ADAMO

Radamo. Good morning. Buongiorno. Buongiorno. Can you hear us well? Absolutely yes. You prefer me

speaking Italian? No problem with that. It's okay in English. What are you going to show us today

from London? We have a laparoscopic sleeve gastrectomy for morbid obesity. Okay. Which is

a pretty straightforward procedure. The interesting bit is this lady had a previous

for laparotomies for Hartmann, reversal of Hartmann.

She leaked from the reversal of Hartmann,

and she now currently has two enterocutaneous fistulas

and a ileostomy.

So we're doing the procedure now so the coloethylguide

can sort her out her enterocutaneous fistula.

So the lower part of the abdomen is pretty much frozen,

as you can see.

And I use a 5-millimeter optical access with a 5-millimeter camera

camera to gain access to the so-called compartment and now we are setting out all the ports and

I'm going back to a 10mm camera because I managed to enter without any damage.

Prof, the audio is excellent but the video is a bit fussy.

Yes, we're going to move up to a proper camera shortly.

10 please.

Okay, thank you.

And that will give you a better view.

I love the 10mm camera please.

So I'm going to change a scope.

I use the 10-millimeter scope now, which gives us a much better view.

The lady, she's a 50-year-old lady with a body mass index of 49,

and she weighs 130 kilograms.

She suffers with asthma and sleep apnea, but not diabetes.

The endoscopic workup was normal?

We don't do routine endoscopies in proselytic gastrectomies,

which is a point of controversy, but in the United Kingdom many units don't do endoscopy

beforehand. But I do test all the specimens for H. pylori. Okay, let's go in and have

a look. So now we have a proper camera. Hopefully the video will be better. Hopefully. Sorry

for the poor quality. We had to use a 5mm scope, which wasn't great. Okay, let's clean

end up. Thank you. Let's move to the fetus camera. This is not really doing much. Can you see better

now from your side? A little bit better, but still not 100%. So we have extensive intra-abdominal

additions, especially in the infracolic compartment, as you can see, to the multiple surgeries that she

had. But we have a limited view for the reasonable view for the sleeve gastrectomy. So we're going to

start pretty soon now. At the moment I'm putting four ports, I can show it to you. So that's

the main camera port. We've got the two stapling ports there and then we've got accessory five

and I've not used the lever retractor yet because the lever has been held by additions.

Okay, I'm moving to a 30 degree camera which gives us a better view. Of course you could

argue that we are pushing probably the limits of laparoscopic access but um we always says yes

sometimes we regret it but this guy this time we were so excuse me do you mind to tell your

technician to remove the picture in picture view thank you on the top left side absolutely thank

Thank you.

Clean, please.

The camera is not cleaning.

Okay.

Oh, this is not working.

Get some more water, please.

Can we have another scope, please?

The scope is not working.

Actually, no.

The scope is fine, at least.

No worries.

Okay.

So, looks like we have a view, finally, of the inside of the patient.

Yeah, it is better, Prof.

Oh, it's decent.

I wouldn't call it great, but okay.

Hold the camera, please.

Can I have some head up, please?

Grasper, please?

So I'm putting the patient in the ante-tendellar book,

and then I start to see, that's enough, thank you,

and the patient's down a bit.

So the liver is held up by, that's fine, thanks, adhesions.

If you look down here, that should be the stomach,

and then that's saying caesura.

There will still be a few adhesions here,

which we have to clear before reaching the stomach.

So the first part of the procedure is just adhesiolysis,

and then we can go and do the proper Slig gastrectomy.

Keep the camera steady, Nick, please.

Okay, center the screen, please. Thank you.

So that's the incisor of the stomach.

That's where I normally would start the dissection

for my Slig gastrectomy.

Can we clean the camera again, please?

Clean it first before sticking in that finger.

Okay, out.

So the first thing to check is

to have enough clearance at the aedus,

and then that's the stomach,

slightly distorted because of the lesions,

and that's the aetus.

So we got good clearance of the aetus

so we can proceed to azelaic gastrectomy.

Come back, please.

So that's pretty much where the incisora is.

Look, follow me with the camera.

The camera port is slightly higher than normal

because of adhesions.

So that's where the pylorus is.

You see the side is distorted again because of adhesions.

That's where the pylorus is,

the first part of the duodenum.

That's the myovain.

Okay, let's go back.

So we started dissection roughly around here.

So the first part will be to access the lesser sac of the abdomen, that will give us a bit

more view of the stomach, which at the moment is not great, I have to say, I've seen better

stomachs than this.

Sorry, Prof, to disturb you, we still see the picture in picture, is it possible to

tell your technician to remove it on the top left hand side?

Oh yes.

