C. COPAESCU sleeve resection

Hello, Professor. Good morning.

Good morning.

So, on behalf of Professor Palazzini, I'm very proud to welcome you to the Congress.

My name is Umberto Grandi, and I will be with you during the session of your intervention.

It looks like every other year, it will be very crowded here in Rome.

This is perfect. Good morning.

I really think 1,500 people looking at your intervention in, well, not right now,

but I really think that in a couple of quarter of hour it will be really crowded.

Anyway, can you tell us something about the patient you are going to operate on

and what kind of procedure you will be performing?

First of all, I want to say good morning to you, to everyone,

one and to underline that we are proud that we we we are invited to be a part of this very important

event and we hope that everything will go smooth and we will be able to demonstrate a nice operation

The plan for this morning is to operate a male.

It is a 41-year-old male with BMI 43 that we have prepared.

And you have probably an external view.

Yes, I have to look to the camera in this moment.

You have the external view of the patient.

and we will perform a sleeve reaction as I told you before.

We prepared...

Professor, I'm so sorry to interrupt you, but unfortunately the audio connection just started

when we first met some minutes ago.

So I really think that the audience couldn't hear anything about the patient.

Can you repeat it again, please?

I'm going to repeat again.

He's a male of 41 years old with the BMI 43, with diabetes type 2, with hypertension,

and the indication in this case was sleeve resection,

and we are going to perform it in a way that we do usually in our Bariatric Center of Excellence.

We just prepared here, and I think you have an external view of the patient, the scheme of the trochers with six trochers.

We do place a trocher at the umbilicus, and then we have another optical trocher at the left side of the median line.

And you will see how important will be this view of the optical 45 telescope for exactly the most exciting point of a sleeve, the upper part of the dissection, just at the angle of his.

And then we have, of course, two other ports of 12 millimeters on the right and on the left side of the patient.

And lever retractor, it's a Cushieri 10 millimeter retractor fixed on support on the table.

So we are going to inspect now the abdominal cavity.

and we see of course a lot of fat here I can feel the thickness of the stomach it is usually for

such a male and we are going to dissect the greater curvature from the pylorus up to the

angle of his and we will do immediately but just look around to see the structure of the liver with

steatohepatitis this is the right lobe we we see here the gallbladder and see

around all the fat distributed all around in the patient's peritoneal

cavity so we will start off with the harmonic please give me the song

harmonic and and I am sure that everybody knows that it is better to

start over in the middle part of the stomach yeah okay and in now the

position of the patient is a little bit horizontal this is enough don't move the

table for the moment yes this is enough and we will start at the level

corresponding with the angle of the stomach we have two monitors and we will

be able to to watch the evolution of the operation entire team and we will start

here just close to the stomach with our harmonic 45 centimeter lengths just

entering in bursal mentalis and we as we do usually and then we will staple the

stomach with echelon in the meantime it is to be prepared the buttress material over the echelon

60. but of course we have to decide that

relative to the thickness of the stomach we have to decide what height what type of the

staples we are going to use probably we will start with the green now as we just enter in

we will go up for two three centimeters more and then i'm gonna dissect to the pylorus

freeing entire the greater curvature of the stomach all along the pylorus so this is enough

for the moment and now we will be orientating our dissecting line to the pilers of course we expect

all the time some posterior adherences in bursa mentalis this is the reason of starting over

at the middle part of the stomach this is the most convenient point and is less

risky for damaging any vascular structure being below now some adherence here are to be treated

in the meantime again again thank you and then we will move down caudally with our harmonic usually

