SPAGNA sleeve gastrectomy and bypass

For the first time we've been working with you and I wish you a good success every year.

Thank you very much. Thanks.

I think we have the patient ready and I think we will start making, starting with the pneumo-peritoneum in five minutes.

because so in five minutes we will start with the surgical field ready to start with the surgery, okay?

This patient is 47 years old.

with a BMI of 54.2, this is a really big patient, it's 162 kg and 132 kg, so it's around 45 BMI,

And the patient came to us for a valentic surgery and inside of a protocol we performed

both.

We performed a fleet gastrectomy and gastric bypass.

But this patient is a patient with, when we start, she doesn't have an active reflux

in terms of symptomatic, very symptomatic reflux.

But the patient, in the preoperative workflow,

she showed to have in the body and swallow,

she showed a small hiatal hernia with an important reflux.

So we have performed this patient an endometry and a pH

The pH metric and the pH metric show to have an important reflux, and the manometry show

a decrease of the pressure of the layerless filter and an important reflux in the pH metric.

So we have performed the pHmetry, and then we have performed a gastroscopy.

There is no esophagitis, but the patient has this reflux with a cooperative workflow of important reflux.

So in this patient, what we're doing is to perform a standard bypass, a standard sclerotic gastrectomy,

and this is one of the important first decision.

We should go in this patient for a gastric bypass

or a sleeve gastrectomy.

So in this patient that we're doing now,

we're running on a study in which we're doing

a sleeve gastrectomy because the patient doesn't have

esophagitis and doesn't have important symptoms.

And we are doing in this patient a sleeve gastrectomy

with closing the crura and placing a mesh in the crura,

and so far with the number of patients we have,

we are having really good results.

So of course, this is the first discussion in terms

that people will decide what to do.

What to do, a gastric bypass directly,

or a sleep gastrectomy the way we are doing it.

Now, she doesn't have comorbidity in terms of hypertension

or diabetes.

This is another discussion.

what to do in case the patient has diabetes, but she doesn't have any diabetes.

So, in all cases, we're doing...

In these cases, what I'm doing is always is to do a

memobritoneum in all the other patients using the various needles.

We are from a school with various needles,

And as you see here, we introduce the breast needle in the left upper quadrant.

So as you see, we check the test, and we start doing the pneumo-peritoneum.

We start doing the pneumo-peritoneum, and we use 50 millimeter of mercury, and normally

in all our biotic patients.

So, one of the things that we decide, like almost more than one year ago,

low 50 BMI, we do a gastro bypass on the patient with BMI more than 50, we perform a sleep

gastrectomy. And also on the other side, our patients, adolescents less than 20 years old

and more than 45, 55 years old, we also do a sleep gastrectomy. So we decide why not

to do a sleep gastrectomy in the patients with reflux because in the literature what

what they say is to do a gastric bypass in this patient.

So we decided to start a protocol

and perform a pH meter and manometry in this patient

just to do it in a scientific way.

And we're doing a sling gastrectomy,

but the variation will be to work on the cruda.

You will see that today the way we do it.

We're going to work as a standard position of the trochanter

for standard anti-rhythmic surgery.

surgery and you see that we are going to use a 55 mm for 30 degree optic so we will avoid

one uh one five millimeter uh one 10 millimeter trucker

i usually use four four ports

Perfect, so we are in.

Baja la mesa, ¿puedes bajar la mesa?

Okay.

How is the view of the internal?

Yeah, it's fine.

Yeah, it's fine.

Perfect.

So, let me just read.

I'm going to place a 12-millimeter trucker for my right hand, okay?

Sí.

Dile que deje de enseñar un momentito, dale, para que se vea la trucker que está...

La de techo, sí.

This is a 12-millimeter chocker.

Then I'm going to place up here a 5-millimeter chocker for the system,

help me to expose the surgical field.

Then to retract the lever, I'm going to place another 5-millimeter chocker in the epigastric.

That's going to retract the lever.

And then I'm going to place a 15mm choker, so I'm going to have a nice view.

Okay, I'm trying to get the best view for you, so I think you have a nice view, so we are going to work on the way we standardize the technique, you see this is the retractor, the lever retractor, you're going to retract the lever, Tony, Tony, so I'm going to go directly to the hiatus, what I'm going to do is start as a standard sleeve,

What I usually do is go into the great curvature, looking for the, starting to go up to the hiatus.