Thank you.

it's not very pretty it's not very pretty inside but i guess that's what you want to see you don't

want to see me exactly i can possibly be on the inside i think it's still uh better than me not

the view no the news is uh fair okay now okay so that's the stomach uh distorted by the additions

so i'm trying to reach the greater curvature of the stomach and just so i can start dividing all

the vessels and progress the section so it's a difficult case as you can see um and it's a bit

tedious because of the additions but it's not a big deal that's the gastroepiploic vein you can

see the gastroepiploic vein going across the stomach there so we are um we are going to stay

very close to the stomach and because this part is going to be removed there is no any problem in

burning the stomach with the energy device. If any questions, please, I don't mind being

interrupted at all. No, no, no, not right now. We're following well. We appreciate the

difficulty because of the decisions. So if you come to proceed. No, it's okay. No, it's

fine. It's no major difficulties. It's just slightly more unpleasant than you would normally

aspect well for the expert surgeons as you are makes it well that's yet to be proven unfortunately

today so that's the lesser suck um which is not that free but it's better than anything

so now we started dissecting and progressing along the greater curvature so normally you do

need an accessory grasp you need just your your left hand with your grasper and the energy device

device, which in this case is the tandem.

We've lost you now.

So the operation is done with my left hand, really, not with my right hand.

So the use of the energy device is pretty blunt.

I just divide the vessels as they come along.

At this stage it's not dangerous.

When we approach the upper third, you have to be aware of the splenic artery,

of course, and the splenic vein.

At this stage, we shouldn't have any major vessels there.

so we can proceed quite quickly.

So hopefully the top part of the stomach, which is the difficult part, will be better.

You see now the opening here is much nicer.

We enter into virgin planes.

Show me this little loser there.

Okay, thank you.

Sorry, Prof, maybe we missed the very first part of the operative positioning.

Does the patient have an esogastric tube?

The patient at the moment has an osteoacoustic tube to decompress the stomach, and the legs

are split, and I'm sitting between the legs.

I'm standing between the legs of the patient.

Okay, in the finished position.

And then we have a position, so the patient heads up, and then I'm progressing

towards the hiatus.

Because there are retractions already on the liver, because of the additions, I'm not retracting

the liver yet.

See, the liver is standing there quite nicely, so I don't need to retract the liver.

otherwise I would replace a liver retractor okay camera straight please

like cable straight thank you so the first part of the section is done so now

approaching more carefully the upper fat of the stomach see there are additions

here but I don't take these additions away because actually they're holding

the momentum for me so it's one shot at the time you visualize what you have to

divide you divide it so one shot at a time sorry prophet a technical question

In case of a virgin abdomen, how would you address the left lobe of the liver?

Just retracting or mobilizing it and tilting down?

I would use an endoflex, a triangular liver retractor with a choker placed in the right upper quadrant of the patient.

So the retractor will come from the right and we lift the liver this way.

and I've got different sizes and shapes of retractors to address the different

types and shapes of livers. Okay can we clean the camera please? You clean the

camera first and you can then use the device. Sorry about that we just cleaned

the camera just to try to give you a slightly better picture.

Now we have the full screen because the picture is gone.

So we have now, we are approaching now the upper

preferred to the sleeve. That's why you have to be

slightly more careful because you can have

significant vessels

and also if you are not

comfortable doing this procedure, you shouldn't use the

active blade this way. You should do this this way

because if you're not careful

you can eat the

splenic vein which should be somewhere down

there. In this patient, there's

not really a big risk. In other patients,

it's quite prominent. So every time

I divide a vessel, I pull the stomach a bit

so I keep progressing following the greater

curvature. This is not difficult

to do that's why the sleeve is so popular nowadays because technically up to here is not difficult

the problem starts when you start dissecting around the itus so so far has been a walk in

the park apart from the additions of course show me that please start having a facial gastric there

so the technical point for the junior doctor is not for the experience agents when you divide

these vessels you don't apply any tension on the energy device so you maximize the

hemostasis so we nearly that's the spleen coming into view over there so we now start dividing the

spinal gastric ligament i'll use an accessory port now the ratchet one please trying to show the

field properly okay come there please with the camera thank you very much i'll delight this

place okay come down with the camera so it's important to divide the vessels that go to the

right but not the west they go to the left because you don't want to divide vessels going to the

the lesser curve.

So this is still going to this way, so we can divide this.

Of course, at this stage, I don't want to damage the stomach.

So I rotate the instruments a bit, so I will not damage the stomach.

Dividing this vessel will already start mobilizing a bit more.

So this one can go as well.

Now, we want to mobilize the posterior part of the fundus.

You see the fundus is coming into view now, the posterior part.

That was the common mistake in the early days of the gastrectomy.

This part of the stomach was left behind.

So you can see this vessel here, really, is in the way, has to go.

Probably posterior. That will free up all the stomach.

You can see the stomach coming into play here. It's quite nice.

And in fact, this is a crucial point for the success of this operation, technically talking.

So at this stage, what I will do is I will swap my accessory grasper

from holding some of the fat down to grabbing the top of the fundus and pushing it up.

up.

That's a quite important technical point.

So now I have the stomach all in front of me.

And I will dissect everything.

And I will add for the basis of the cruz, of the left cruz,

of course.

So come back a fraction, please, Nick,

so that these adhesions are distorting the stomach,

so they have to go, not the vessel behind that.

That's pretty much reasonable about this stage, I would say.

So what I'll do, I'll go to the top now, topless.

please. Nick, thank you. And any residual vessel will be divided. You can do blunt dissection

if you want, trying to feel the vessels rather than if you can't see them. Okay, that's pretty

much okay. Going to the diaphragm. Camera, please. So this is diaphragm. This is stomach.

