M. KRAMER sleeve gastrectomy VLS

My name is Michele Golia. Thank you for participating to this live surgery meeting.

Can you please tell us what's the case and the procedure you are going to perform?

Okay. Buonasera a Rome.

Buonasera.

My name is Michele Golia. Buonasera.

Buonasera.

So we want to present you a very special case.

The patient has BMI 43, so he has 140 kilograms with a height of 1.80, but he has had a severe accident in 1984 with splenectomy, adrenal kidney nephrectomy, and a little bit of liver ulcerations.

and he has a very severe hip problem so we think that the sleeve gastrectomy is the best operation

in this case so i would like to show you the sleeve gastrectomy with adhesiolysis and maybe

you can see very well we have a little bit i'm sorry a red light we see that he has a medial

incision and a square incision below his left thorax. So I would like to start the

operation at least 16 centimeter below the xyphoid and you will go with me and

we will see if I am in trouble or if we see a wonderful sleeve resection.

Okay, we are ready. You are listening. How is the weather in Rome?

Beautiful day. What about you?

Better than in Munich, but here's no snow, that's the problem.

So, when you have a question, please ask me.

So, you see, I used the XL trucker, I like it very much because of the adhesion,

and now I think we have a sensible situation.

So, I can see if we have any severe adhesions there, but it goes very nice.

and now you see when it's a little bit darker now I'm inside yeah yes okay now we start the

normal peritoneum so the first part of this operation of course if the adhesive uses I

I performed a cholecystectomy before a couple of months before and now we start and how was

the situation of adhesions two months ago yeah we haven't seen so bad adhesions in the upper

stomach but now I have to look for it you see here we have a little bit yeah now I'm free okay

Okay, so the problem is now, so I want to have the first trockers and then we can do the, now you see, we waited a little bit, now you see we have to start here first, so I will start with a trocker right in the right abdomen, with a large one, do you see everything fine?

yeah now probably that the laparoscopy is so I thought it is better to start

with the operation in this point maybe it's a little bit boring for you but now

Now you see...

No, it's not boring at all, because besides many expert surgeons, there are also many

young surgeons and residents, so please say everything, even the simple things.

I explain everything.

So the first thing I want to do now is to do the atesiolysis by the ultracision, and

I think we will do this quite easily.

okay here we go so when we have done this I think we will we will see so the most important thing

is to be very careful in this part of the operation of course so we when you do the

gastroscopy you see no abnormalities with his stomach so I think when we when we have a good

window we can perform the operation much better so maybe this is a little bit

exciting for you too that's what I expected

can you repeat the operations that she had before and the fact I said so he has

had a motorbike accident in the 80s okay this accident he has had a severe hip

injury yes and a splenectomy splenectomy and a nephrectomy and now he has no

possibility to walk very well and he has a BMI of 43 okay and so I think this

operation is the very good opportunity to help this guy because he loses a lot

of weight in a very fast time and when we see the stomach we can do this the

sleeve gastrectomy the problem is of course you know that I cannot promise

you before how severe are these adhesions yes but I think it went very

very nice in this time so we will see is the picture quite okay I would like to

do go forward it's it's okay just a little flu just okay you know I'll

transition yeah so now we are in the business the only advantage I have is

that i cannot do any plain injury now yes that's for sure my advantage you like to see the you like

to see the advantages of the situation yeah do you my question is do you see a lot of standard

or have you seen a lot of standard procedures so that was my my thought maybe to show something

special or would it be interesting to see a standard procedure it's better

like this it's better like yeah and you see I think the situation becomes much

these picture problems, please let me know. I would buy everything.

Now you see the situation becomes more peaceful.

is to reach the normal troca position for sleeve gastrectomy.

me all i do now is just a little bit of improvisation because i don't know where are the

severe adhesions but now i get clear about the situation and we can start with the operation

maybe in a couple of seconds when we have done this movement what kind of laparoscopy do you

have a 30 degree yes right you're absolutely right 30 degree and the last part is here

here just to do it like this I think he has a hernia here as well we will do a radical cut cut

up here so you can only my opinion is I only can perform this kind of operation with 30 degrees so

So without it, it wouldn't make any sense.