You see I'm going to try to find the grease.

So here we are.

So I'm going to start working here.

I'm going to go close to the stomach.

So you see how the system is always, he will go getting the fatty tissue that is covering

the stomach in the greater curvature.

So I usually go like this and while I start coagulating the system go and get the fatty

tissue that is covering the stomach.

In this part of the area I go like very close to the, very close to the stomach.

I don't care, I don't worry about even having burned in the stomach because this is the part that is going to go out. So you see how I start coagulating the assistant and myself, same deposition to be ready for the next step.

You see one of the important things is how Maria Sotas and Antonio Barranco, who are the surgeons who assisted me, they really know how to, they are expert surgeons in this type of surgery and they really know the surgery and they know who want to move the instruments to do the surgery.

Now I'm changing my left hand to an extra long grasper.

This is important for bariatric surgery.

You need to have the extra long grasper.

We are going to go all the way through to expose the left cross.

It's important to expose the left cross to be able to work on the hiatus.

So the first step will go to go all the way to the greater curvature and then be able to expose the left cross.

Assistant, so once he exposed this area, okay, so now I can control the...

And one of the important things, one of the things of having the retractor to be a grasp

instead of a standard lever retractor is that it will usually assist you to do this triangle.

And then you will push here.

Then I will move to the posterior part.

out so and then we will open and making this triangle you see i'm pushing down the system

is pushing here and the other grasp is pushing here so it's easier easier and safe to get through

the um to the short gastric vessel by this position you can control also from here

all the adhesions of the posterior part.

So you see now that we are getting to the hiatus.

The Varian Swallow, what it shows is that we have a patient with a small hiatal hernia,

are less than three centimeters but the balloon swallows talk about the of having an important

and very important uh uh reflux of volume through the hiatus so i'm gonna work down to be able to

observe the lower part of the left cross so as much as you dissect here as easy will will be

to go later on from the other side.

Does the patient have already a nasogastric tube or not yet?

Now what we have is a standard nasogastric tube

that we will just place to decrease

the insufflation in the stomach. So it's only

so far there is no extra tube

So now we are going to work over here, so now there will be, you see, we are going to

work, you see here, the level of caudato, here is the cava, the vena cava, and then

here we have the right cross, the vena cava, and here we have the right cross, so we are

The tissue here, we have the gulf finger, not the gulf finger, not the gulf finger, the separator and the flex.

So you see here, now we start working on the right cross.

Are you going to identify the left vagus?

The vagus, we don't identify the vagus in a standard procedure of anti-reflex surgery.

We know where they are, and I think the posterior babus nerve usually tells you where you have

to go to dissect the hiatus, but normally we don't look for it.

So you see I'm going down to the right cross, so this part is already done, and on the other

side you now have the dissection of the other side.

You see how the esophagus here, everything is dissected through the other side.

Here is the esophagus. I'm going to work a little bit on the posterior, on the anterior.

So one of the things, or the question that we have at the beginning is where to start from.

We start placing the mesh, doing the sleeve, and what we have learned that the best way to do the surgery...

is to first start in the greater curvature,

then go to the esophagus,

the third esophagus, place the mesh,

close the cruda, and then end up with a surgery

doing the sleeve gastrectomy.

This is something that we have standardized

after doing different cases.

How many cases, by the way,

you've done in this way?

How many cases, by the way,

you've done in this way?

We've done more cases, but cases in which we have the cases with pH metering and manometry

before and after, that inside the protocol, we have done so far five cases.

Now we are going to introduce...

No, no, no.

One would say it's a goldfinger.

Goldfinger nodule.

endoflex to retract the esophagus. So now we are going to do one of the important

step of antireflex surgery is to have the enough stomach, enough length of esophagus in the abdominal

so we really want to increase the length of the esophagus.

So we want to have a medial spinal dissection

to guarantee that the esophagus,

the lower sphincter is under the pressure,

the intraduminal pressure.

So because one of the thing of the, I think.

Is this stage proper to get the left pleura?

To get the left pleura? The left pleura is right here.

No, the pleura.

No, the pleura.

Ah, the pleura. Well, the pleura is there.

We can see the pleura back here.

