C. COPAESCU Sleeve resection

do you have a video signal from us yes good morning good morning thank you very

much and morning again with a new procedure of sleeve rejection we are

prepared to demonstrate do you have video signal from us

Okay, and the sound, it's okay for you?

The sound is okay.

Okay.

We started to free the greater curvature

because we were not able to connect with you,

so we did some steps of the operation, not too much,

only with ligature from the middle of the stomach to the pylorus.

We cut all the vessels that are addressed to the greater curvature of the stomach.

And now we go on towards the left pillar with ligature at last.

We are going up, staying close to the stomach in order to free all the great curvature of the stomach.

We have here a male, in this case, with BMI 34 and with diabetes mellitus on medication.

Please follow me with the camera.

Follow me up.

Follow me up.

Instead of the BMI, there is obesity with the central determination.

It's the central obesity.

with the metabolic syndrome,

and these cases do fit very well with metabolic surgery.

And the indication was not only obesity,

but the metabolic syndrome and diabetes mellitus.

And from our experience, even the BMI is below 35, even we are discussed about gastric sleeve, the remission of the diabetes mellitus, it's very, very good.

Go up with me.

Please go up with me.

Now we want to cut the last gastric vessels.

Let's see behind, we have to start from this point in order to free the posterior aspect

of the stomach, a little bit far from the superior pole of the spleen.

Come up with me, we have to make some space here, seems that the 10 millimeters instrument

again another one here please rotate a little bit okay now it's a little bit

better please pull a little bit the stomach just one second it's a big

stomach with a thick wall okay we have to open the space with the aid of a

forceps introduced through the left quadrant and now I am lifting up the

The posterior aspect of the stomach,

please come with me.

Okay, thank you, this is better.

This is better, okay.

Just be patient here, okay, again.

between the stomach, right?

there are very short adherences

and the space is here very narrow.

and there is a potential risk of injuring the spleen or leaving too much part of the stomach

here above laterally to the angle of his and this redundant stomach will limit very much the

the weight loss process okay this is supposed to be the last movement before seeing the left

this is the left cruise and now i am continuing with the energy instrument far from the esophagus

far from the stomach in order to prevent the thermal injury to occur here okay step by step

the final part of the gastric fundus is freed okay we check all the time about

hiatal hernia and if there is a space here around the esophagus even small hiatal hernia we close

it up with several stitches okay and we are about to finalize the posterior freeing of the last part

part of the gastric fundus, okay?

I hope you see very well the left pillar.

Here is the stomach.

Just let me grasp the stomach here

and let me cut a little bit here

just to see the left pillar.

The esophagus is behind.

There is a small fat here,

here, but no hernia I can see here.

No hernia.

Okay, leave it free, okay?

We put the stomach in normal position

in order to appreciate where will be the line.

The line will be through here.

There is not an obligativity to dissect too much this area

because you may injury with the electric instrument

the esophagus we will introduce a Bougie of 36 French 36 French will be the Bougie

okay and then now I am asking the cameraman to enter through the through

the other optical troca which is placed close to umbilicus we have two optical

trochers in order to see from two different perspectives the organs we are

going to treat dissect cut so on so give me now do it I'm using endogea do it

okay I'm gonna start from two centimeters from the pylorus after the

The first firing, I will ask the anesthesiologist to introduce a bougie, but now I am concentrating

in the way of grasping the tissue with this stapler.

The stomach is sick, but thin enough to be cut with a blue cartridge, I think.

Sometimes I make mistakes in appreciating, but after closing the cartridge, I can feel if the staples will be formatted adequately or not, and this comes, of course, with experience.

I can tell you that this blue cartridge will be closed properly, but as this generation

of staplers do have an anvil which is very thin and flexible, I am closing better the

stapler in order to press the tissue for 15 seconds and to spill out all the

liquids that are inside of the tissue you have to dry the tissue yeah

providing providing that okay this is better good for mating of the staples

please give me a view okay did you try to to use other staplers yes I used all

kind of staplers okay but if you use green at this point will bleed but of

course sometimes you need green

etikon was the demonstration before was with echelon which is much more strong

instrument and may close better so in case that you are using endogea you

have to be patient with the instrument waiting in between moving the blade

several seconds like I'm doing now and here is the end of the firing let's see

what I did okay as I expected because it's not a thin tissue the internal row is not

adequately formatted but the other two are perfect so now I am introducing another stapler

and I am asking the anesthesiologist to push in the bougie,

the 36 French bougie, okay?