Yes, I agree.

So here we have the first trocha position.

And when we see it clearly, we can start the operation.

I think in my philosophy, when you see here, we have an incisional hernia.

But I think it makes no sense to treat this hernia when you have a very high BMI.

so the next step will be to treat the hernia when he has lost weight so it won't be the last

operation don't know what is your philosophy so when you have a high bmi more above 40 it is

better to do a sleep gastrectomy or a bypass before and when you want to implant an ipom mesh

i think this is very important to follow on for the young colleagues so now we are in good position

And we start.

Okay, maybe I can show you the normal position of the sleeve gastrectomy I prefer.

So normally this is the 12 mm trocar and 12 mm trocar I prefer here.

so I can see very clearly the stomach

and the other 5mm trochars

I have to look how it works

I think we don't need a liver retractor

because this patient has had some liver injuries as well

so maybe when you have liver transplanted patients

sorry

so I've done some sleep gastrectomies

for liver transplanted patients

and you don't need the liver retractor of course

because the liver is fixed with a peritoneum this is very nice so now here we go okay right

I don't see it very nice so I think I have another small part but I can bring in the original trucker

Okay, I get another 12mm printer and we clean that up again.

Okay, but it's not nice.

Okay, I'll do a little more, give me the ultrasonic.

So I complete the adhesiolysis.

So the omentum myosin, this is all omentum myosin.

And behind that we have no adhesions anymore, I promise.

You see?

usually the patients are selected in order to be very easy during live demonstration

you selected you selected exactly the contrary like a difficult one yes

which makes everything more interesting okay now you see the window is opening the secret moment

i think you see the liver here yes yes we do now when we mobilize this one

So I think, ah, and you see it is a stomach operation.

And now we can start.

So what I want to show you is don't be afraid when you have such a situation.

Okay.

So that looks easy.

Okay, now we start with the procedure.

As you said, the liver is up.

You listened, yeah?

Yeah.

I think I won't mobilize it too much, but maybe I need a retractor.

Yes, of course.

okay so my i prefer here in the below the left thorax another 12 millimeter trucker

so normally i don't use too many 12 millimeter truckers all 12 millimeter trucker has to be

closed by a stitch after the operation don't know if it is a consensus in your room yes but i have

seen yes okay because i've seen some of my patients okay you always see these all right so

and i think the most of all are happy not to operate ah look at this

Wonderful, very good, very good. Here we are.

Sorry, I have to give some instructions in German.

We clear it again.

Okay, here we go. All right, so we don't have to be afraid that we do any splintrauma,

but you see the very large stomach. Is it, can you see this?

We now, we bring the gastral tube a little bit forward, yeah, to bring out all the air,

and maybe we should remove this one here.

So then we can, we have done the complete athesial lysis.

It's about 40 operating theatres from all over the world.

And everything went fine.

So you see, I need now another trucker.

Here, I'm coming.

Yeah, you see, right in this position.

This is helpful for the preparation.

But now I need just 5mm truckers.

You see, here is another 12mm.

And between these two truckers, I bring in another one.

Okay.

I think we are all, if it's consensus, that it's not a question of number of trocars.

So the total number of trocars now is?

The number of trocars is now 3, 12 millimeters and 3, 5 millimeters.

Okay.

Yeah, that's all.

But it is for me.

Normally, so now we do together with the anesthesiologist.

so she brings up the gastro tube into the stone now how large is it um it is a the length is 50

centimeters all over all of this this tube and he has um 12 millimeter size 12 millimeter bougie

it is 34 and i like to do the sleeve gastrectomy with in in especially in risk cases like him

with uh seam guard reinforcement i and i use uh echelon flex i show you okay so now you see i

take off the the air you know a bit yeah here we are okay so this is just for for emptying of the

the stomach and now we start actually we start with you okay so

Okay, so here we are.