The crux must be somewhere there. We have to find it. Come back, please. So the dissection

in the gastrectomy nowadays tends to be quite aggressive at the aedus. That's what has changed

in the last five years or the consensus is to be more and more aggressive okay at this stage

the view is not ideal so i will readjust my accessory grasper going towards the

the top of the fundus and come on straight please yes the angle of his do you address it all the

so now I need to release all these tissues there because they are holding

part of the stomach up okay light cables light on my right thank you I'm using a

30 degree scope of course that will give me a reasonable view so the bottom of

the cruise is there but the view is still not what I would like to see so

I'll clean the camera and allowed another look give it to me how many

cases do you perform like this? Well overall I think I've probably done

around five six hundred myself not that many I've been doing sleeves since 2000

2001 so it's well as all that the sleeve really but the technique has changed

during the years so the sleeves results shown in the early days are different

from the sleeve outcomes you get nowadays clean the camera again please

because it's that the reason the technique has refined and the devices are refined so the

zygostractor means mainly two things one is dissecting the aedus the cardias and two is

the way you do the stapling okay top please i'm not interested at the bottom please thank you

hold this up ratio please so with the proper retraction of the two graspers you can see

that the bottom of the cruise start becoming into view at this stage we feel if there's any

any significant atrial defect, which there isn't in this case.

If there is, that's the cruz there.

If there is, we'll do an atrial repair.

If there isn't, of course, there's no need.

So there's a bit of ligament here.

You can see this bit of ligament going from the cardia

to the sleeve.

And that's the muscle of the cruz.

Show me that, please.

Oh, sorry.

We dropped the accessory grasper.

Shame.

That was a good view.

Hold it.

Quick clean.

Quick clean.

in. Thank you. Okay. Come into the top, please. Clean again, please. It's very frustrating

when the camera doesn't really clean properly. We have state-of-the-art facilities, but sometimes

you get let down by these little things. Thank you. It's fine. It's fine. It's fine. It's

just going. The bubble will go. If you wipe it out, we'll get fogged. You see? We'll get

fogged. Sorry about that. That's the joys of laparoscopic surgery, unfortunately. Okay.

Okay, just a gentle wipe, it's fine, okay, go in.

Oh, wonderful.

So we go in quickly, and then the ligament is here.

I was just saying, we just divide this.

The reason for dividing this is you want to have a full view of the crux.

Make it steady with the camera, please.

You want to get all the GOJ, the gastrofagia juncture, to come down.

And if there's any hernia, of course, it has to be reduced.

If you leave any stomach above the diaphragm, that will result in reflux and poor weight loss.

it's fine so you can see now you can see pretty much all the left crews you can see this is

actually strand is going to the right so there's no need to be there so this dissected you can see

the white line of the where the georgia is the painting of reflection there okay so what we'll

do now uh come back with the camera please i will stretch the angle of this as i was going to do a

bypass so i will pull the fundus away if this gospel works thank you hold it please and i'll

go there with it i'll grab the the biggest fat part which is this one i'll probably move it

immediately coming with the camera in that corner i should have retracted delivery and then i'll

divide that now the view is not great so just in this way okay thank you okay show me that please

so you want to see the top the top of the of the items as well just to make sure you're not leaving

anything behind interesting looks like there is a bit of a how to say after all so i will put the

liver retractor now because i need to have a better exposure of the i just waiting to come out

liver tractor please any question guys no everything looks here we're just wondering

whether it's necessary to put a liver tractor yet or not well that's that's the question is because

Because if I want to see this corner properly,

I could probably compromise.

Let's see if I can have another go.

And I'll compromise a bit.

So because I can't see the corner here,

I just want to make sure that the view is actually proper.

Just a little bit.

So I can do something a bit not orthodox.

I'll pull the fundus medially.

I will stretch this corner here.

Come with the camera, please.

and then really i want to see what's happening here because that's something i was not expecting

to see this level of additions at this corner here that's the cruise there um that's probably okay

what do you think over there yeah the view is good i think you're doing very well prof

there's nothing more to ask at the moment okay okay so fine so we'll uh hold this place

question? So if you want to do any dissection of DOJ, like here, my advice is to dissect

against the cruz. So if you burn anything, you burn the perimetrium of the cruz. You

don't burn the esophagus. Pretty simple, isn't it? So that's cruz. That's DOJ. So I dissect

across that if I want to dissect more. I think that's enough. If you go into the muscles

muscles too much. The patient will have a bit of pain afterwards. So if we are satisfied

and the fundus is free, we lift the stomach up like this, so like a sheet, like an enswallow.

And we want to see that the back is all free. If the back is not free, you won't be able

to staple it properly. So you see, there's a little adhesions here, which is something

that might be worth clearing out now. It's all about releasing anything which is not

or lesser curve. See, that's now pretty free. And I can have a good view from that. And

you can see this bundle of fat here. Can you see this at the bottom of the cross?

Yes, yes, very well.

So one of the questions at the moment is, is this should be removed or not? Should it

be divided or not? Most of my colleagues don't touch it. I personally, most of the times,

divide it. There's usually a vein here. You can probably see the vein I'm playing with

at the moment. There is some question if you divide too much, you can create ischemia at

the top, which can lead to a leak. On the other hand, if you don't do enough, you leave

a large up fundus and then the sleeve is not going to work much. So in this case, this

vein here, the vein is going to the, over there, it's probably the cardiophrenic vein.