And I will guide the bougie to the pylorus.

Please, please come.

Please come.

Here is the bougie, okay?

Here is the bougie.

Please go in.

Please go in.

Very good.

okay okay thank you very much now the stapler is introduced also through the

right sided 12 millimeter troca and is manipulated by my left hand I am

checking how this second stapler is crossing the previous line how the

The stomach is contributing to the new gastric tube,

equal from posterior and equal from anterior, okay?

And when I am ready, I am firing.

This is a very important message.

It's very, very important, and I will show you later on

that it's necessary at the level of the angle of the stomach

to leave a little bit larger the stomach

because here will be a bented tube otherwise will be an obstruction now

let's check about how this staples were formatted this is better than in in the

previous firing because this tissue is much more adequate than at the antrum is

Why the angle here is going to be created?

And this is important.

I will show you at the end.

Because at this level, the gastric tube, the very narrow gastric tube, is going to be bented.

And if you respect the calibration tube along the way, here, the bented will obstruct the stomach.

In order to respect what I said before, to tailor the stomach with the equal participation

of the anterior and posterior aspect of the stomach, we check posterior all the time.

Okay.

Again, anterior.

Okay.

Please enter through the upper optical trochar, which is 15 millimeters above the umbilicus.

or but the image is not as we want clean up the camera in hot in heated serum saline I presume

that you do the same in order to heat up the camera now I am happy with this positioning

and I'm firing okay see there is a wide angle that is correspond with the

angle of stomach and after we will remove the calibration tube you will see

how important is that point now we go up towards the angle of his I'm okay let's

take out this non-well-formated stapler all the time we have to do this then i presume from the

anterior view that it's okay with my line is parallel with the small curvature but let me see

what is on the other side this is again a very important message to check all the time

the stomach the direction is not okay we have to reopen and to place the cartridge parallel

with the small curvature in order to obtain a uniform gastric tube okay okay and now i am firing

and I am preparing another duet covered with batter's material which is a sort of biocene

on a film from Covidien you know very well this product it's nice that we can have any time

on the surgical table a product ready to be fired okay remove this again the same

procedure towards the angle of this another one please a posterior view again

we reopen and replace in a proper position because otherwise remnant

stomach will remain too much, a redundant one on the top, okay? Now, let me check if the position

is what we intend to. We don't have to pull too much the stapler here because the tissue

will stuck at the in between the jaws and we may have misfiring so we have to

leave one millimeter here in order to let the tissue to go backwards or

upwards okay this is another one and probably this will be the last one we

We know very well that this duet is a slicing surface and about 10% of the length of the

stapler will be lost at any firing because, as I will demonstrate, the tissue will be

pushed forward by the internal mechanism.

mechanism now here should be a mistake if you are not looking very well there is a gap here

but they will not living like this that can be a mechanism for fistula because i am reopening

and okay we have here something that should be out stapler was not well formated this is the

a problem of duet come with me this this stitch is hanging the tissue okay so again i'm not happy

with the position okay a little bit backwards okay maybe you need another sometimes we need

please come here sometimes we need the aid of the other surgeon in order to be

sure that we cross properly from the previous line but anyway is not enough

this table we will need another one I am sure for this let's go and see here what

is happening as I am pushing the system you will see how the stomach is pushed

up you see you see and you lose about one centimeter with any firing another

one over do it please now we are about about to finish the

resection of the stomach and we do ask the anesthesiologist to rise up the

blood pressure in order to see if there is any bleeding source now the blood

pressure is 130 okay we leave few millimeters here in between the angle of

his and laterally here is the angle of his if you go to medial you get the

the esophagus in your stepper line and there is a potential important risk of fistula.

Now, I need the forceps, please.

Okay.

Okay.

Now, please remove, okay, the calibration tube.

Now we have to check if the stepper line is visible along the line

because sometimes if you tailor the stomach with the with unequal

contribution of the gastric wall then will be retracted anyway is going to be

retracted because stomach is very nervous you see this is the the angle I

told you about yeah please go forward to see it's another nasogastric tube you

see traveling inside of the stomach our anesthesiologist introduced it and now

we taste we test with Medellin blue please enter through the umbilical

optical trocar in order to have no no no we we need a clear image clean up the

the front lens sorry how many days does the tube the nasogastric tube stay 12 to 24 hours

until tomorrow we'll stay until tomorrow it was a time when we and the patient begins

the patient begins to drink tomorrow begins to drink tomorrow morning yes it's it's possible to

to swallow liquids even today if it's necessary.

