ADAMO

okay just so when i do for a mini bypass i would put up the stabling port is in magical so that's

a stabling 12 accessory five that will help you know when you do then the section we open section

irrigation as well at some point please we can open everything thanks then the other port will

will be saving port there so my advice is learn to use both hands for the ports so and develop

the feeling of the port going through the domino wall so you don't have to look at it

so that's the advanced type of skills you need to require saves time not much but saves a bit

time leave a retractor please actually let me just have a look just one second please uh give

me the pretzel please the pretzel the pretzel can i buy some made up please that's fine for

I think we should speak in English, fortunately, for me.

The door of the chamber is out of the midline, on the patient's right,

and the two stapling ports are symmetrical,

and an accessory door from 5 is on the left side.

You said 42 of BMI?

42.

42.

42.

Do you prefer me to speak in English or in Italian? I'm the same.

We should speak in English, because we have internet connection with the world.

Okay, that's absolutely fine.

So, the others will understand me then.

So, the first part of the procedure is to create a gastric pouch.

Now, the technicality of the gastric pouch in a single anastomosis gastric bypass

is completely different from the gastric pouch in a gastric bypass.

The pouch has to be very long, and otherwise it will be by reflux.

And the pouch is normally created on the incisora.

So the first part of the procedure is to perigastric approach around the incisura on this side and

then do a 45 stapling transversely.

If you can hold the stomach there and lift it up.

Thank you.

Give the camera to Heidi.

So as an energy device, I'm using the Thunderbit to start, a bit of bleeding, a bit of color.

In the perigastric approach, the important thing is not to go too far away from the stomach,

otherwise it will bleed as it's bleeding now so we'll assist I'll use the

assistant attraction to grab the edge this instrument is still loose okay and

grab the edge and then coming with a camera like cable on the light on the

left please and just the focus that's a stomach wall that's the perigastric

approach in can be quite time-consuming sometime it's a lovely demonstration

demonstration. Camera clean, please. Quick, please. Sorry for the bleeding. A bit of London

flavor. Okay. Camera in, please, before we exsanguinate the patient. So I just grabbed

the vessel just before we lost you. And the bipolar hopefully should seal it. Job done.

okay so I grab the ligament and I'll try to go suction please the annoying thing

when you have a bleeding is you lose view okay that should be okay let's

start again closer please with the camera closer so the idea is to reach

the lesser suck it's not a huge dissection just enough to introduce a

stapler it's a combination of energy and just called the instrument and the

a blunt dissection, there are some veins that have to be divided, nothing exciting at this

stage, and we are reaching the lesser sac. If you have no great view, what you can do,

you can move the assistance grasper proximal to the line of the dissection to lift up the

posterior part, and that's a reasonable window. And in bariatric care, the dissection is always

minimal. That's the difference with cancer surgery. We try to go straight to the point

to save time.

So that's the back

axis. I'm comfortable

enough that I've got enough space.

If I'm not, I will do more

in this section.

That's done. It's not very pretty

but it's functional.

Thank you. Staple, please. Is anything in the

stomach?

Can you

bring it back into the esophagus, please?

So the first stapling will be

a 45.

Remove this one, please.

from my left hand

and of course we are making sure

there is nothing in the stomach

otherwise we will cross table it

so I tend to use

a 45 purple

and I will give it a full

angle

so some technical

I always use the anvil

on the lower side

trying to get as much

as low as possible

so we are at the corner

we are checking now that we go enough space

in the remnant, otherwise the remnant can get blocked.

There have been a couple of cases reported in literature

of the remnant being blocked.

So that's a 45, a full 45, fairly straightforward.

So you just come over to me. Thank you.

Mount a 60, please.

Man, can you introduce the tube into the stomach?

Would you mind?

Would you mind to repeat the caliber of the...

It's a 34 French gastric tube.

It's not going to be used as a bougie.

It's not a caliper.

It's just a guide.

Okay, so that's the tube.

It's pretty obvious.

That's the space there.

Staple, please.

So now the patient is severely hypertensive.

And what we learn in mini gastric bypass is we have a long staple line,

like in a sleek gastrectomy.