One of the surgeons I know called this vein Kate. I don't know why.

Why? I thought that was about the mask.

It's probably not a very nice girl.

I've asked the same question, but I have no answer.

You can see now very well the basis of the cruise.

Okay, that's where you want to see the base of the cruise.

So you can get your instruments down to touch the base of the cruise.

So it means your job is complete.

There is not any funnels left behind.

So now we can go back and then do a bit of dissection at the antrum level.

I normally dissect up to four or five centimetres from the pyloric valve all the

pressure we can open the stapler and oh you already opened it perfect and then

you start with a green cartridge so again all these additions have to be

cleared you see most of the additions can be cleared with blunt dissection you

don't need to use energy unless you go vessels there it's very nice doing a

blunt anatomical dissection yes they are very loose and easy to do blunt dissection

i guess if you if you were doing open surgery you probably would use your finger here if you

were allowed to use your finger um so that's a gentle you have to be gentle though if you are

too rough you cause bleeding if they are too big additions sometimes you can of course put a bit

of energy and you see now when I pull the stomach these additions are getting us not the proper view

of the lesser care which is down there so if we ought to leave this in place we would do incomplete

stapling of the stomach come back with the camera please you're too close thank you okay

what is right now the situation in UK concerning the morbid obesity has anything changed and

concerning the diet yes we have a situation where the government wants this most patients to go on a

let's say pre-op program over about 12 months they can demonstrate education and they can

demonstrate a commitment um there is no any evidence that makes the surgery any better

or makes the outcomes any better so now this lady didn't go through any educational phase

just standard multidisciplinary approaches in the dietitians, the

psychologists and the specialists. And one of the reasons for her to have surgery is

she can drop her comorbidity for having subsequently a colorectal procedure for

revision of her colonic fistula. So these additions have to be divided now.

At this stage you don't want to burn the stomach too much because you might

leave some of the stomach behind and bleed sometimes, as you can see. It's fine. So because

of all the additions, I would expect a bit of bleeding. I'm not particularly concerned

about that. The planes are slightly distorted. Okay, that's absolutely fine. So I'm freeing

up the antrum now. Okay. Man, in terms of bougie, I use the round end bougie. I use

the round end, not this one, the other one. Because the stomach is distorted, I will use

a round end bougie rather than a fine tip what size prof 32 is the tightest possible bougie

available 32. okay trying to solve this bleeding it's just annoying so you see these additions

here it has to be taken down otherwise you won't be able to staple the stomach correctly

it's a bit tedious but has to be done okay show me this one as well so careful when you do this

is not to bug the vessel going to the lesser curve.

So it's still going a bit away from the vessels.

Trying to catch these additions, really,

just to free up the stomach a bit more.

That's fine.

OK.

So the stomach is all free now, pretty much,

except this point, which is going down to the bottom

anyway.

So I think we can probably take it.

Hold it, please.

Don't pull it too hard, otherwise we'll.

so if I'm correct there should be no vessels here

because the vessel just that's a turning point

see there is a that's where additions

is so I can just divide it

sometimes I cool down the instruments

by touching the nearby fat

so just one second man for there

okay so that's fine that's reasonably

free if we go back to the

antrum now

don't go back into the port please Nick

you can see now it's all free

that's the pallor is around here

actually so what I do is

This will be the stapler.

So I need to have a safe landing for my stapler, which I have.

It's quite free.

So now I can start removing the orogastric tube first

and then putting a bougie in.

OK, orogastric tube out?

OK, so I put a 32 French bougie in now.

So I will lift the stomach so the anesthetist will find it easier to introduce it.

That's the bougie there.

Yeah, keep going.

Just one second.

Yeah, so the bougie will go as far.

Just one second.

It's fine.

It's perfect.

Perfect. So the bushing is in place and it's a solid bushing. So you can see, you can feel

it with the gasper. The bushing, if it's compressible, you won't be able to use it properly. So now

stapling. Stapling is a key part of this procedure and if you get it wrong, there is no way back.

You have to do a bypass, which in this case is impossible. So we can't do a bypass in

this case. Stapler, please. So I will use a green cartridge with reinforcement. I use

start at the satellite dissection. Thank you Nick. Any questions about

stapling before I start? No, just about how many cartridges do you think you're

going to need in this big stomach? Mostly it's three and a half to five, 60

millimeter cartridges. And always use the green one? Yes, I start with the green. I've got the

option of a black but it's a female patient so I would use a green. So I use

are a power directional stapler. So first thing to do is just to feed the gun into the

stomach, which at this stage, it's a bit tricky. As you can see that, it's not very easy to

do. So once you're in, I half close the gun so the bougie will not slip, and I start going

tighter to the bougie. I'll try to make sure that the dissection line lies in the middle

of the jaws. See that? It's pretty much in the middle of the jaws now. Okay? Try not

distort not to distort the stomach so at this stage what i'll do i will pull the anterior wall

against the bougie that's pretty much anterior wall once this is done i will flip the gun 90

degrees to expose the posterior wall you see how much posterior wall is left and i will do exactly

the same for the posterior whatever bougie you want to use the bougie is a caliper so you have

to be tied to the bougie you can use a 32 you can use a 40 you can use a 50 but you have to be tied

Correct. So now I will maximize or reduce the tension on the anterior wall because anterior

wall is the wall I can't see. So maximize on the posterior, then back to the anterior.