The first thing now is to see where is the pylorus.

So he has a lot of fatty tissue inside.

That is maybe the problem why we have this very much.

But here you can see very nice the pylorus.

Yes, we do.

and we of course the german companies you see karlstorz we know very know that where the k is

is five centimeters for all the the starters i think it is very easy to see that there where we

have the pace and the renos on the contra part yeah so i would we'll start with the resection

right here right here okay and here we go with the sleeve extract to me from munich

are there what is the normal size in Italy 46 inch so okay yes so I think he

has a little bit more adhesions in this area than the normal patient but not too

bad preserve the antrum is something what we can say everywhere I think

it's safer it's helpful for all the starters it is very important to do it

very carefully so you prevent bleeding if you do it slow you are very fast I

like to do this procedure before a section do you have have you seen some

resections when they start with the resection and do this maneuver behind no

not so far because they sometimes say it is better first to resect and then

next question we will have in a few seconds is what can we do with a with

With the angle of his, my experience is very straight.

Where do they come from?

Here where we have the camera, or from the outside?

Don't leave a lot.

I have to make it reach the quality of the reporter.

No.

Ah, did you do it?

Ah, then yes.

You have a good atmosphere.

So I think the most part here is now to have a good overview.

And you see of course of the splenectomy you have some adhesions here.

The thick hose, you can now pull it back, the gastral tube back into the feeding tube.

Pull back the tube, yes, that's good Steffi, you can do it again, Daniel will do it like this.

No, it's not like that.

Yes, a little more alignment.

Yes, that's it.

So you see it is very important to have a good overview here.

The right hand is not in the zero position, the zero position is always wrong.

Now we have to look here again.

Please put this down here.

I think the cameras always switch between each other.

Yes, it's always a little bit in between.

Yes, yes, that's right.

Yes, yes, all of them.

Hello, you just say hello.

So you see, it's actually a very special case.

You hold it.

Yes, I wanted to.

I wanted to hold it like that, you have to turn it over.

And now ultrasonic.

Gives it a little bit of a hook.

It's the same as Berlin, right?

Yes, but that's not such a cover.

That's great.

On the sleeve, live to Berlin.

That's excellent.

Excellent.

Jiri, how was it at the congress?

Today?

Yes, generally today.

It was very good, yes.

How was your Wednesday? Was it good?

Great. It was overfilled.

Okay, we're already in full swing.

Let me just take a look here.

Ah, now we're in trouble.

So that was now for them.

The difficult thing is always when you don't even know.

You're talking into such a black box.

You don't even know who's in there now.

It's difficult.

I didn't know, they didn't ask me or anything, but I thought, let's do it.

So, that's very good.

Let's move on.

This is the part where you could help a little bit.

But that doesn't matter now.

Let's go a little further.

Now you're driving again.

Yes, down there.

Very good, okay. So, now comes the hose maneuver.

Please proceed with the hose. I think now the operation is running just parallel on a screen, right?

Yes, yes, it runs on a screen, so they can see what we are doing.

Yes, great.

They are commenting now, because they have another one live, so to speak, and they have 40, as they said.

Very good. Pull back a little, Daniele.

So, now Daniel's flag goes short.

Clean up again at the front.

No compromises, please.

your stapler comes from the left from the right of the patient right okay okay yeah right the camera

is now on the right side yeah and now i i do my first bite and i think it is very nice when i do

it like this and i try to be very close to the tube and the cartridge is green right right green

seen how i have mobilized the funders yes yes so i haven't talked anything you you saw another

operation in the minutes in the last minutes is that right yes yes wonderful okay excellent

okay so normally i use and i do it today as well i use um green for uh for the first

and then golden until the angle of his that is my my philosophy okay i think better to have a bigger

one than a too small one oh i'm sorry i did it by myself to clean the lens and you see it is not

Okay, we have envida forward, so we have no over-stapling, yeah?

And between the bites, I look if we are free everywhere.

Sometimes you have to do a correction of this situation,

situation, but I see we are very, very nice.