So I will reinforce the staple line with separate reinforcement

to prevent or minimize the risk of bleeding and that's a trick I've learned

from a professor Chevalier in Paris who has done about thousands of this bleeding

stable and bleeding is one of the probably most common complication you'll

see in gastric bypass yes there was it was a question they would ask so of

course I know it's not like in silly gastrectomy we have the leak issue but

But there is a bleeding issue.

So now from a technical perspective, putting a reinforcement on the staple line,

it makes it slightly more difficult in terms of accessing.

Can you go grab that corner, please?

Accessing the back of the stomach.

Thank you.

See, minimal dissection.

I just introduced the stapler.

Before locking the stapler, I'll make sure that there are no any distortion or any twists.

No, that's fine.

Okay, so I'm not anywhere near close to the bougie.

Can we wiggle it, please?

So every time you use a bougie,

always make sure it's not caught in the staple line.

That's what I always tell my juniors.

Okay, again, please.

Thank you, back in.

Okay, strings out.

Strings, strings, strings.

You can remove your grasp, thanks, Lima.

And then I prefer power staplers.

This is manual.

It's quite hard to fire when you have the reinforcement.

But today, we ran out of the power one.

Okay, that's done.

Reload please. Grasper please. So you see it's a lovely plane. Of course we don't want to get too much of the back of the fundus.

It only takes about four firings. The important thing is always remove the misfire staplers at the corner like this one.

Otherwise it may impact on the blade and ruin the staple line. Small tricks.

step so again I engage in the V of the previous staple line I don't want to

like I don't like when there is reinforcement I don't like to over

staple the staple lines okay bougie please wiggle come back with a camera

fraction please thank you in perfect strings so that's why this procedure is

becoming very popular it's fairly straightforward to do compared to a

runway gastric bypass okay reload please so what I'm not done yet is I'm not

than any dissection at the aethos.

It will be done later on.

The original inventor of the procedure,

Dr. Rudgeledge,

claims that you don't need to do any dissection of the aethos,

but I'm not sure this can be followed.

So what I'll do, I'll fire another shot,

and then I'll go to the aethos

and then check if there is a hernia,

and then complete the stapling.

I can see, actually,

it looks like there is an aethos hernia there.

Interesting, in patients with endoscopy,

before surgery, showing there was no

eye to cernia, but I'm not

sure if they were right.

Unfortunately, nowadays, most endoscopies

are done by gastroenterologists, not by surgeons.

And occasionally, you get

surprises.

Okay, so what I'll do,

I'll just...

It's not like a legal strike when I make

a big effort in trying to just leave it,

just to make sure that I don't get very tight

to the bougie. Here, it's fairly loose on the bougie.

The bougie is just for

safety. Not to make it too tight.

Bougie, please. Wiggle it.

So the main difference of this procedure from a standard

gastric bypass, this is actually malabsorptive, rather

than providing severe gastric restriction.

Patients tend to have loose stools rather than constipation, as you normally see

in a runway gastric bypass. Thank you. Reload, please.

Same 60 with SIM card, please.

Could you grab this, please? Pull it over still.

So we are approaching the end.

So what I'm going to do now is put the patient in a steep ante-tendelburg.

Can I have more head up, please? Sorry, man.

Can I have more head up? Thank you.

So increasing the ante-tendelburg, you get better access. Thank you.

So now I will grab the back. Thank you.

So you have a reasonable view in this patient.

BMI is not very high. This is fairly straightforward.

forward so what I'll do I will create a bit of window at the back coming close

with the camera so remember the concept is minimal dissection we always tend to

do too much that's more than enough then we go to the top if you go up there

please I got that the Betsy fat part you can see there is an eye to Cernia which

means I will address it and it's questionable some surgeons not address

it come closer please grab the remnant thank you but not at this stage I will

complete the stapling first that's the ligament so always use the energy device

as a blunt dissector as well that saves me time rather than using a Maryland

okay that's pretty much the window for the stapler you can see that there is

that's the cruise which I will dissect and repair now repairing this in a mini

bypass is controversial some surgeons don't and I feel like even the patient

has got no symptomatic reflux,

I think it would be potentially dangerous

to the living eye, to Cernia.

So I will repair it.

Okay, that's probably okay.

Come back, please.

Stapler, please.

I'll have one gogete stitch available, please.