I'll make sure there's no folding. Everything is nice and straight. So it's fine. I can

probably pull a bit more there. So now seems to be reasonable. Stomach is quite thick.

Seems to be reasonable. So I'll now lock the gun and ask the anesthetist to wiggle the

the bougie, to make sure the bougie has not been caught in the staple line.

Wiggle, please. So this has two functions. One is we are sure the bougie has not been

caught. Thank you. And two, we're sure the bougie is not too tight. So now we can remove

the strings. Essential waiting time. So if you look every day, the instructions for use,

the of the gun, said you have to compress for at least 15 seconds in order

to have a proper staple line

that we squeeze out all the fluids

from the tissue, makes the staple line

thinner. The current agreement

we have with surgeons doing lots of

sleek gastrectomy like Michel Gagné

is to, for the first staple

in compression time, it can be up to

two minutes. So staple is

locked and we wait.

The two minutes time

that you correctly said

it is a rule

or it's due

to the thickness of the stomach wall it is a rule uh we can't really we can estimate the thickness

we can judge the thickness my judgment was a green cartridge with reinforcement would be enough for

this antrum but still i'm pushing it to the limit of the stapler so compression time will make sure

that we have as much a thin stomach as possible second technical point the cartridge is placed

underneath the stomach. So I can see the stapler being fired down up. So once the stapler line

is complete, I can check the closure of the staplers. Okay? Simple rules. So simple safety

checks. I think it's all right. Always looks longer. So I'll now fire it. I'm firing with

my left hand from the patient's right upper quadrant. So that's the first one. Now the

the staple is being reloaded I expect the staple line so inspection number one make sure there is

no any misfired separate at the top something that can block the blade that's fine inspection

number two is I will expect actually there the staple themself you can see that they are just

just closed you could hear there's not lots of staples that are not completely closed the staple

line, it is intact. But the green, they were just enough. So probably a black would have

been better in this case. That's fine. Staple line is complete. There is not much bleeding

through the staple line, but that will be addressed later on. So now we prepare for

the second firing. Second firing will be still a green because we are still close to the

antrum. So stomach, it is thicker at this stage. So same story. So gun straight, cartridge

down I grab the remnant now so I can open slightly the angle and I feel fit

all the gun in completely I've closed the gun so the bougie will remain on

this side and I will feed my weight room so anterior wall first see easy and then

flip the guy 90 degrees back wall is paused and then make sure that I will

remove the back wall so we'll not get included into the left behind it is really extremized

this technical yes because the important point is to stick basically to the bougie

especially in the posterior wall the stomach right i mean you the bougie again is a caliper

so you can choose your caliper size 30 to 40 but you have to stick to it if you don't

some days it will be larger, some days it will be tighter

then you don't have continuity

of outcomes, so

posterior wall done, so now I will

do it again on the

anterior wall to make sure it's

the way I feel happy with

and I lock the gun, bougie

please, again the anesthetist will

again wiggle the bougie

to make sure the bougie is

free and also that

is not too tight, and again

this firing is from my left

left hand, as you can see, from the patient right upper quadrant. For the following firing,

I will swap ports. I will use my right hand from the patient's left. So clearly at this

stage, while using my left hand, the maximum compression point is at the basis of the gun.

The loosest point is at the tip. When I change over from this side, it would be the other

round so that the tightest point would be at the tip, the loosest would be at the bottom.

And it's important to know these dynamics

because if you get it wrong, you might get a leak.

So the next staple will be this way.

So we're aiming to follow the natural curvature of the stomach.

I think that's enough, hopefully.

You can tell the stomach here is thinner

than the one we stapled earlier on

because if you look at the quality of the staple line,

the number of staples formed is far better than...

Look lower down, Nick.

Look lower down.

The other staple line is much better than, look down, please, than here.

It is still satisfactory, but it is not, in your regard, a pretty staple line.

You see, the staples are not very in line.

Look down, please.

They go all the way through it.

They close the stomach, but they're not perfectly closed.

So that's why in the zygostectomy, I've been reported some leaks at the bottom of the sleeve.

which is probably the incorrect cartridge or an incomplete staple line if you look down there's

a bit always a bit of a material left at the top of the staple line some staples misfired

always clear that otherwise the blade can impact and then they can't ruin the stable line it's

fine so we now move to stable number three i will switch to a gold because now the stomach is thinner

and i want to maximize hemostasis as well and you also switch hand as you said before

Yes, I switch hands.

So now this is my right hand.

You can see it's coming from a different way.

You want to make sure that your reinforcement is actually covering the entire cartridge.

Sometimes it can move a bit.

Okay.

Can you pull the port back a bit, Rachel?

So the gun will not open.

Yeah, pull it.

Thank you.

So now, same story.

I grab the remnant.

I move the remnant to be opening a bit the angle.

I will feed the gun all through.

Crucial point is you have to center the stapling at the V.