Okay.

Please.

Have you turned the stapler a little on one side now or is it

always straight?

It is now.

It has an angle.

You see here?

Okay.

Now I do.

Yes, now I do.

Yes.

Okay.

so I think that is makes the operation much better now that's why you do not

need to change the port for the stapler that is my philosophy yes okay and then

to look yeah you see it's it's quite nice

yeah wonderful so that reason and now I'm very horizontal

now we have shift to the gold cartridge huh yet to go so I the first one is green and then I do

until the end okay I'm very easy okay I think I have problems with a blue one because I go very

close to the angle of his normally and I think when you have blue one in the angle of his with

reinforcement I think that is maybe not enough and I think when you have a gold one you are on

the safe side with it with this product okay control between every bite if

everything is fine of course we don't have any any splint

plane injuries but we can do it here very nicely maybe I have some adhesion

maybe I should do something so you have to be patient but it's going on yeah you

see this angulation here yes we do yes okay so be very careful of course now I

have no plane that's okay and my assistant he pulls in this direction and i open up again a

little bit and now we look down and we are happy okay that's okay on the top as well you see okay

Okay wonderful, then pull back a little bit, yes, and forward again.

So I need a minimum of another one.

I also need a little bit of what Mr. Mahan has given me.

So, stop pulling.

Yeah, you see, you shouldn't do that.

That's okay.

I think we complete now the resection you see what I've done I thought it is

better to mobilize anymore and now I have a small bleeding here but I think

it's better now to do the resection to complete it and to look for the

bleeding afterwards but now i can i'm free here and maybe we are better behind okay next shot

wait and see

Yes, in any case.

Yes, yes, yes.

The emergency position is 90% wrong.

It's down to the mill.

Do I have the shot?

No.

That's the list I wanted to have.

Now pull the maneuver a little again.

Go ahead again.

Where are you?

Go ahead again.

Are you in there?

Yes, always forward, it's good, forward, forward, forward, very good, yes, very good, wonderful, excellent job.

Who is that?

A girl from Pisa, her name is Buccia, I don't know her name, her name is Buccia.

Okay, we need just one last one and then we can finish.

it are you going to switcher the stapled line or not because i think when i i would overshoe i i

would be too sharp i would have i would have this comfortable uh swallowing i wouldn't do this

i think that's enough okay and so when i have done the atesiolysis so when i wouldn't be

successful with my weight reduction i would transform it in a in a one single anastomosis

is bypass yeah okay but not oversewing you see this is my last shot now and then we have i think

a quite good situation now you saw i i have done the mobilization and after that i had i've had

some bleeding but i think it is necessary be careful to do this right here to remove the

fat body yes yeah i think that's okay good

okay here we go

So, Steffi, so, watch out, now we make the fan short, now the filling comes from another window.

No, you can't do that. That's just a blue sample now, then we'll bury it, then we're done.

So, Steffi, wait, start the camera, please.

Hmm?

Sleeve gastrectomy, right?

Sleeve.

Sleeve gastrectomy, and now we are doing a blue, the blue probe.

yeah excellent have you already done the blue methylene test yeah we have done the blue test

and we have now no signs of any leakage and now we remove the tube perfect and we remove the

liver retractor do you drain yes i i drain with a 15 french strain how long how long do you leave it

i have it now it's friday yeah and we do the an x-ray swallow on monday and when we don't see

any problems and when we have good good results in the blood tests we remove it on monday evening

okay yeah and how long how many days does does the patient stay in the hospital after the operation

the problem is that he he could leave on uh on tuesday but the german health care system i hope

that no job in the room um needs a longer stay that's the problem so we could we could leave

him earlier and i i do the the drainage from the right side i i have this idea from professor

adhesions but i think that is more interesting for you to see or isn't it that's right was it okay

and i think it was very uh well done we want to congratulate with you and your team you were very

kind to participate to this meeting and it was a pleasure for us and we hope to see you again

next year and I want to come to Rome and all my nurses around they want to see

all the nice Italian guys