Usually we can find here a lot of fat and should be treated layer by layer in order

to understand very well the anatomy of this part of the stomach in order to delineate

the both sides of the antrum and later on to adjust the staper here is already we have

the pillars here but we still have to dissect the posterior aspect of the antrum in order to

see very well all the structures here and to be sure that the jaws of our staplers will fit equal

on the abdominal wall on the gastric wall now professor i have to tell you that the images

go on simultaneously but you are in one of the major one now in this moment the audience is

able to see your procedure in wonderful images and perfect audio really big compliments of the

technicians okay and big compliments to your technicians because it's a it's a bilateral

effort we to transmit you to receive this high quality HD images and I'm

happy for this thank you to all of course we have to dissect here very

clear the posterior aspect of the stomach in order to understand very well

the anatomy of the posterior part of the stomach and to be sure that our new gastric cube will

be the product of an equal contribution of anterior and posterior part of the stomach

this is the reason of being a little bit

insistent in this area because we like to be very anatomic in our decision now of course we

discovered as usually a lot of posterior adhesions of the stomach and these are also to be treated

in order to understand exactly the size of the posterior aspect of the stomach if we don't do

do this then we will have a twisted stomach and we will have important functional problems with

the patients now I'm gonna try to understand which type of stapler is going to be prepared will be a

gold will be a green by checking with my forceps from my left hand introducing from the right

trocker and I am asking my assistant to prepare a green one with peristrepe

veritas then there is another thing that I want to mention to the participants

sometimes we find here adherences of the stomach to itself and this is very

important to find out because you will be facing the situation of stapling not

only two layers of the stomach but four layers imagine that sometimes and if you

look in details you find this situation with the stomach a little bit

imbricated inside and then when you put your stapler you are going to stapler

four layers of the stomach and you will have misfire this is an important

technical detail probably details probably most of you knows but let me

underline this very important thing for the just first firing of the stomach because later on we

will have for sure only two layers of the stomach this is the main important point where you can get

misfiring now we are going to dissect further up to angle of his I have introduced through the left

stroke our forceps that is handled by my second aid and now with my and the

stomach let me see the stomach is pulled to the right and to caudal now the

telescope is going to enter to the other optical trocker and from here the view

especially in those patients who have a lot of fat inside and have difficulties

I want to clean up the image don't compromise the quality of the image okay

that's perfect and I want to demonstrate the usage of this above place optical

Now I have a perfect view of the upper part of the stomach and I'm going to dissect more just being close to the stomach and going to the angle of his.

there are some other adherence please go up with me go up with me step by step trying to avoid any

bleeding in order to be sure that we see very well the structures that we are going to dissect

to divide there is an important landmark that we have to check all the time especially in those

patients who have a lot of fat and it will be very very difficult to

understand probably the anatomy in this area this is the sign of the left

cruise so we are going to orientate to the left course anyway we can see the

spleen here now you can observe that no instrument is going to grasp the fat

being left-sided to the stomach because this is very fragile and as pulling the stomach to the

right my dissecting space is going to be opened like a book as you can see so there is no effort

that you have to to or no traction that you have to apply to your stomach or fat no exaggerated

traction now go back a little bit I'm gonna replace my left hand my left forceps closer

closer to my dissection line and going up now now please go up go up with me go up with me okay

again we will be back on that line because we have to go out in outside from bursa mentalis

we have to dissect the diaphragm above as you will see the spleen is very close here and there

There is a very important trick that we have to understand

that I'm gonna demonstrate to you immediately.

I want some water, please.

My instrument is not slicing through the trocker,

so I cannot feel very well the structures inside.

Now, my left hand is pulling up the stomach,

and I am dissecting furthermore another step.

these are the last the most cranially distributed short gastric vessels and now I am back to see

two centimeters in order to to enter outside of bursa mentalis I want to see very clear this my

My left hand is grasping above, and you know, you would be all the time attracted by this point in order to dissect the vessels here.

But imagine that there are two layers of the serosa, one above and one below, and it will be very difficult for you to control the hemostasis.

will be risky with a lot of emotions when you dissect but if you come a little bit below and

you start to dissect the inferior part of of this serosa structures you go above bursa mentalis we

We are outside in the backside of the peritoneum,

and this is going to invite us very close to the diaphragm.

And then there will be no emotions for us

regarding the injury of some vessels in this area.

Then there is another point.

If we do insist very close to these vessels,

we can transmit a chemical effect to the vessels and these are carrying blood

direct to the portal system and there is an increased risk of portal thrombosis

so we have to stay as far as possible to these vessels and by approaching the

posterior aspect of the stomach as I could demonstrate I hope to you now we

can free up the entire part of the stomach that is on the posterior aspect

and everybody knows that the posterior aspect of the gastric fundus is bigger

in size than the anterior part of the stomach due to human anatomy so again

Then you see from this line where they were inserted, the gastric vessels, I could recuperate some like three centimeters below.

