H. VAN DER WALT by pass

I wonder about. Can you hear us?

Good. Morning.

Yes. Welcome back to Rome.

Can you tell us about the next case?

Right. The next patient is a patient for a RUI gastric bypass.

This patient actually did very well.

He presented with a BMI of 44, and his big problem was actually the diabetes,

diabetes, and he used insulin for his diabetes as well.

This patient went into the pre-operative preparation.

We have a three-month period where we prepare the patients with a psychologist, a dietitian,

see the patient in follow-up, so there's a multidisciplinary team that manages the patient.

This patient actually lost 23 kilograms just in the pre-operative preparation on his diet,

So he's actually lost quite a bit of weight.

He's a very short, short person, and I think that's one of the reasons why his BMI is also

so exorbitantly high.

I'm going to do a Roux-Y-Gastic bypass, I use a six-port technique, and I'll show you

as we go along.

Our first port, there's the confluence of the rib cage with the top of the xiphisternum.

Our first port is just under the rib edge at Palmer's Point, that's more or less mid-Clevekele line.

Then I go in under direct vision.

Somebody wants to say hello to you, somebody that you know.

Hello, morning, how are you?

Annuncio, how are you?

Morning.

Good morning, how are you?

Good to be here in Rome with you, but I am obliged to go to Naples in the morning so that I want to say you hello and good work and my compliments for your operation before, Nissan operation, and I am very glad to see you.

I hope to see you in Naples quickly or in another side of the world.

okay yeah uh um yeah thank you anuncio um yes i've known anuncio trico rico since the early

90s we're very good friends um i'm i are you going to torino for the ea yes yes i will see you but i

hope to see you there okay okay i'll see you in torino okay for sure thank you bye yes good bye

Right, that was a nice surprise.

Good.

Now we continue.

That's our point of reference.

Now my camera, I put in 20 centimeters below that point.

Right.

So I use the grip cage, 15 plus 5, that gives me 20 centimeters.

And this is for the optic.

And you'll see at this stage, again, I'm standing on the left-hand side of the patient.

Right.

Alright. There we go. Right. What is good about this good preparation is that the liver

shrinks immensely. We do preoperative ultrasound to make sure that the liver is small. We're

still on the external picture, eh? No, no, we're internal. Now we're back external.

Okay, let's... Good. Now my next port is going to be sort of halfway between these two ports

ports in that area over there. Now this is a 12mm port. Then at the same height as this

one on the right hand side of the patient, slightly lower, is another 12mm port. So we

have a 5 in Palmer's point, a 10mm for the optic, two 12s over here, and then for the

The liver retractor, I put a 5 over here and I put another 5 in between those over there.

This one I'm retaking, I re-angle it to the right.

So those are my six ports, 5mm, 5mm, 5mm, all the three top ones, two 12s and one 10.

That's very clear.

Right, we can go to the internal picture.

Yeah, we're internal now.

Good.

Good. Then I put in my grasper, pick up the tip of the liver, insert my liver attractor,

and just pick up the liver like that.

My assistant holds that, and I just use a pneumatic arm to keep the liver attractor in position like that.

Not too much traction, otherwise we get too much right.

Okay, first step.

Now, what I normally do is I always repair the hiatus in all my gastric bypass patients.

The reason for this is with my early gastric bypasses, I saw the patients eat their esophagus

full right up to the aortic arch, because the esophagus in the stomach becomes a common

cavity.

So now I normally close the hiatus, I always use it for a little bit of restriction as

you'll see, but this then makes sure that your esophagus in your stomach does not become

one cavity.

I always start my dissections on the right-hand side of the patient, my left-hand side, and

the reason for that is that the esophagus always lies in a position to the criss on

the right-hand side.

It's a constant.

It doesn't matter how big the hernia is, there's the vagal nerve.

We're picking that up, exposing the criss on that side, opening up there, there we can

You can see it a bit better.

Now what I do is I make a window through to the lesser sack.

Keep that up like that for me.

Up towards the roof.

I do a few every week.

I've probably done well over 1,000 gastic bypasses.

And if we have a busy week, we do two every day.

depends on how many patients of course we have but on average I do about 10 to 20 a month sometimes

more sometimes we do 10 in a week depends on the demand you can see the posterior part of the

stomach a so I'm into the laser check over there right and this I'll show you why I do that now

Now, let me just, right, okay, that goes back there.

Right, I want that one just to keep it over there like that.

Let's just have a look where this little bleeder is.

It's over there.

That's it, right.

Stitch.

