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hello everyone I think we are live now for a in the outstanding Congress and the case today is a

patient with previously gastric sleeve that encountered a weight regain and we are now

intending to do a change of the operation to to do it in all switch of

course what we need to do now is to to understand the anatomy and we saw that

it was no higher than hernia there in place we lift it up just seconds ago the transverse colon

up into the abdomen and now we started to encounter the lengths of the small bowel you

You saw the iliopsocal valve and now we are going up, measuring 100 centimeters up approximately

from the iliopsocal valve.

And here I am placing a stitch, as you can see this will be hanged up at the side of

the abdominal wall and we remember that from this side downwards distally we have 100 centimeters we

need to bypass 150 for a limited limb and the 100 for common panel that means that the elementary

flow will have in this situation 150 centimeters to know exactly where is the distal part of this

side I am placing this a different color this stitch and now we go up from the 100 centimeters

meters that we encountered from the heliosecal valve let's go up and go to

the stomach to see exactly where we have the 150 now it's a clearly seen the

stomach that has been sleeved four years ago it was a good evolution and now we

we have encountered the weight regain.

Sleeve is looking nice.

And as you saw at the beginning of this demonstration,

there is no hiatal hernia.

There is no twist of the postoperative healing.

But this is for sure the need to dissect clearly

the antral area, the pylorus from both sides

and the first parts of the duodenum

to transform this operation into a duodenal switch which means a duodenal ileal anastomosis

posterior aspect of the uh of the uh pylorus you see the pylorus we see the

constant presence vessels on the anterior aspect of the pillars and now step by step by using

energy the harmonic it's a wonderful device for such a dissection any time for ultrasonic device

it's useful for this and you saw the pillars as we see the powers from both

sides we go now distally to three centimeters towards the d1 toward the

t2 in order to free up the inferior part of the duodenum we do always preserve

the right gastric artery which means that carefully dissection is going to be

continued from inferior as we try to demonstrate now slowly without damaging

electrically or thermally the duodenum on the posterior aspect and this is

going to continue without any hurry up you see we progress we progress now we

have already three centimeters some pancreas is hanging up on uh climbing up on the posterior

aspect of the duodenum we have to see clearly these islands not to damage them and continue

the dissection until we will clearly see the gastroduodenal artery which is uh in a second

And to be seen gently, we will put it, demonstrate it, see it, look into it, how it is, how it is pulsating in here.

because this lead mark means that we have to stop here from posterior and go on the posterior aspect

of the duodenum cranially to see the upper margin of the duodenum and it is very useful to open the

window with the monopolar hook and now we are sure that we are going at this right side of

the right gastric artery which means that we will keep the right gastric artery without being

damaged and now we can transect the duodenum and be sure that the first part

of the duodenum will be with a good nutrition and vascularization care

should be taking always not to damage the pancreas not to damage the vessels

that are distally and cranially from this opening and of course to use the best size of the stapler

that is fitting with the size now we see the pillars and we see that we have at least two

centimeters after a proper retraction of the inferior part of the duodenum and on

the upper part because we didn't dissect there is no retraction and we can see

even much better how the the duodenum has been preserved and nicely colored

From the stitch that we placed on the wall, now we go up for 150 centimeters, which means that we are encountering the length of the alimentary limb.

we are using step by step of five centimeters and together with you we are in counting the 150 which

which is almost here, let me change the, you know, go up now.

It is, in our experience, possible in most of the cases

because all these cases are revisional cases with patients that already lost some weight.

We are not performing this operation in super, super obese patients

or in extreme obese patients, it is possible to have the anastomosis antecolic, to put all the small bowel and the mesentery siding the duodenum without any tension.

Of course, it is important that this side at this moment to change the OR table position to horizontal and slightly to Trendelenburg. And now we have the ileum siding the duodenum.

It is important that at your right side of the image you have the first part of the alimentary limb, which means the proximal end, meaning that the peristaltic movement will continue exactly the peristaltic movement of the duodenum.

And the transection of this now double loop small bowel will be exactly at the inferior part of the anastomosis.

That means that it will be a physiological continuation of the peristalsis from the stomach to the duodenum and then to the ilum.

We are performing always a four layer anastomosis, a hand soon anastomosis. And this is a non-resolvable 3-0 monofilament polypropylene stitch that is positioned all along the posterior aspect of the future anastomosis.

involving the previously fired the staple line it should not be ever a hurry up for this gesture

which is essential and the posterior aspect which is of the step line which is nicely supplied with

blood and oxygen from the right gastric artery and the branches will be exactly

the posterior aspect of the anastomosis opposite to the ilium so the stepper

line will stay inside and any problem at the side of the stepper line will stay

in the aluminum so by this we have protected the anastomosis without having

any problems and from our experience and not only ours this type of anastomosis

it's rarely associated with complications meaning here leakage ischemia or bleeding of course we can

think about mechanical suture or mechanical suture will associate more rigidity and sometimes see a

stenosis of the anastomosis and cannot be delineated as we can nicely do always with

with a hand soon by using classical gestures of surgery we have to block this stitch now because

we will continue from inferior to anterior now completing the posterior aspect later on now we

We have both the duodenum and the ileum closed and we need to open them and the ultrasonic

device or any type of energy you want are very good to get in the small bowel with the

the evidence of the bile inside the evidence of a potential bleeding that we need to control

and a large opening is mandatory to be sure that we will have a good anastomosis care should be

taken not to injury the vessels that are filling up the pylorus and the D1 from

the cranial aspect of the duodenum you see the constant present vessels that

it's marking the pylorus on the anterior aspect don't touch it but open enough

large enough to pass through a boujee of 35 French as I am asking the

anesthesiologist to prepare the second posterior layer starts always from

from cranial because we can go on from up to down like from 12 to 6 o'clock with well

well controlled gestures and we will see both the duodenum and the ilium

wall with clearly evidence and pass the stitch from right to left involving both of them

they are protected already by the previously performed over swing continuous running suture

and now we are about to end the first the second layer of the posterior anastomosis and