If you don't dissect this, then you will have a redundant stomach and your patient will not lose weight.

Then there is another risk of twisting the upper part of the stomach.

and of course you will have an important functional problem with your patient that

is not going to swallow even liquids in a proper way and this is an important cause

of reflux the de novo reflux that we observe in some of the sleeve patients now as I said

the five minutes ago we intend to dissect the diaphragm here we can see very well the left

cruise we have to free up the left cruise in order to be sure that we can see this is the

anterior aspect of the left cruise and just below just nearby we have the esophagus now we have to

to be satisfied with this dissection.

I don't want more, probably one here, but not too much,

because we still need vascular sources

for the posterior aspect of the stomach.

But please go down a little bit.

Please understand how much I could recuperate from here

to this point, where it was the insertion of the gastric,

the short gastric I want to go up please because there is a fat here that we have

to dissect in a clear and very well seen image please this fat is going to to be

dissected and we will be able to see in a very nice way the anatomy of the angle of his which

is just here below and then we will be able to orientate based on the exactly the anatomy of

the upper part of the stomach and the esogastric junction we can orientate our step of line because

we have to preserve five to ten millimeters of the stomach just close to the esophagus now we

have here the esophagus and the stepper line will follow this part if we have this fat here we will

be probably determined to fire to this point if we fire here then we have a pad of fat that is going

to cover very nicely as you will see the stepper line now we enter again with our 45 telescope

scope through the trocar that is placed close to the umbilicus and we will have a good view

of the inferior part of the stomach and this is very important especially in patients who have

an important size a big size of the stomach if you limit yourself to only one optical trocker

then will be difficult especially in this area we start at one to two centimeters from the

pylorus the pylorus is here this is one and a half centimeter from the pylorus uh i don't want to

dissect more and it's rare the occasion when i start directly from the pylorus why because from

my opinion the next step for all the operations uh the sleeve operations is a duodenal switch

So, I want to have still a virgin area here for my duodenal switch if it will be necessary in time.

But thinking about the BMI of this patient, probably a sleeve should be considered as a sole procedure.

Now, we have to consider the anterior part of the stomach and the posterior part of the stomach

to contribute equal to my to our gastric gastric tube new gastric tube again if there is no

imbrication exactly the greater curvature of the stomach should enter inside of the

of the jaws of the stapler exactly in the middle and we leave one two millimeters here because when

we will close the tissue will be stuck here and there is a risk of misfire if we don't do like

this at this point we didn't introduce any bougie inside of the stomach but is prepared and will

will come over, as you will be able to see in a minute,

through this channel that I already

performed in our patients.

Please.

Which size is the bougie, professional?

The bougie is a 36 French bougie.

And our colleagues, again, again, gold, please.

Gold, please, again.

We will go all along with gold and probably blue more.

now I am waiting for the bougie

this is the bougie

stop for a moment

and as I fired the first stapler

we have a channel here

please push a little bit

push a little bit

thank you

thank you

and my bougie will stay here

go above

go above

and we can see almost

with the help of this bougie

the line of our division of the stomach.

Now I have again from the left hand, this is the right-sided stroke, the second application.

And then probably we will move through the left stroke.

Again, we have to consider the principles of any stapling process in order to avoid any gap.

And this is mandatory to cross a little bit the previous line and to be parallel with the smaller curvature of the stomach.

mark at this point this is incisor angularis at this point at this point we

don't have to be so close to the bougie I feel the bougie here we have here

something like two three millimeters far I've repositioned again I'm looking for

crossing the previous line anterior again posterior and when I'm happy with

the position I'm closing the instrument and I'm gonna fire this is the gold one

with very severe it us now let me see what we did this is only incision

angularis we will start now from the right side with another one please okay

okay okay now now we we will be able to respect the direction to the angle of

his as you can see to the instrument and by by a voluntary attitude I'm gonna

to leave here a larger angle because this is exactly the incision angularis and in order to

prevent the bent of the bending of the very narrow gastric tube exactly at the crossing of the

horizontal with the vertical component of our longitudinal sleeve we have to leave some more

more space here at incisor angularis.