B, you cannot have overlapping staple lines on the sleeve gastrectomy.

You can't with a bypass.

You can't with a sleeve.

Camera straight, everything straight, please.

So you see now, same story.

So anterior wall first, okay?

Look how much stomach I'm eating.

So now we are pretty much close to the bougie.

Come back, please.

90-degree flip.

Roll the remnant, which has now become bigger.

And a bit of fancy camera work.

Come on this side, please.

No, no, we're doing.

Yeah, Nick.

Come to the top.

So that's why people are conservative.

And then you have to be careful

so the folding stomach on the tip of the gun,

you don't perforate it with a stapler.

Because if you're not careful,

you can perforate the stomach with a stapler,

which is not a nice thing to do.

So you see that's pretty much as tight as you can possibly be.

And if you're not sure, keep pulling, keep pulling, extreme.

So that's pretty tight.

That's the bougie there.

I can feel the bougie with my stapler.

Back now.

now. So now I'll book the camera, the stapler back to neutral position. You don't want any

tensions when you staple. See that? That's neutral position. Now this stage, if I judge

it's too tight, what I can do, I can stretch the anterior wall and move the gun slightly

lateral or medial. But I'll do it on the anterior wall, which I can't control. So that's pretty

much OK. Come back, please. OK. Bougie, please. The bougie is free to go up and down. The

anesthetist was very expert, feels

that there is not any unnecessary tension in doing

that.

So I'm pretty reassured by that.

So now I can remove the strings.

Patient is coughing, man.

Patient is contracting a bit.

That's why we are losing a bit of space.

No big deal.

I think, Prof. Adamo, it's also quite important

to be synchronized with the anesthetist in the moving

moving up and down the bougie in case of going too much fast and going towards the suture line.

I only operate with anesthetists who are experienced in bariatric surgery.

So they are excellent anesthetists, they know exactly what to do, and it's a teamwork.

So it's not just me. I mean, I can forget some steps, they will not. It's teamwork.

teamwork. Okay, that's pretty much okay. I can fire this. So that was fire number three.

And then you can see the staple line. It is quite pretty. It's quite nice. And then if

you look back, does it join up there, the staple lines? There's no overlapping. So that's

exactly where I want to come back, please. So now we reload the gun. In the meantime,

I will check the staple line again. So I grab the remnant, open the angle a bit, go with

camera in and make sure that there is no any misfire stapler like there is one here can you

see that can you see this stapler there yes yeah if you don't remove this that will potentially

damage the staple line okay so all this all the rules we have in gastric bypass with stapling or

other type of gastric surgery yeah they don't don't apply those legal strength to me it's

legal straight to you pushing your stapling technology to them the limit so everything has

to be spotless otherwise you get a leak and if you get everything is right you can still get a leak

so you see that there's a lot of funnels there which we have to include in the next stapling so

again same story a gun from the my right so patience left cartridge down open dangle and

gun straight in at the v you have closed the gun so the the butcher will not sleep and that's the

hard work now just getting all the fundus out of the way so this part easy the difficult part is

now twisting the gun putting down 90 90 degrees with the staple line rolling over the remnant

accessing the gastric fundus with the camera yeah you can see that how much stomach is there

that's the procedure that's why you do the procedure so that it's a bit of fundus

and a little bit of fundus and a bit more and a bit more and a bit more look like a german sausage

sometimes you can use your accessory grasper to help you holding the fundus in place

it's fine so that's pretty tight so there's not really much space left uh you want to add with

to towards the base of the cruise with the stepper exactly there okay exactly the section point of

earlier on so you are on the cruise at the base of the cruise right near the goj come back please

it's important then not to fire till you see the cross very well well if you are too conservative

some surgeons are because they're considerable leaks you may end up having a lot of weight regain

or lots of reflux afterwards because you leave the stomach behind so now it's it's okay this

is number four so clearly we'll have a number five needed in this case so it's fine so i'll lock the

gun and then a bougie please if you're not sure you double check everything is the way you want

happy with that or it's too tight it's like tighter so i'll release them so i'll open the

gun gently and move the guns gently towards the right so you can see just very small adjustments

okay fine so probably was a faction to extreme you don't want to stretch the stomach too much

Okay, strings out please. So that's the beauty of the

procedure, it doesn't take too long. That's why surgeons love it, it's not very tiring

either. See, the staple line is pretty tidy, the reinforcement stops any unnecessary

bleeding. The more you go upwards, the better stay the staples line. Yeah, because the

stomach is thinner. I will use gold now all the way up. But you could use green if you

like all the way up. Some surgeons use black all the way up. I think it's a combination

of hemostasis and complete staple line. The staple line is complete. Go nice three rows

of staplers, fully formed. But bear in mind, all the leaks up since here, they don't happen

lower down. So where the staple line actually looks awful, it's fine. Here, it looks fine

and you can get a leak.

So we're nearly finished.

We just go last firing and then

hopefully we'll be able to do it.

Prof, do you do any intraoperative

tests for possible

leakage or just as a

rule to be

sure that

technically everything is perfect?

It's a very good point. I think you

are legally obliged to check the staple

line you created. It's watertight.