The gogete one.

So again, I'll just go to the previous V

of the stapling,

close it to the spleen.

Try not to staple the spleen, of course.

It's usually not good.

Pull it down.

Yeah, perfect.

Okay.

bougie please thank you perfect so in a sleigh gastrectomy going so far away

from the GJ will be in my opinion a mistake leaving all these fundus all

this stomach the mini bypass makes no difference at all thank you we probably

missed it let's have a look lift it up maybe a short gastric no that's not

It's not a short gastric. The short gastric is a little blood-dominant.

This is just a little squirt.

It's one of the posterior veins.

Just me being careless sometimes.

Just to provide a bit of entertainment for the guests.

I love the suction, please.

I just made the window a bit too medial from my stapler.

That was the problem.

And now I'm approaching splint territory anyway.

way so the other option is to control complete the stapling and then control the achieve the

mosesi afterwards um sorry just pressing the port otherwise it won't reach it give me this one please

um okay i think i'll do that actually i can't really start ligament you can see the spleen at

the back so it's very uncommon getting splenic injuries doing this type of surgery but it's not

impossible and there is no limit to talent so that's the spleen is there sometimes you get

polar veins. So I'll have the next one, I'll have it without

seam guard, please. Without seam guard.

I will cross this way rather than progress there and then finish

off later. I feel like if we progress this way, we are very close to the

splenic vessels and unnecessary risk. So I am happy

to accept the compromise because we nearly finished the stapling.

But because I already got a layer of seam guard there, I

don't want to double it up otherwise the cartridges might be not big enough okay

let me look please thank you show me the tip of the gun please yeah camera light

on the left camera straight ID thank you okay let me just show that I just don't

like this weakness a pull towards to you thank you perfect that's a staple across

cross. It looks very unpretty, but sometimes that's what it is. Okay. Okay. You're cleaning

up, making sure we are not leaving any stomach behind. Closer to the camera. Camera close,

please. Camera close. Okay. This is just fat. Okay. I'll complete the freeing up of this

corner. Camera in, please. Okay. That's complete. Okay. You can drop the remnant. So now I want

to concentrate one second on the hiatus and this eye needs to be done. Okay, close it,

midline please, thank you. If you grab this, grab it from the seam guard, grab it from

the seam guard. No, just grab the seam guard, you know the stomach, and then pull it towards

to you. No, no, towards to you, towards to you. I want to assess this corner. So it's

It's quite fatty, I just...

Wow.

Come on, guys.

Sorry.

Trying to assess what's the best strategy.

That's the edge of the crust there.

I can dissect from there

and then get a view of the hernia,

which is actually there.

Okay.

So the question is,

360 degree of dissection,

270 dissection.

I just do as less as needed.

because that was going to be an additional procedure okay it's quite a quite significant

lump of fat and yet true which is quite hard and i'm trying to reduce it interesting isn't it

it's not uncommon to see these ernias in bariatrics if you look for it you will find it

okay the landmark here is this one with the cross that's your landmark um so this has been mostly

that's the reflection of the peytonium as you all know that's what we're

looking for so I can now separate the part from the cross if you're in the

right plane you can do that with blunt dissection okay so probably if you all

this one with the grasper rather the stomach is probably easier thank you so

So now we can see the lining of the GOJ and the repetitive reflection

and separate this one from the cross.

There's no need to use any energy at this stage,

just reduce the fat from the mediastinum, the abdomen.

It's like a treasure hunt, more than we bargained for.

Now it's been reduced. That's the space.

So it looks like nothing and ended up being actually quite a lot.

but do you think there's any hernia i i don't know if this is only fat or i there's a i'm

reducing the part we're doing we're doing much of anti-anti-reflex surgery and for type three and

four hiatal hernia i've never seen a configuration like this i do lots of uh as well as well

Yeah, Sergio as well.

Unfortunately, in the morbidly obese,

it's a different ball game.

Now, it's just difficult to define the anatomy

because of the fat.

And then the choice is either you leave it,

and when they lose weight, you address the problem,

which is an option,

or you are more aggressive.

Come closer, please.

I had lots of patients operated on with the sleeves

or bypass.