But I am keeping the gastric tube there

in order to orientate the healing of the stomach.

It's not for other reasons

because, as I told you, the stomach is very nervous.

Please introduce the methylene blue with pressure

and with the stomach filled up with the liquid,

we check how it will behave when it will be filled.

And this is the angle I told you about,

because here the stomach is going to be bent.

You have to be very patient with this,

especially when you cut the antrum.

When you leave the antrum in place,

you can start from here, no matter about this angle.

but if you take out the antrum you have to do this now we have the pressure 140

waiting for a greater one we will remove in the meantime the specimen through the

right side the left sided 12 millimeter trocar and okay give me an outside view

please okay okay now we don't have an inside view we have only an outside view at this moment

slowly by feeling how the stomach let us to extract give me from inside please

okay as i told you this is a sick stomach okay that's very good that's very good and i want to

close this opening with the fascia closure it stores fascia closure that I

like very much it's a very solid instrument and easy to close access for

any operation not only in bariatric surgery now please give me again the

trocar I will introduce the trocar inside and we check for the bleeding

along the stepper line we will check any millimeters any millimeters of of the

stepper line please go up go up the blood pressure is still 140 we are

claiming a greater blood pressure now here seems that we start a little bit I'm gonna place titanium

clips and this is routinely we started this procedure two years ago and since that time

In the last 600 cases, we had a very important decrease of postoperative bleedings, very much, significant.

significant anyway out of our 1,500 clothes gastric sleeves we have a

percentage of reoperations of 1.2 percent for different reasons leaks or

bleedings and probably this is that we are very very we do care very very much

about the technical aspects sometimes checking the operation the stepper line is lasting more

than operation itself because we don't want to leave anything that will cause reoperation this

is impossible that anyway we want to limit that number we should be happy with the orientation of

of the stepper line, excepting this part

where the anterior wall retracted a little bit,

the stepper line, and this is the potential twist.

Even for this reason, it's better to leave the gastric tube

for about 24 hours after the operation.

So, we have 140, can we have more?

okay waiting for now we are waiting for a greater blood pressure value in order to check what will

happen in the afternoon when the patient will be will be nervous by staying in the ICU I'm joking

okay okay we have close to 160 and still there is no bleeding this is important

we know that biocene do not have any hemostatic properties it's only pressure

but it's good enough and it's looking very nice and is resorbable this is very

very important. We had the experience of several migrations of the non-resorbable

buttress material that we used, the peristrept dry, and the migration, the

intragastric migration was not nice with pain. We had an abscess outside of the

the stomach we used for bypass and we had the rejection of peristyle dry so sometimes

is not okay to use non-resorbable buttress material so we use all the time resorbable

buttress material we have 170 now and we declare satisfied about this blood pressure

Because immediately after the operation, the anesthesiologist will administrate drugs for decreasing constantly on an automatically syringe, constantly the blood pressure.

All the patients will get this medication to keep the blood pressure as much as possible in the normal values.

Now, we are removing the elevator that was fixed outside to the operating table.

It's a Cuscieri retractor, you know, and I remove it, and we are going to check any excess

port for the bleeding, and we close all the ports that are bigger than 12 and all the

ports that do bleed.

We use a Ternamion trocker for this epigastric port because this do not use any blade.

And here there is a potential bleeding area, so we use Ternamion.

Again, checking this one.

There is a bleeding here.

We will close it.

And here is the other optical trocker.

we check for the bleeding around the drainage tube it's silent okay is it

necessary to close here let me see no it was from the from the skin going in now

please show me how I'm gonna close with the state stitches stitch that I placed

10 minutes ago this is the 12 millimeter trocar enlarged a little bit with my

finger in order to pull out the specimen as you noticed and now okay we have the

building we're bleeding here let me see no it's not a bleeding let me see again

Here, laterally, no more bleeding here.

Okay, and we finalize the procedure.

Thank you very much for your attention.

If you have questions.

Compliments, we'll see you again, maybe next year.

Sorry?

We hope we'll see you again.

Okay, thank you very much.

Thank you very much.

Success.

Thank you.

Okay, best regards to the whole team of Professor Palazzini.

Thank you very much.

Okay, bye.