And all I do here is just a posterior repair of the hiatus.

You still use that Ticron tool, yeah?

I still use the Ticron one on a 26mm needle.

I just want to shift that liver out of the way a bit.

There we are.

Good.

And what also helps is, you'll see I actually close up this hiatus very nicely,

quite tight actually, I suppose it's my form of restriction,

but that also stops the patient from eating some steaks directly after the operation.

Safety factor.

Yes.

If you do enough of these things, it's very important to have your psychologist actually

identify these patients that are untrustworthy because if you really learn something about

patient personalities and how deceiving they are, I think the only surgeons who really

know that are the bariatric surgeons.

Dr. Abidrat?

I agree.

agree, it is of paramount importance, the psychological discussion.

Oh yeah. We had two patients on the list this morning. The one we actually disqualified

due to her psychological makeup. Why? What was the real reason?

She was just one patient that was really schizoid, deceiving, lying, manipulative, not adhering to the preoperative program.

And if they don't adhere to the preoperative program, you can be sure they will not adhere to the postoperative program.

And all that happens is they start eating or they don't come for follow-up.

they develop problems, and at the end of the day, it's not a bad patient, it's a bad surgeon, you know?

It's always like that.

Never their fault, it's always your fault.

So, if you can identify them, it's wonderful, you get rid of them, and you try and stay a good surgeon.

That's right.

very tight it's very seldom it's rare that any of these patients ever have dysphagia

and i'm not quite sure because if you do the same type of closure in a patient with

anti-reflux procedure you're bound to have a patient complaining of dysphagia

I think it's probably the added effect of the Nissen with the diaphragmatic closure.

I agree with that.

All right, so that finishes that part of the operation.

Now what we're going to do is to make a window at the top.

That's it, just hold that.

Just going to shift our retractor a bit over there.

Okay, I'll just pull that one down there a bit.

Let's retake that one over there.

Pull that open over there.

There you can see the tip of the spleen coming out.

Just a minute.

All right.

I'm actually mobilizing the top part of the fundus here as well.

Pull on yours.

Come back, come back, come back.

Okay, don't worry.

Just a little bit more there.

All right, and I'm in the same area.

There you can see the suture, eh?

Yes, there may well be.

Right.

So now we know we've got the tunnel.

we're in the lesser sack there as well.

Good.

Now that's put back over there.

That we take back over there.

Right.

Now what I do is,

and I've done a few things

to make this operation a bit easier.

Let's check.

Another.

A little bit bleeding there.

I think it looks in about this, isn't it?

Like so.

Right.

Now the next step of the operation

is to now start making the pouch.

What I do is,

I pull all this fat back.

sac. There's our left gastric artery over there. Now pick this up and open up the lesser

sac there. Can you see it? Yes, very clear. Hold that one. There you can see. That's the

posterior aspect of the stomach. Right, now the next thing that we do is grab this. Okay,

now the most important thing of this whole operation is to take out the nasogastric tube.

tube. If you don't take out the nasogastric tube, you'll take it out just now, after you've

stapled it into position, so it's better to take it out beforehand. You can take out the

nasogastric tube. We just cleaned the lens there. Alright, keep that one like that. Oh

yeah, I see that's right, yeah. Okay. Now in the beginning, I actually made a little

hole there on the lesser curvature, but I don't do that anymore. I just go through here,

and this is where I make my first

grab on the posterior edge

bring it through the wheel

and this maneuver has taken care of

all this bleeding, trying to go

through the

trying to expose the lesser curvature

always hitting the artery, it's always bleeding

this is one of the

problems if you make

the pouch and you have to go

through the medial side, so what I do is I just

put a stapler over

and then manage it from there

Alright, we eat our first staple. Always wait a while.

And now what I do is, I just take care of the blood vessels.

Let's just check where they were at, because that will now bleed as well.

There we are. That's it. End of problem.

This happens always with your staples at this stage.

Yeah, for sure.

Right, there's our sac over there, there you are, do you know what, I just want you to

pull that one like that for me, go in over there, let's put that in, convoverator, right,

in there, that one in there, and it's very important to try and get that nice into there,

then I go in underneath, and I grab this blindly and I pull on that posterior part of the stomach,

because what we're aiming for is the angle of ease.

So actually make more of a stomach tube than a pouch.

All right, and now we have to wait 20 seconds again

for the tissue compression.

And I use the old 45-millimeter ETS stapler of Eticon.

The larger stapler is with a 60-millimeter.