So I'll do a leak test when I

I finish. I'll do a methylene blue leak test because also my patients don't get any gastrography

in swallow. This lady will probably go home tomorrow morning or Saturday the latest. So

the hospital stays one to two days. So you want to make sure that, so let's come back

a bit. So first point, you want to be at the centre of your staple line, perfectly there

in line. Then once you're there, you half close the gun so you are in control and now

Now you move the stomach away until you see the back of your gun.

Can you see the back of the gun there?

Yes.

The gun bill of the gun?

Yes.

Okay.

Because I'm always paranoid, come back, please.

I will flip the gun and do the same all over again.

Even though it's not needed, I want to have a view of the back.

This stage, it is a bit tricky because you have to fish all the stomach out.

Come in, please.

So that's reassuring that we are on the money.

Okay, thank you.

Come back, please.

I'm not sure about that, so I'll release the gun a bit.

I want to make sure I'm on the right spot.

I am.

That's fine.

See, the stomach is a bit squashed here because there's no room because of the adhesions.

Otherwise, you'll have much more room.

But that's bariatric surgery.

Sometimes you have to use a little space.

Okay, fine.

Bougie, please.

Come back, please.

Come on.

Thank you.

Strings.

So the staple line is complete.

judge and then you end up with a smaller defect at the top which is the last

thing you want so I don't mind wasting some money and then staple that even

though it's complete there's nothing left I will just divide it with it with

a separate and then the last but not the least of course in this case yeah that's

fine so now if you all you know if you've done a good job you know if you

a good job come back if your staple line okay from the bottom to the top is straight okay

so that's pretty straight so i've been good today so the amount of tensions between anterior wall

and posterior wall has been equal so the step line all runs pretty much okay if you have a

stable line that goes up and down up and down you can have a cork screw effect cover tapping

so that will create a stenosis or might create a stenosis so this is straight line no problem

so what i'll do before uh can i have some um tonsils workplace before um doing a leak test i

will put some clips in the bleeding spots sorry prof maybe i missed the point because we lost

the audio just for a second you said that of course as you correctly said you do an

an intra-op test with methylene blue, and then the patient won't need a swallow check?

No, the patient will leave the theater without a drain, without an astrogastric tube, and

we start drinking straight away.

So I would expect this afternoon to have a cup of tea, a cup of coffee, milk, ice cream,

anything liquid.

If she's able to drink tomorrow fully, she will go home tomorrow.

Amazing, Prof.

of realizing a fantastic

That's

what we call enhanced recovery.

But you have to work on this.

The patient has to be properly

counseled. They have to know

what is going to happen to them.

So the staple line is pretty dry.

There's a couple of points where I like

here where I want to put some extra additional clips.

Can I have a multiple clip applied, please?

So if you want to put clips over the staple line,

do it with a bougie in place.

Otherwise, you might create

a stricture.

Yeah still for the same reason when you do the when you fire them exactly the same principle.

Okay come back please I want to see the bottom where the staple line was a bit

okay look down down okay it's fine so that will be a couple of clips I will put it from my left hand

it's easier so that's usually a bleeding point at the start of the staple line I always put a clip

there because it bleeds and then you could argue you want to reinforce the staple line even further

area with clips now it's just mostly for hemostasis be careful when you put clips

because that's something that patient will always see at x-ray so you want to

put them straight you don't want to cross them you don't want to put too

many I think that's more than enough so at this stage what we'll do is give me

camera please we'll check the bottom of the sleeve to make sure there is no any

bleeding that's fine so there's no much antrum left see the antrum is nearly

will all full excised. What is the follow-up for this kind of patients? Well

they get seen, they get seen by the nurse specialist staff six weeks, they'll get

called at four weeks and then we'll be seen by the dietitian at three months,

surgeon six months, dietitian nine months, surgeon one year and then we'll see

them once a year afterwards, unless any problem. So then we get about six

appointments in the first year and one or two in the second. Currently we are

not allowed to see the patients longer than two years. That's what the government is telling us.

But of course I try to ignore that sort of dictate to try to see them as long as possible

because you want to see the patient in the long term. Clip again please. What happens in Italy?

Do you follow my long term? No, it must be followed after a month, after three months

and six in one year these leaves are placed on vitamins especially for the first year because

otherwise the mega vitamin malnutrition and lots of our patients have got to vitamin D deficiency

anyway before surgery so putting in clips of a staple line is accepted is not dangerous okay

and doesn't cause any problem other people prefer dietary again accepted I don't feel comfortable

with dietary the staple line but you can do it if you want so pressure is done now we remove

the bougie please love the becky's so the bougie is out in one piece which is good remove the

tonsil swap so what i'll do i'll clamp somewhere down in the antrum as low as possible and then

i'll wait for the nice is to pass orogastric tube stop please this is of course a very careful

maneuver uh most most of the time it's straight forward i've seen a couple of stomachs perforated

by rushed NG tubes.

I can't see it.

Can you wiggle it?

It's there.

Okay, it's absolutely fine.

So normally, I will ask the institute

to do a bit of compression at the throat,

at the cricoid,

and then to inject a 60 milliliter

of diluted methylene blue in one go.

It's a blast of methylene blue.

60 ml should be enough to blow the sleeve.

I'm ready when you are.