But this should be equal on anterior and on posterior.

So this gesture that I'm gonna demonstrate

should be all the time performed.

You see the orientation of my stapler

now it's a little bit to anterior.

So I have to open and reorientate

to go parallel with the small curvature,

then again anterior to check if it is correct.

All the time we have in mind that there is a difference in between posterior and anterior diameter of the stomach in favor of the posterior.

So in order to obtain an equal gastric tube, we have to orientate to the smaller curvature.

and now at the end of this firing my stepper line should stay at the middle part of our

gastric tube please clean up the image and again it is very useful the position of garden process

again it's very useful the positioning of the optical trocker above again crossing the previous

line parallel toward the angle of his and looking back to see what is the direction of my cartridge

again open up orientated parallel and then again anterior these are gestures that we do routinely

and now in order to prevent the retraction of the posterior aspect of

the stomach oriented 15 degrees to the right and again grasping there the

tissue and now after of course counting 10 to 15 seconds in order to compress

tissue we are going to fire again give me another one give me another one and

we should be happy or for seeing the stepped line just in the middle of at

the equatorial part of our gastric tube because stomach it's really a very

nervous organ okay okay go up go up and we we will notice soon a lot of

contractions of the of the stomach again this is anterior this is our direction

where I dissected again I want to see on the other side this is the other side

this is the posterior aspect of the stomach that is enlarged I open up I go

Go parallel with the smaller curvature and again anterior to see if there is no gap here

below, grasping down the stomach and put it parallel in the same way that I did it before

and I explained, counting 10 to 15 seconds and then fire with my gold echelon cartridge

and again I need another one please okay this is probably the last one on the step line that

we're going to approach this staplers that are misplaced we have to take it out and again you

see this fat that I dissected before it's going to be moved to the right and we can see very well

the angle of his please I want to see the other part sometimes you cannot slice up with your

cartridge because because of the posterior aspect of this fundus it is the same now now I'm slicing

up again anteriorly in order to see very well the orientation of my stapler the last part of

the stomach okay this is good this is good go up with me please go up with me okay and we

need to leave five to ten millimeters from esophagus in order to preserve the mechanism

is of of cardia and and the vascularization at this point we should

be happy with this grasping of the tissue again I'm trying to catch it in a

good position and then if we are firing too close to the esophagus there is a

risk of retraction of the upper part of the line inside of the inferior medias

Steiner and probably a greater risk for fistula at that point now I need Caesar

because I am sure that the entire stomach was here dissected there is no

more stomach here let me see let me see again yes there is no more stomach

everything is stiff it's stable and this fat pad is now covering very nice the

upper part of the stomach where is the greater risk of fistula now again the

cameraman is entering through the ombilical port and we are going to

withdraw the stomach out in the meantime we do ask our colleagues from the anesthesiology to

rise up the blood pressure of the patient because at this point we have 102 with 60 we will be not

happy with this blood pressure by seeing no drop of blood on the stepper line we have to check

exactly with 30% more blood pressure than usual to the patient and the patient has usually 15 so

we expect our colleagues from anesthesiology to rise up the blood pressure with neosinophrine up

to 17 or probably 18 and then we will check every point of the stepper line in

order to see if there is any bleeding from our experience no matter if we use

or we don't use but as material bleeding may occur so we have to check

intraoperative if there is any bleeding I want a forceps and now we are going to

see how the bougie that is still introduced inside of our stomach the

bougie is going to be withdrawn please take it out slowly take it out slowly

slowly slowly slowly slowly you see you see this the stepper line still remained on the

occurred equatorial part of the stomach and this is what I said this is the incision angularis we

left here some excessive tissue because this is exactly the crossing of the horizontal component

with the vertical component of the stomach if we follow exactly the margin

of this of the bougie then we will have less stomach here and this angle will

provoke a dented area and the liquid will pass with difficulty we will have

high pressure above and the risk of fistula now we are looking to the screen

of the monitor we have blood pressure almost 165 and now we will be able to

see some bleedings yes there are bleedings and this occur in the

afternoon where you sleep well and being satisfied about your operation you see

was no blood here, but now at this level of high pressure, we can notice some bleedings

and we want to take the occasion of making hemostasis now, not in the afternoon in emergency.