I suppose you save a stapler out in there,

there, but they're sometimes difficult to use inside the abdomen because they're so

long. Yeah, you can see the blue color. Yeah, and I'm using a blue staple, yeah. The top

of the stomach is quite thin. If I do a gastric sleeve over the anthem, my first two staples

will be green, but then I use blue staples for the rest of the stomach. But for sure,

yeah, if you don't use blue staples, you will get a lot of bleeding.

Come here.

That's right, like that.

Come back a bit.

Grab it there on the posterior side, pull it through a bit, to the top.

Always make sure you don't staple into the esophagus.

What's nice about doing the little stomach tube is that you have a bit more length.

Your volume is the same, but you really gain a few centimeters on the length.

And especially in the very thick, fat patients where they've got these thick mesenteries,

it helps quite a lot.

Right, there we are.

ok there you can see you can see you've got enough blood vessels yeah good blood

supply there's our area that we opened here you see all right there we are just

pushing this port a bit more that's it okay

make this pouch nice and narrow it will not blow up or enlarge over time right

Here, we've still got a few little staples.

Do you follow up with a contrast study for this temple?

No.

Do you proceed?

No.

No, I don't.

You can see the staples are right to the edge, eh?

Yes, very clear.

Good.

Right, so that's it.

Now, just go to the external picture.

Now I change around.

Now I change around on the external side to the right-hand side of the patient.

So I do that part of the operation, standing on the left-hand side of the patient, tilt

for the patient, and now I'm going to tilt the patient towards myself, I'm tilting the

patient towards myself, stop, tilt the patient, head down, right, and now what I do is, there

is my stomach, and this is a method that I use, and I've used in a number of patients.

I do not split the omentum, I don't do the retrocolloid anymore.

Now what I do is, I just take the omentum, I just move it over like this.

We see the external, okay, now we're in.

Okay, oh sorry.

What I do on the internal side is, there's the omentum lying, I go across,

I grab the omentum and I just pull it over towards myself and towards the head of the patient.

patient. Right. Then what I do is identify trites. This is the ligament of trites. You

can see it there? Yes. Very easy to find. Much more easier than with open surgery. Right,

and now I'm going to go 10. How many centimeters do you go down to the jejunum? I usually go

go about 30. That usually gives you the nice loose piece of the eugenium. Hold that one.

Tilt the patient. Now what I do is I tilt the patient back, feet down. So I tilt the

patient head down just for this maneuver. Once we've got that bowel there, then we go

down.

At 30 centimeters length, is it a fix for any patient? Or it depends on the eye?

It's a fix.

Okay.

It's about a fix.

You know, it's a funny thing is even if you're big or small,

the length of your small bowel is very much the same.

It doesn't seem to be a big difference.

Right.

And a little bit less lateral tilt.

Okay.

Right.

What we do now, you can see this patient had a very creamy meal last night.

You notice the lymphatics are very nice.

Yeah.

Okay.

There you go.

There we're inside the bowel.

Right.

You can turn it around, right?

Yeah, that's right.

I'll check.

Now, we grab the stomach.

Bring that down.

Turn it back here.

Now, I'm going to burn my hole over there.

Just on the...

Until I'm inside.

Now, I'm inside.

I think...

Ah, I made it bigger.

Now, I'm quite sure I'm inside.

You can see the mucosa coming out.

Right.

Now, I take my stapler.

stapler, and I use a linear stapler, you see this is very cheap and a very simple operation.

That goes in there, like that, that one lies like that, I'm going to put this over there,

down like that, grab the stomach, does your patient slap?

Okay, come back, grab it like that, keep it, right, now if the, yeah there's our, now I

Now go in there, come up towards this side, blood back, just keep that like that for the

time being.

Again, wait a couple of seconds, you can go and have a look and make sure that you haven't

gone through the bowel there, make sure there's adequate, you mustn't be on the staple line,

you must be away, like that, gives you more than enough blood supply.

Shoot it, take it out, and now what we do is we're going to close up the, I just want

to shift this liver retractor a bit again that's it good now my first suture i take through the

stomach over the bridge and out on the gastric side over there you can come up all right again

i use the same knotting technique okay that's it good take away that clamp out of the way all right

Right.

A little bit like that.

Right.

Next stitch, through there, and I come in through the staple line, then I take the staple

line and I invert it into the stomach like that to put the corner back into the stomach

and invert it to take care of any chance of leakage there.

That is a good bud for thickness, huh?

through the blood vessel

it takes a lot of practice

and it's only done by the experts

you said before

that is simple

of course in your hands

this looks very simple

in the surgical rotation

I beg your pardon

I was asking

for the surgical rotation

for the young registrars? Are they trained? What are they start performing

gastric bypass under the supervision?