Sometimes if you have a hole in the pleura, even there are some surgeons who say that

you don't need to do anything, but some prefer to close it, but there is no problem with

that.

So you see how we are getting through the esophagus to have a good megasternal dissection.

I really am more and more doing a dissection of the last part of the esophagus to have

have an important length of esophagus and to guarantee that the new sphincter is going

to be exposed to the intra-dominal pressure and to guarantee to avoid that slippage of

the lower sphincter through the mediastinum.

So here is the spleen on the other side.

Here is the…

Oh, I'm sorry.

The only thing is that we don't measure that.

We try to standardize the technique.

We don't want to introduce a rule to measure what is the length.

I think what we want is to have as much as we can.

And you see that we have an important length of esophagus.

So, the esophageal junction, I think, is here.

So, if we increase the traction now, you see how the esophageal junction is going to be exposed to the interdominal pressure.

Okay?

There is no traction there.

So, we have increased from the original position.

Without traction, we have increased.

This is 3 centimeters.

So, we have increased 3 centimeters the length.

Okay?

Let me give you 5 minutes.

we're going to, not 5 minutes, no, 30 seconds, we want to close to have a better view. So you see how

it's a very obese patient. I'm going to increase, I'm going to clean, let's say clean, I think this

is important, see we are going to place a mesh, it's important to clean all this tissue around

here to guarantee a good exposition and closure of the cradle and to be able to place the mesh

properly, it's not just placing the mesh, it's preparing the, let's say, the landing

zone of the mesh over the cruda. So, you see how we have to clean all this. So, you will

say, well, do you really need to close the cruda? Well, what we have in the

preparative test is that there is a hernia. What that is, is I'm not going to place a permanent mesh, I'm going to place an

absorbable mesh to guarantee that close properly and another thing will be is that it's so important

to do these two things clean the courier close the courier and have an important mediastinum

intra mediastinum dissection of the esophageal junction i'm going to increase the length if i

sometimes the system tell me stop, please stop,

because I keep going and going and going,

but I want to do the best surgery for the patient,

this, I'm guaranteed that this surgery works.

So maybe I increase the length every month.

Remember that the obese patients are difficult patients,

Are they also supported in the workup by psychiatrists or by psychologists?

Yeah, of course. We follow a stand-up protocol in terms of being analyzed by the psychiatrists and the endocrinologists of our hospital,

and they control them even in the post-operative, those patients who need any follow-up.

All the patients are followed up by surgery and by surgeons and endocrinologists, and the psychiatrists just follow those complicated patients. Let's take that. So we have here the crura. We have, another thing is that we preserve the perineal of the crura, you see. So to guarantee a proper closure, we try to respect this tissue and not to open it and expose the fiber of the muscle.

So we're going to close the cruda with a mesh.

Excellent dissection problem.

Excellent dissection problem.

To dissect the cruda in the patients, you know, this patient is very difficult.

So to have a barrier dissection, the good thing is to start dissecting all the greater curvature,

and this is the best way to expose this area, okay?

I'm using endo-stitch as it is a great suturing device for the cruda.

I think I'm going to close the cruda with two stitches.

So, second stitch. We use a lot of large herniated hernia.

We use, in those cases in which we have a large hernia, we use permanent meshes.

In those cases in which there is a small hernia, I use an absorbable mesh.

I think there is a nice and important discussion about what type of mesh to be used depending

on the case and in the future there will be with these new absorbable meshes there will

be a good discussion because we have increased the number of meshes since we have now in

the market available these absorbable meshes.

So, I mean, I think there is territory for absorbable meshes and for permanent meshes.

You said that you're using the absorbable one?

I'm going to use in these cases in which we don't have an important opening of the hiatus,

we use absorbable mesh.

I think you don't need to use in those cases a permanent mesh.

So only in the very, very large hiatal hernias, in those cases, we use the permanent ones.

And I think another important issue, in my opinion, is the way to fix the meshes.

I think it's important. I'm going to explain to you my theory about how to fix the mesh and my experience.

So here, so you see that is close already, you see this distance is 3 cm, so there will

be 4 cm the length of the esophagus, you see that the release tension, the esophagus is

going to, this is the standard position, you see how we decrease 3 cm the esophageal junction

that was here and without traction, the mesh, the software will cover all the openings.