I think you understand very well what I mean.

It's a perfect professor.

Yeah, and it was really, for me, unpleasant in many occasions before starting over with this attitude to reoperate some patients,

knowing very well that at the end of the operation, it was no drop of blood.

Everything was perfect.

we could see again and again the videos of the previous operation there was no blood and then

we ask ourselves what's the problem what but it's going up in the afternoon as we left everything in

a proper condition and we got the answer the rising up of the blood pressure in the afternoon

is the cause of the post-operative bleedings and trying to increase the pressure during the

operation not only in sleeves but in all bariatric operations and on not only even in colorectal

surgeries and all kind of laparoscopic operation that we perform we rise up the blood pressure and

And let me tell you that in the last 1,000 sleeves, we had no re-operation for bleeding, post-operative bleeding.

Of course, never say never, but it seems for us to be a very efficient prevention method for our post-operative complications named bleeding.

Now, we are looking...

Professor, excuse me, but you just told us that in the last 1,000 liver sections you didn't have any bleeding.

But I beg your pardon, how many bariatric procedures are you performing each year?

It's a huge, huge number.

Big compliments.

Yeah, it's really a big number.

Probably we should be proud of the largest number of sleeves.

We have 1,700 sleeves in the last seven years.

And totally we've reached 4,000 bariatric procedures.

now let's let's see the nasogastric tube that it will be introduced by our anesthesiologist yes

please please go up with me go up with me I'm gonna help you a little bit please go go go go

go go go go this is the nasogastric tube the nasogastric tube is okay will will stay here

for 24 hours this is unpleasant for the patient probably is the most unpleasant aspect post

operatively but we are happy with this decompression of the very narrow sleeve that we performed and

And please introduce methylene blue.

Let's see.

Let's see now the shape of the stomach.

Okay.

Go up.

Go up.

Okay.

There is no leak.

And now we have to see again the stepper line.

We have to follow from the angle of his.

Go to the incisura angularis.

and then this is the original horizontal part sometimes I can tell you that the

operation is lasting less than half of the entire procedure I mean the division

of the stomach and the dissection and half of the precision is checking the

haemostasis I want this clip here is really checking wise to behave in such a

manner I think it yes yes because you should be happy of being a very rapid surgeon and leave

everything for the organism of the patient to heal up but we have to to check all the time in detail

every millimeter every millimeter of the operation then there is another thing we are looking in

in details i want a forceps now i want to demonstrate something the upper part of the

stomach the upper part of the stepper line should stay in the abdomen if this part is going up

through the hiatal you see this is another another point please another bleeding point

just touching a little bit the stepper line which is happening because

sometimes patients do have at least a sensation of vomiting they have nausea

and the stomach is going to be contracted and exactly what I

demonstrated now is going to be produced with the stepper line and this is

opening up as blood source what I wanted to say I want to complete is the upper

part of the stomach of the stepper line should stay here you see my excessive 5

millimeters tissue just left side into the esophagus so this should stay here

to prevent reflux and leakage in the mediastinum then again then there is

another aspect I have to underline regarding this clips of course there is

it will be a problem when we will intend to do a gastric bypass to this patient

if you want to fire through the line you have to remember how many staples you

placed and where you have to look back to your video anyway we we encounter all

the clips and it is noted in the computer that the clip application

should be limited to the stepper line because if I am gonna place a clip like

this crossing the normal stomach I mean not staple stomach for two three

millimeters and another stapler two millimeters below or above then I will

have an ischemia and for sure I will have there with all my good intentions

fistula at the level of the clips so we have to be also very cautious how we

place our clips not to cross over the stepper line of course there is another possibility to

oversee the stepper line and many of our colleagues do routinely this procedure we did the same for a

longer period of time that later on I understood that with my running suture

I'm gonna change the geometry of my stomach and I want to have a very

uniform gastric tube because it is very narrow and it is possible to provoke

these functionalities in emptying this very very narrow stomach now I'm

checking again we have almost 200 blood pressure thank you very much you can

decrease the blood pressure at this moment especially in young male you can

expect of a higher level of the blood pressure in the post-operative period no

matter if you try to control continuously the blood pressure and

And there is nothing you can do to prevent the bleeding.