Usually not if they are registrars. They do the basic procedures. We've got

theatrists at the hospital. They come and rotate with me and they work with me.

me. I have two registrars from two universities, one from Natal and one from Pretoria, and

then I actually have a fellow at the moment. The fellow is Ahmed Zawad. He is from Bahrain

and he's working with me for this year. He spent one year in Cape Town with Philip Bormann's

unit. Right, now this one, make sure that you pass the staple line. You can see that

that we've actually gone past the corner.

Gas.

That's very, very important.

Now, this is the part that I do first.

Now what we're going to do,

grasper, grasper,

is to divide the loop.

Brandt, I'm going to grab that one over there,

just hold it lightly like that.

Go over here,

and then just open the,

just make a little window there.

there. Sometimes if they're very fat it takes a week or two to make this window, but I think

we're through there. That's a white stapler now for the small bowel, eh? Yes, we noticed

it. And make the limb not too long. Not that I think you'll get a blind loop there because

it usually absorbs, even if you make it a bit long, a post-operative endoscopy, that's

usually not a problem right divide that there we are i'll take this one that's left over there

Let me take that one over there.

So this 150 centimeters is a fixed figure.

150, yeah.

So I like making it a bit longer.

Any reason for that?

I see the result seems a bit better.

In the beginning I only made it 120.

They don't do so well.

They do better with the 150.

I know there's no science in that,

but that's my feeling, what it looks like.

Yeah.

Yeah, and despite randomized trials and graded A evidence,

a surgeon's feeling is still important.

All that.

Then I turn my stapler.

That guy there.

Put that one in there.

Slip it in.

That's it.

Right.

That's the anterior anastomosis.

And now I'm going to show you my stitch that I use here.

And I've done many, many, many anastomosis like this.

I'm talking about well over a thousand with this stitch.

That's what I call the figure, well actually my registrar's called it the figure of 88.

It's not a figure of 8, it's a figure of 88.

Yes, 88, got it.

Yeah, right.

Right, that's the first suture over there.

We go back, leave it a bit long there.

Ah, come on, that's it.

We have that one there.

Now sort of in the middle there, again,

the corner there again, right, go back in the corner, like that, right.

When you pull this, it actually closes up that endostomosis like that.

Make sure it's OK, that the lumen is going to be nice and open.

There we are.

Right.

And that's the operation.

Yeah, congratulations.

Just make sure.

Just neat, clear, quick.

And now it is going to suck out all the blood.

That's it.

That's that side.

Now you ask, your need is to push down the NG tube

or not at all?

No.

No NG tube.

tube? Nothing. No NG tube. I've never used NG tubes in my life. Never, ever. Not even

in open surgery. I don't think it does anything. The patient starts his fluids tomorrow. He

goes home the day after. The same with my nissens. No nasogastric tube. One day in hospital

and then they go home. They see a dietician. They go on to a post-operative diet. I also

Also, don't blow up or test my anastomosis.

I'd rather spend my time making them properly.

Yes, agree with that.

What are the results, your results?

My results are good.

I'm very happy.

Yeah, well, all surgeons are always very happy with their own results.

But we've actually got good results.

We follow the patients up post-operatively quite intensively every two weeks for the first month

and then every month for the first three months,

and then the patient goes out on parole,

he goes on to his long-term diet.

I see the patient six months down the line,

then we repeat all the blood tests

and make sure that metabolically the patient is stable,

and then I see the patient one year down the line.

If the patient's okay and he's doing well,

then I see the patient two years down the line.

Most of our patients come down to a BMI below 30 quite nicely.

And concerning the diabetes,

Oh, the diabetes, that resolves within the first week in the majority of patients.

I usually stop the insulin and the glucophage in the hospital now,

and we monitor the glucose very well in the first week,

and 80% plus, 80-85%, there's complete resolution of the diabetes

within the first two weeks after the operation.

That's the good thing, or one of the interesting things about the gastric bypass

bypass or all these duodenal bypass operations is that the effect on the diabetes comes long

before the weight loss. And they gradually lose weight, they lose

about 80% of their weight in the first year, about another 20% in the second year, and

then they usually stabilize. Dr. Okay, Prof. Excellent. Congratulations

for your good hope. Listener, we would like to know in how long will you be ready for

for the next procedure.

15 minutes?

15 minutes.

Thank you, because you have to connect with

somebody there.

Thanks to you, Leder.

Thanks to your team.

Thank you.