So, don't place another stitch because if you release tension, that is the proper position

of the software, you will have a dysphagia posteriorly, okay?

This effect is the main problem with the post-operative dysphagia.

It's better not to close the exposure.

That's right.

The exposure is an example.

Where is the technician?

Miguel.

The mesh.

The machine is outside.

I'm going to show you the type of mesh I'm going to use.

So, this is the mesh that we have.

It's going to be absorbable.

This is the bioarray.

I'm going to place the mesh in this position. In my opinion, some surgeons tell me that this

is difficult to place. It's difficult to place because they don't trim it, and I think it's

important to trim it. You see this is a four centimeter, so I need like around five and a

half, I'm sorry, three and a half, more or less. So this is where I'm going to go. So I'm going

going to leave it this way, and this is the position of my mesh. So it's important to

place some sign to guarantee where we are, to know where we are. So this is going to

be the middle line, the middle area.

What material is that though?

What kind of material?

DOA is an absorbable material, and you will see that the composition will be like the

the standard Maxon that we use for suturing. So I'm going to place one stitch here, one stitch here

and then just to fix the mesh and I don't use tackers, I don't, my recommendation is to use

tacker in the hiatus and I place one stitch to stabilize the mesh and then I fix it with

fibrin glue. Thing is very important to know that because at the beginning I used to use tackers

long time ago, and even a mesh close to the esophagus and placing tucker, the mesh

can go through the father of the esophagus and have a migration. I have a

migration of a mesh in the esophagus and you could see the mesh and the tucker

inside the stomach. So I think it's important not to get the esophagus in

contact with the mesh and the best way to avoid the esophagus in contact with the mesh is

first using an adsorbable mesh and second is to cover in this area with fibrin glue. So the

sulfurous it will lie over not over the mesh it will lie over the fibrin glue and the fibrin glue

in 15 days it will transform into natural tissue because it will be there will be fibroblast and

at the base of the cross that stitch on the cross is it below the lowest yeah it's as

then I will position the mesh, okay?

Déjame un clinch.

Queda corto también este.

Would you also to mark the mesh

in case it twists and take back to the normal or correct position?

That's right, I think it's important to mark the mesh.

That's very important.

A ver si hay otra pinza larga, es que no llego.

Déjame un clic en esto que no es largo.

Okay, so you see how the mesh covers the hiatus.

Okay, just to guarantee a little .

So the mesh is stabilized, and I will need the extra stitch.

Are you going to put the glue?

So, you see how you think, well, how are you fixing the mesh? The mesh fix by itself. It

gets stuck in the area. So, what I'm doing is just guarantee covering the mesh with the

So by covering the mesh with the fibroblast you guarantee that the process of all the fibroblasts go through the mesh and you will have a good enough tissue covering the mesh since the glue will transform in natural tissue in 15 days.

okay that's that's what I think that's important thing is that now it looks

like more natural so do we have something that we have saved into a

natural tissue and below you have this glue that this mesh table also we have

salt and it will transform into a natural tissue, so you will have a natural hiatus.

What I have is, when I was using the standard meshes, one of the things is to try, I have

a migration of one mesh into the esophagus. So you see now it looks like natural tissue. So

I'm going to stop now. The hiatus will go back there. We have finished this part. We are going

to go back so now we can see here how the hiatus is done so how the esophageal

junction is going to be below the hiatus how we have natural tissue a bio covering

by filtering glue and then it's time to remove this and we are going to continue

continue doing the split gastrectomy okay so in the clinch

so now i'm going to go to look i'm going to go to the pillows i'm going to try to

I'm going to start doing the standard sleeve gastrectomy.

So we, in our group, we use a distance from the pillars

of around four to five centimeter,

and we use the torture of the,

that we use when introducing the stomach is of 40 French.

We have performed a retrospective analysis of our results

because two other surgeons of our group were doing the sleeve gastrectomy with a 58 and the other two surgeons were using a 40 degrees.

It's been said that there was a difference in computation regarding the tooth in terms of if you have a smaller tooth,

you will have more intraluminal pressure and no potential complication.

But there is no difference and what we have is that there is some more

loss of weight of our patient when using a 40 French bougie, okay?

So here's the pillows, you see here.

And so this is three centimeter, okay?

