postoperatively.

and now again to the axis from where the stomach was explanted and as the stitch

was placed already I'm closing it now and the cameraman is checking about the

quality of the hemostasis at this point and we have another two truckers to

to explain.

Professor Copescu?

Yes, please.

You have in schedule another procedure or just this one?

Yes, we do have two other procedures.

One will be with Ethicon G&G with Echelon stapling

and another one with Colgene.

Excuse me.

In how many time?

uh in about one hour we can be connected again live okay so we we will call you again in one hour

okay thank you very much if you collect on other questions i'm happy to answer to them

okay okay the professor palazzini says thank you very much and also a lot of

people appreciate by internet view your surgical procedure thank you very much

professor Palazzini for this kindly invitation I'll be all the time ready to

join your very very interesting event and wish to all the participants great

success in this very important international conference thank you very

Thank you very much.

Bene azzivenit.

Ciao.

See you later.

Ciao.

See you later.

Ciao.