It's quite nice and blown up.

Can we put a extra?

Actually, no, it's quite nice and blown up.

Put a bit more.

bit more, just a nice tension. Leak test takes only, as you can see, a couple of minutes

and then if you're not doing a gastrography afterwards, I think you're obliged to do it.

Yeah, keep going. That's fine. This is quite nice and blown up. Let's leave now. We don't

see any blue seeping through, just a bit of red, which is fine. Thank you very much. That's

fine. So now the orogastric tube is actually removed, so there's no need to keep it in.

And because the staple line has been reinforced, that's the strongest point of the stomach

now, hopefully that will protect from leaks.

Come back, please.

Look down, please.

Tons of swabs, please.

I mean, I haven't used any suction.

There's no need.

So I'll try to clear the excess of blood with the swabs just to give the patient less pain

post-op.

Bear in mind, you know, she had extensive adhesions anyway, so a bit of pain will be

expected.

Okay, it's fine.

So it's done.

done. It's a straight sleeve, reinforced, 32 French bougie, very close to the parlorus.

The stomach is distorted by the adhesion, so it's very difficult to judge, but roughly

I would say it's probably less than five centimetres from the parlorus. I think the parlorus is

around here, so it's probably two and a half, three centimetres. So it's an antral resecting

sleeve, really. And that's it, quite mobile, so job done. So now we take the stomach out.

Excellent, Prof. Concerning the weight loss when the patients start to appreciate the job that has been done.

Straight away, I mean the weight loss with sleeve is very fast. It's as fast as with gastric bypass.

So that's why patients love it, because they don't have to wait.

So what I'm doing now, I'm just extending the porcite incision, so that's my finger there, so I can extract the stomach.

stomach. I don't use a bag. There's no need to use a bag in sleeves. There's no really

infection rate. I tend to stretch the muscle rather than cutting it. I use a gynecological

speculum to, or eisenhower retractor, just to stretch the wound. See the retractor there?

And then, show me the stomach, please. Show me the camera quickly. Clean. Camera clean.

Camera clean, please. So what I'll do, I don't put the pores back in. I know it might look

a bit rough, but I just put the instruments in with my finger. That's the big crocodile

grasper. In the UK, we call it madre-in-law or suocera. How do you call it in Italy?

It's a good point. We start calling it like that now, I think.

That's the official name, madre-in-law. So now I grab the tip of the stomach, and

the stomach will come out easily. And then to remove it from the abdominal wall, I use

use two caulkers so usually it is pretty straightforward thick device please so now

this because I've extended the port side just leave the specimen there I'll have to close

this port the other ports will not be closed because they are bladeless so I use a device

to just with two needles hook the two edges of the domino wall see that's closed now and I'll

pass a guide wire suture suture piece and I'm closing the port with a PDS one so stitches in

in place, show the stitch please. Stitch is in place, I will tie the knot, check with

my finger that it's enough, otherwise I'll put the second stitch. So just to, that's

fine, clean the camera. So today what I did, I did not select the case for the course.

I just took a random case from my waiting list, and then because I'm very lucky, you

know, she had a full laparotomies, Atman procedure for perforated diverticulum. When she had

the abdomen reversed, the abdomen leaked, so she had another laparotomy. She has got

ileostomy at the moment, and she has got enterocutaneous fistulae, which are going to be repaired.

So that's not your standard laparoscopic case, and probably many surgeons will not do laparoscopic

surgery, but I think it was okay. We got lucky, and there was enough space in the subarachnoid

compartment, but we would be unable to do a gastric bypass because, see, all the small

more bubble is fused to abdominal wall so this has been an excellent teaching

teaching case for everybody not just for the youngest but also for the senior

it's been quite intriguing complicated but has gone absolutely smoothly within

your hands thanks so what I'll do now do an extra procedure we're just taking a

a little bit of momentum because we're doing research at the moment. We are doing DNA genotyping

of the intra-abdominal momentum, so especially being consented for that, so that's an additional

procedure, nothing to do with the Zilli gastrectomy. I'll take a little bit of momentum to give

it to our researchers. Just one second. That's it. That's the two pieces too. Sorry, that's

as much as I can tell you. So yes, that's the procedure. So she will start drinking

straight away if she has gone on nausea and then hopefully hopefully home

tomorrow that's the plan okay I think we can well I've got another one coming

coming up so if you still go line um I will be up love another Zika straight to

me hopefully without all these horrible additions later on yeah no longer will

you be ready probably half an hour just the time of the turnover just to wake

this patient up and put the other patient to sleep it's up to you uh i don't mind i'd love

to operate anyway it's okay yes absolutely so we can ask to get the technicians to get the link

with you and anyway from prof malazzini thanks very much for this excellent case and

continue with a good job for your day oh thank you very much it's been a real pleasure and i

want to say hello to all the all my friends in the audience i'm sure there'll be lots of them

Yes, so I'll just say hello to them. I hope I didn't disappoint them

Pretty much. Thanks to all your team and to the entities especially

Okay, they are thanking back. It looks like the blood-brain barrier has gone

That's fine, thank you very much. Okay. Thanks. I'll put the course out. Okay. Bye. Bye and good luck. Bye. Bye. Thanks. Bye. Bye