And this here will be around four and five.

So we are in the place.

So what I'm going to do, prepare the probe, Igari.

To clean, I think it's important to make an exam,

an examination of tissues that the patient

to have here to avoid twisted because if you have this uh adhesion it will twist like while doing

you see here so it's important because you have this is here um it will be a perfect entrance of

the boujee and it will twist so it's important to clean all the adhesions here to avoid a twist

So I'm going to control the potential of lesions. You see here, these lesions here to the pancreas, so you can control.

to introduce the bridging, and as I told you in our series, we have more workload with

a bridging of 40 than with a bridging of 58 with the same rate of complication, okay?

How many kilos are they going to lose and in how long?

Sorry?

I don't understand you.

How many kilos?

The weight they're going to reduce.

Yeah, we have a 67% of excess weight lost of these patients with a sleeve gastrectomy

in our series.

So if we compare our series of bypass and sleeve gastrectomy, so if we compare our series,

we can say that it's mostly not much difference between the patients with a sleeve and bypass.

We have extra, more weight loss with bypass than with sleeve, but we are happy with the patient

with sleeve, especially because we are doing this technique in those patients with higher BMI,

Okay, so we're going to see how the bougie goes into the esophagus.

So you see how it goes through the...

It's coming down now, yeah.

So you see how we call it the maneuver of the socks.

Continue.

Placing the socks in the...

Okay.

So...

So, I'm going to use a black cartridge covered in balsamico.

So I like to use the black cartridge in all operations, in the first and second.

So you remember that we are here, here we weigh in four centimeters, so it's between

four and five.

I don't like to introduce too much.

You see the bougie is here. I don't like to introduce all the very different catches because

I don't want two directions, this direction and this direction, because you will have an

asthenosis here. So I guess Mark, let's say. And regarding the single, I prefer to use single

Because two reasons. First is the bleeding, of course. We have less bleeding by using Zynga.

We have a study that we want to publish of using Zynga even in bypass, in the last two cartridges of the bypass,

and we have less content of blood in the drains, in the ductal, in which we used to use drain.

we didn't use drain anymore you see now uh and then the singer beside of having um

you see here the bougie i don't have to over suture i don't like other suturing

the sleeve and the reason is because you will take longer and you chain i'm pretty sure that

by just changing the size of the, of the,

si, seguimos, ponemos una negra?

Si, dame una negra, dame una negra mas.

We like, we don't like overshooting

because by overshooting the size,

uniform size of the, of the, of the sleeve,

it will take longer also.

So you will see here the bougie is here.

I'm using, since it's a very, this patient almost,

I'm going to use a third black cartridge.

I think black cartridges in this type of surgery really is an advance because it will give

you the possibilities and I remember in the hour before of having the green cartridge

in which we have really difficulties and it was very tough to go through all the way.

So I think black cartridges are really an important improve in this type of surgery.

And so I usually use two black cartridges in any sleeve and in super obese patients I use three or four black cartridges to start the surgery.

Okay, so in this case I just check the two and when I start not using the black is when I don't have resistance while going through the stomach.

up uh is the good point that you made that for the first you see here we control the poster

for the first cartridge is a very good point

so it's going to go to the other cottage with the triple one that it will be and in case of using

the etched and i will use the the the gold one as you see we have a big great scope nurse she's very

fast because for surgeons like me to stop until they change the cartridge is

really make me nervous so this is the good thing of having a great scrap nerve

okay we are controlling that so you see now that I don't have resistance that I

used to have before so that's the important thing of using the black cartridges even there are

surgeons who use um we use a black cartridge all the way with single and you see how it doesn't

bleed at all and that's one of the important issue of this uh single

and now we're going to analyze another important thing of this surgery so now you see here that

the system is going to grab the posterior side and this is one of the important things what to do

with this pad of tissue here of the fat pad here so i usually what i do

And since I don't want, I would like to go all the way through this fat part, I usually,

especially when there is a hiatal hernia, I remove a little bit of this tissue.

And especially if the patient has a hiatal hernia, the amount of tissue, this,

and I prefer to move it that way, okay?

And then it will cover the, what is being said, the more dangerous part of this surgery, okay?

So you see that this fatty tissue will be in the middle of the cartilage that we don't

remove it.

So let's see if we need an extra.