And then I had to be operated on for eye to cell repair

I'm just thinking I want to assess the situation, and then when this has been all reduced now,

that's the crux there, so now I can address the ligament there, but one option would be

to do nothing at all.

So I'll just divide the patella and then get the fat down, get to the muscle.

It's probably unnecessary work, or something you can do in the second time.

No, I don't think so.

I don't think so.

or you think it's needed?

I think so

probably it's unclear

the anatomy is still not entirely clear

and that's the reflection

so that's helpful

I can push this one back

when you operate in non-obese patients

these patients are very very

come back to the camera please, camera straight

so I'll take a break and I'll see where we are

just I don't want to focus

too much in one single point

come back please so that's the gastric pouch with the tube in so the bush is

still in come back into the hiatus this is fairly clear now that's the defect

that's the bush down there so this is above it so this one can be opened up

safely and then perhaps we have to address the other side as well now thank

you one of the things in bariatric surgery during the year so what we've

been doing more and more is this type of job vital dissection there was something not done at the

beginning come back with the camera i'm still not doing a standard dissection because normally i

would start in the pars flaccida down there at the moment i'm still addressing the aedus

closer please see how much i need to do really um that's the muscle down there finally so what i

can do is follow the line of the section i just created there put the stomach a bit more on the

the left thank you that's the perimysium of the cross that's the space i just created

it just ain't clear just ain't clear so we just have to proceed more slowly that's the

ligament there okay can you wiggle the bougie please man can you wiggle the bougie would you

mind so just uh if i wiggle the bougie yeah you know out please that's why i'm i'm the joy just

Just wiggle it.

Just wiggle it.

Don't push it.

Just wiggle it.

Okay.

Oh, no, I can't really see much.

So it's buried under the fat here, so it's fine.

So I can always do blunt dissection.

I don't need to do any energy.

And when I've got these small veins, I can divide them, pull it down.

Of course, I don't want to open the pleura either because that's not good for the patient.

Okay, so bring it back to straight, please.

Orientation is not ideal in this case.

The last thing you want is bleeding.

Corner.

That's the crux.

That's the ABC down the back of there.

Just let me just open this one a bit more.

Okay.

Let's get just more light.

The latage branch should be just there.

If we can press it.

Pressing it is not really important.

And I just need to scale this corner here.

Okay.

So now we are sort of completing our anterior dissection of the aegis, if you like.

Now the crux are becoming more obvious by peeling off all the fat.

Okay.

It's more vain.

Just ripped. I like having the option of the bipolar when I do this type of surgery.

But there's the option to seal a vessel without dividing. I think it's a plus.

That's the space we're up for between the cross and the G.O.J.

There's a space there. OK. So release your grasp, please.

See if you can grab this fat and push it down. So that's the space at the top.

some veins there, the problem is they tend to bleed, okay, probably be slightly more

careful than I should be, but I don't like holes in the esophagus.

That's opened up, there's a reasonable dissection, so the question is should we address the back

as well and that's something we need to decide now come back please so that's

all all the stuff that was stuffed in it's been removed that's the the cross

followed up that's the apex that's the bottom so the question is any defect at

the back ideally I would prefer a posterior repair which is possible of

course okay if you can come up with a camera on the corner there we just

assess this corner now so it seems to me that there is no any big defect at the back so i can

potentially compromise come back please and do a repair at the top just an anterior repair with a

couple of stitches and then i proceeded the bypass i love the um gogetex stitch it's slightly longer

please so i can use it twice so the bush is still in place that's right that's fine what kind of

What kind of material is this here, John?

It's a Gore-Tex.

Gore-Tex, okay.

I started using the Gore-Tex the last couple of years.

It's slightly more elastic.

It's not too expensive.

And I quite like it for idle repair.

The only difference with a normal stitch

is you have to put slightly more throws to secure the knot.

It's good quality material.

I'll have a scissors, please.

Thanks.

Another one, please.

I think another stitch down there

it should be should be okay to cover it yes i agree yes thanks i know anterior repair is not

perfect uh by textbook we should do a posterior repair and possibly anterior as well but

should be complicated in this case yes it's probably a good compromise definitely better

than doing nothing on the idols but at least that's my feeling yeah the sutra handle slightly

slightly different from an 80 bond but after a bit you get used to it and this

I like the fact it's really more plastic so it's like more rubber so it's more

elastic so hopefully should should less chance to cut through the muscle okay

that's fine do you use meshes well I normally use

meshes yes in bariatrics no no no I'm talking about hiatus repair yes I

I normally do absorbable meshes to reinforce the repair.