Again, I want to see, again, from above, from above to below.

Go, go, go, go, go.

Okay, I am satisfied.

I am removing the Cushieri retractor from below of the left liver, as you can see.

And again, we are going to check every access port for bleedings.

And if necessary, yeah, there is a bleeding point there.

We will be again to check.

Please, please.

This is a terranomian port that we use routinely on the epigastric part, port.

because here there is an important risk of bleeding please put your finger here

then there is another one here okay in the meantime I want to close this this

port as you could see we used a fascia closure and a resolvable stitch was

It was passed twice through the abdominal wall.

That one, I don't know if you use the same name, Bersi, B-E-R-C-I.

Yes, it was a Bersi needle.

Yeah, definitely.

It was a Bersi needle from Karshtolz.

Yeah, it's a very good one.

And we will use again here.

There is a small bleeding.

We don't like to see blood in the operation.

Please give me again.

Keep the camera, please.

Keep the camera.

and we will pass again twice the abdominal wall please come with me this

is one yes it's a fascia closure for from castors okay take it out and again

this is another point we have to underline checking the ports of any

operation because bleedings may occur also from this part and we had the

chance of reoperating patients for exactly this complication so this is

probably the reason of being so patient exactly at the end of successful

operation so can compromise your post-operative course such a problem so

there is no bleeding now again please check again check again the stepper line like yeah there is no

blood here so we should be happy again the um yeah this is from the stomach this is very good

so please remove that troca and the last troca is going to be checked with the telescope as we

we will remove it slowly through this stroker.

As there is no bleeding, we thank you very much for being with us,

and I am waiting for questions from all the colleagues being there.

Well, Professor, as a matter of fact, I must tell you that there is no question

because everything was such in a way clear that everything was simply perfect.

I repeat, the images and the audio is perfect.

your explanations were I mean exhaustive and so everything looks like to be it has it has been

really a great occasion for us to see such a skill in performing these bariatric procedure anyway I

do have a question as you already performed so many operation I really think you are so happy

about the results you have with the sleeve resection as you told that this is male this

this young male of 41 and BMI 43, you told us,

and you really think this will be the sole operation for the treatment of his obesity.

So are you happy about your results?

Can you tell us something about it?

Probably it will remain a sole operation for this patient.

Actually, in our experience, from 30 to 40, up to 45 BMI,

the sleeve procedure may remain a solo procedure over the time we are so

excited about the result of this procedure as we are operating probably

85 of our surgeries sleeves now and the rest bypasses and very few got the

gastric bendings and some gastric placations and probably we have thinking

about the result of the operation and for the failure step we have to consider

a procedure that it is easy to be to be changed with another one and taking in

consideration bend plication sleeve VB G's any other procedure that you can

can consider as a first step, not a solid procedure, the most convenient one is sleeve.

You can do anything for a first step with the sleeve.

You can do probably a duodenal switch if there is no reflux.

If we have reflux, we will do a gastric bypass.

So, yes, we prefer SLEEV due to very good results that we encountered, including type 2 diabetes, including the patients with insulin.

They have a very good remission with SLEEV.

and the second important reason if we intend or we will be in the situation of changing the

procedure there we do of a sleeve it's a the simplest possibility there we have in bariatric

surgery thank you professor one more question when are you going to feed the patient and when

When are you going to discharge the patient?

The patient will stay for two days in the hospital.

All the patients will stay in the ICU over the first post-operative night.

This is our routine.

And starting with tomorrow, they will drink clear liquid,

and they will be discharged as soon they will be able to drink enough liquids

that are necessary for their body.

I mean, this is 1.5 up to 2 liters.

And this is happening around two days after the operation.

And then we see the patients after one week, one month, three months, ten months, six months, one year,

and then at every year recording any element of the follow-up in the European registry of IFSO

as we are Bariatric Center of Excellence.