So this is always the question of what to do since there is no tissue in the middle.

I prefer to use a 45.

Looks like there is no plastic wall here.

Well, it looks like that, you know.

What I'm going to use is to cut that part with a 45 without sink guard.

I'm pretty sure that there is nothing, but, you know.

I want to have a nice weekend.

Yes, we also want to sleep tight.

You know that the company did this on purpose to sell a little bit more.

We won't tell this to the superintendent.

We won't tell this to the superintendent.

Okay.

Now we are going to have an overview.

You see the nice sleeve.

And if you go up here, you see how the gastroesophageal junction is five centimeters away from the hiatus.

And how there is like a new wall here with this bio-layer mesh that we're going to reabsorb.

It's totally, there is a good movement, it's not close enough, and we're going to have nice, good tissue, natural tissue here because of the fibrin glue and because of the cellular mesh.

So we're going to ask the anesthesiologist to remove the bougie.

and we are, as always, we control with methane in blue.

I think it is important to have a direct control.

So, because sometimes the pressure of the Bougie

make amostasia, so it's good to control.

So it's to control the amostasis, the amostasia.

Now we are going to ask him the necessity to introduce the Fibroin Blue, the Methylene

Blue.

Sorry.

We are going to, I'm not going to place a drain.

I don't place drain in a sleeve gastrectomy and either in the very, very difficult cases

and in the redo.

So I'm going to make a pressure here.

And it's important to see how the Methylene Blue go all the way.

So you will see that there is a nice, it goes perfectly down. So there is no structure and there is no twist. Perfecto. And you see here where the pillars is 60. So you see, so they filled with 60. So you see very small pouch.

You see here the distance, there is no bleeding thanks to the technique and the method and

the syndrome.

And the way we remove the stomach is we always grab one of the corners with this, you see,

with the endolip so we know when we pull this part will come there's an extra long part

and then i always remove the stomach i'm going to show you different things how to remove the

stomach and then how to close the troca i think it's important always in the back

So now the good thing of having the angel loop is that I have, you see how the part

of the stomach that is coming, that's where I want.

So I'm going to use two, where I pull, I pull from the greater curvature, okay, inside.

Let me show you the piece, the camera, let's see.

Let me show you the camera for a moment.

You see here, I'm going to remove it.

And here, sorry, it's dirty.

No, what we're going to do now, I'm going to show you.

So we are going to check that there is no bleeding and the way to close the chocker,

so there is no bleeding there. You see how with the standard position, this is the junction,

so for the GI junction, we are going to check. The way we control the trucker is we check this

trucker in, we check this trucker in, we check this 12-millimeter trucker. This trucker, we are

we are going to close it. And for the 15 millimeter trocar, we use a prophylactic mesh to close

how we close it with this prophylactic patch. So because avoiding the stitch here, the good

thing is that you will have less pain so the reason is to avoid hernia chocker and to avoid

pain the reason why we use this plaque here okay so we are done are we going to feed start feeding

What we're doing in this patient is the patient will go home in two, three days, okay?

And they start with clean liquid tomorrow morning and they go home with 15 days of liquid

and then we start with a mash diet during another 15 days.

In a month, we do a body and swallow,

and this patient who is included in a protocol,

we do a body and swallow one month after surgery

to see how the sleeve is,

and then we also do a body and swallow one year after

just to control and to see why the patient,

if there is no proper weight loss, what had happened, okay?

Excellent, Prof.

Congratulations and compliments from the audition.

Congratulations.

Confidence.

Platinous.

Procedure.

Procedure.

And you made us enjoy it.

You did very much.

And the team, of course.

Thanks very much.

And your assistance.

And the team, of course.

And your assistance.

So thank you very much.

Professor Palazzini and to all the coming organization committee thanks to

all the invited and all the assistant in the Congress and of course I have to

say Antonio Maria who is a great surgeon they you know they know how to assist

the surgery and all the team here and the sociology and the scrub nurse and

all the team that make this possible and it's been a pleasure to be in contact

talk with you and to participate in your Congress.

On behalf of Professor Palazzini again, thank you.

I hope to see you in Rome one day.

Hasta la vista.

Sure. Hasta luego, hasta la vista.

Hasta la vista, yes.

Gracias.

Thank you.

Ciao.