Bio-A?

Yeah, bio-A, if there is a weakness in the edges.

In bariatrics, I always use it.

The problem I'm using in this case is I don't have a posterior ground,

so if I use it, I'll do it upside down, which is still, you can still do it.

I don't think it will be needed.

What would you do?

Would you use a bio-A in this case?

No, no, in this case, no.

No, no, no.

not okay but we're using biological meshes okay so I'm just checking the

repair now so the bush is still in place so that's there there's a bulk of it

esophagus should be still in one piece there's a bit of gap there you

potentially could take another stitch there I don't want to close this and

this otherwise it would be too tight.

phage okay all right and then with a malabsorptive procedure as well i don't want to cause it too

much so it's in it's okay consider the anatomy the amount of fat i can't really be displeased

um so we can now what i'll do now i'll leave as it is and i will move to the infracolic compartment

to measure the the limbs okay come back please can we have the patient fluttered please now

yes that's fine thank you come back with the camera look down so that's the

unpleasant part of the procedure we have to look down you have to go down the

triads just keep it like this okay so I'm moving that and do you divide the

momentum no if there is a not really I will always divide it for a wrong wire

but not for a loop anastomosis so if you grab the epiploid I'll grab this one

And thank you, I lift.

So we lift the transverse colon.

It's fairly heavy.

So just push it rather than lift it up.

Yeah, that's fine.

So that's the transverse mesocolon.

That's the trites.

It's fairly obvious.

So normally I measure 150 to 200 centimeters.

It's like a contention at the moment

how long should be the limb.

limb. I tend to do the measurements I estimate, because I don't have a marker on the grasper,

but I still measure on the anti-mesenteric. That's a 10 centimeter border, scoping arrow

style. So stretching on the anti-mesenteric border, that's a 20, that's a 30. And of course,

the bowel is looping, it will be this way, which means that the efferent limb will come

coming from the left of the screen,

the afternoon limb will come from the right of the screen.

So that's 30, that's 40, that's, show me that please,

50, that's 60, that's 70, that's 80.

Just to keep the camera straight please,

straight the camera, thank you, 90,

meter, meter 10, meter 20, meter 30,

meter 40, and meter 50.

So the question is, and that's a debate at the moment we have in bariatrics,

is should we stop here at 150 or make it 2 meters?

So some surgeons use a BMI approach.

Above 50, they do 2 meters.

Below 50, they do 150.

In these patients, BMI is 41, 42.

So probably 150 should be enough.

Of course, we want to balance the metabolic effect to the risk of malabsorption, malnutrition.

So I think 150 would be okay.

Okay, show me that.

please remove the column please so if you can grab the bowel there so see there is no big deal

the bowel reach very easily the anastomosis is very low so there is no need to split the

momentum if you can grab the bowel there just just clean that clean the instruments okay it's

fine so now we are matter of doing anastomosis so i would probably do an entrotomy around here

and then an entrotomy around there at the corner and i will ask them all this part

this is the boring part of the procedure so I'll make the entrotomy in the

stomach first so I use the ultrasonic drill okay so I'm through now so I just

I cannot stretch it or use more power I tend not to make it too big and then

introduce the instrument so we are in the in the stomach lumen now can you

withdraw the tube now please it's about five ten centimeters that's fine thank

you that's perfect so that's the entrotomy there so the other entrotomy

would be done in the anti-mesentery border so it's around there okay so again I'll press first