And we are continuing this closing of the anastomosis from inferior now to cranial, to superior toward the liver, being sure that the mucosa is staying inside,

being sure that we will not damage the vessels there I just did it now there

are filling up with the new anastomosis that we are now performing we go slowly

up passing one by one the stitches and before closing completely a tube a

naso-gastro ileal drainage tube is passed through and it's kept in our

protocol for 24 hours in order to decompress the anastomosis and to check if we have a good passage

at the site of the anastomosis be aware that after the first day inflammation can occur at

this side of the anastomosis and no matter that we have proven that we have a good passage at

the side we can have an obstruction and the decompression with a radiologically if we

replaced or repositioned tube will be very helpful three layers are already

done here and we can see from posterior that we have a complete a complete

anastomosis and now we need to complete the fourth layer which is using the same

type of material or I saw some other colleagues in different other hospitals

using barbed stitches which is very good it's a easy to be performed running

suture but I don't think that this is making exactly the difference what is

making the difference is that you need to gentle involve the tissue without damaging the vessels

there are nearly by coming from the right gastric artery you see now in these images and trying to

to protect from any complication naming the bleeding and the dehiscence, the duodenal

ileal anastomosis.

This is probably the most delicate part of the surgery of duodenal switch and I am aware

that this operation is rarely performed now because the new version of for study

is what the bariatric surgeons are doing often I mean the operation is ready now

ending with the last use of the needle holder for the inferior corner the loop gastro ileal

anastomosis is completing the surgery in the case that we prepared for demonstration we will

continue with the ileo ileal anastomosis which is completing the duodenal switch but as has been

to now demonstrated is exactly what i told you the completeness of the study and there are some

Some other issues that maybe it is good to comment now. When we go for a study there is no need to go for a closing of the mesenteric gaps. We have two mesenteric gaps that we would need to close in Duodenal switch.

switch. Methylene blue has been introduced and it's the time of seeing if our anastomosis it's

without any leakage. We see that there is a distension of the entrum, an equal distension

on both proximal and distal part of the anastomosis naming the ileum and now we

are bringing for the entero entero anastomosis side to side ileo ileo

anastomosis the previously marked ilium at the 150 at 100 centimeters and this

will be the bypass of of the video pancreatic limb which is from here to

the angle of traits from the alimentary flow which is starting with the stomach

duodenum d1 ilium for 150 centimeters and the common center channel for 100

centimeters totally 250 and this is not something that you are not seeing very

often it's a anastomosis side-to-side enteral anastomosis approximating here

Here the ilium and on both sides and the anastomosis is going to be completed with this linear stapler as we use the white linear stapler can be clearly seen here.

and the closing of the opening after seeing if there is any blood source inside you saw that

in our procedure we are sometimes using buttress material to be sure that we have protected the

the intraluminal stepper line from complications, naming here, especially the bleeding from

the stepper line, which is unpleasant, especially in a patient where we cannot easily access

with endoscopy.

we are very far from the stomach we are I mean impossible to get up you have to

run at least 250 centimeters in the bowel and impossible to go there from

the from the colon so that's why being sure that we did our best to prevent any

post-operative complication at the site of this anastomosis it is not wasting

time it is something that any of those who are attending the outstanding

meeting organized and I have to thank you again for this invitation and the

brilliant idea to bring in front of the surgical word so many different

procedures you have succeeded now we have to transact in between the ilo-ileal anastomosis

which is exactly at the right side of the stepper line and the duodenal ileal anastomosis which is

on the other side and we usually transact by removing a short specimen a

small one it is yes you can say a an excessive usage of stapling devices but

on the other hand we know for sure that we will have a good nutrition for both

aspects of the two anastomosis closing the defect in duodenal switch is mandatory because you know

any obstructive complication can can affect dramatically the post-operative evolution and

And the first one we are starting with is the so-called Peterson space because it's just below the transverse mesocolon and it's getting together the mesentery at the side of the ileum and the transverse mesocolon.

to be sure that the bowel coming from the right side from the left right side of our image from

the left side is not passing through this gap and having that feared internal hernia consequence the

The barred stitch is always an alternative for what you may have to use and also the stitches that are monofilament that we love because they are sliding very nicely through the

through the tissue. Sometimes it's delicate to handle the fat tissue in abundance there. This is what we now try to avoid and the table is in Trendelenburg.

more decided to use the advantage of the of the gravitation to put the targeted tissue in front

of our instruments yeah we perform knots all the time but we buy some relaxation by placing a

metallic clip there and I think that this is a nice to see tip especially when you are not using

a barbed thread if you are using a broad street stitch then probably there is no

need to place a clip there to keep in place the stitching material not to

slide back to the origin and this is already closed and the mesenteric gap

the second gap should be always closed you see the bowel ready to get through

to pass through this opening just before closing and we should never allow this

to encounter after the surgery and always we should close the opening as we try to demonstrate

now the closing of any mesenteric opening is by means of a continuous running suture but not a

piercing surrounding appendectomy is always performed if has not been before

performed for that very patient and go rather removal in order to be sure that

the duodenal duodenal switch patient has nothing to do with the with the

complications after the surgery the go brother is out and we check now the

anastomosis with with the endoscopy as you can clearly see here this is the

interior aspect and the demonstration is over thank you so much