I'll fire once I'm through I stop and then I'll rip it I'll have a 45 tan please I use a 45

cartridge you have the option of using 35 or 45 I think is 45 is better from a technical

perspective I'm not a big fan of this anastomosis I use normally silk cross stapler for the gash

run wise so I will use it there I will put the anvil into the bowel and the

sorry the catch into the bowel and the anvil into the stomach so there is no

tension it's fairly relaxed and make sure everything's nice nice and flat the

patient is not on head up at the moment okay come closer please the camera so

before firing just do not just just fine let's just leave it leave it just align

the bubble in front of the gun align the bowel in front again you know they want

in front of the gun if you align it push it push it up push it up yeah push it so i can that's fine

it's fine that's perfect so now i will so it's better to suspend them for a couple of minutes

just to make sure you are perfectly happy with the stapler before firing it that's fine so that's

the result we can relax thank you so the back is free that's the reasonable so can you wiggle the

bush to make sure it's not caught please is it free back it back put it back into the surface

so that's

stapling and then

I will close the entrotomy

with two vacuum tools

some people does it

straight in the middle to the staple line

I prefer to use a virgin

stomach

suturing, I'm not particularly

convinced by the seromuscular

old fashioned suturing

in laparoscopic surgery

we buried lots of myth

so it was just simply for thickness okay come back with see be a longer this

stitch was it be longer that's all I just made and you don't use locking with

suture grapes no we lock no I know but you like the V lock pardon I don't

particularly like the V lock I can see it could be very useful for this but no

I tend to use a standard backer tool and it is slightly cheaper as well so I have

to make an effort sometimes to save money. And also for training, most of the time this

part of the procedure is done by a trainee. I want them to learn to suture with the normal

sutures rather than a V-lock. I don't want to make it too easy for them. So that's the

reason why I don't use a stapler for closing this part. Some people use a stapler to close

centrotomy I think okay so what I'll do I'll pass two or three stitches I will

put a stitch at the top and I will pass the bougie back into the anastomosis to

make sure I'll have some form of calibration the focus is not brilliant

is that me sorry this is true that's to this Rosa

that's the Rosa there if I'm not happy with the stitching I'll put a second

layer and of course I always put a second layer because I'm always want to

make it look pretty and that's that's the problem with stitching you always make it look nice okay

mucosa just protruding and okay so that's pretty much okay so can we pass actually let's pass it

put the other stitch there and then we pass the tube stitch please oh thank you tend to use a

straight needle holder so some people prefer curved but it's not very big difference oh thank

you this length is perfect thank you very much i think this procedure is becoming more and more

popular because it's very it's easier has got more room for mistakes and it's

easier to create anastomosis at the bottom of the stomach rather than the

top especially in men with central obesity like this one and then by

definition you don't have to close the defects because that's what the

procedure is saying that's the data saying so it's a less technical hustle

But the reality is that probably the function of the procedure is actually slightly better

than the wrong one.

Because of the added malabsorption.

I think there are still lots of things we don't know about this procedure.

So that's why in most institutions we have started a new program to start evaluating.

Do you think the long-term results in terms of the EWL will be the same as...

Yes, what we focus on at the moment is trying to understand more the physiopathology

of the procedure and the way it works. So all our single nostril bypass we go with test meals

and we're going to test the gut hormone profile. Okay because it has the same effects on diabetes

like gastric bypass. The claimed effect is even better. Even better. So we we have a population

in this hospital about 2,000 gastric bypasses and the results are pretty good but there are

some questions, some problems

with gastric bypass

which are becoming more

obvious. One is weight regain. We have about

20% weight regain in the long term

compared with other series.

And also a large number of patients with reactive

hypoglycemia, which doesn't seem

to be as frequent

in the mini-bypass. Okay, can we pass the

tube through the anastomosis, please?

So now go stitch, stitch, pass the tube through.

Some of these

steps of the procedure are just

us the safety checks and you have to understand some of the procedure are not done by me or one

of the other surgeons just done by training surgeons under supervision so it's important

for us to have a safe just quite quick so slowly slowly slowly otherwise we'll perforate and then

we will we'll have to do more work that's perfect thank you very much so we have a safety steps in

place to make sure that we minimize the chance of complications plus you know we sometimes we

we do mistakes as well so it's nice to make sure you have a safety uh safety checks okay

you leave this tube nasogastric tube for how long no no no the tuba will be out at the end

of the procedure okay pressure will drink tonight it will be on free fluids yes and

And if the blood pressure is controlled, if he's fine, he will go home tomorrow.

So we have one or two hospital, two days hospital stay for bariatric patients.

He has no diabetes, so there is no really any reason to optimize his diabetes.

So I know that in Italy, usually length of stay is slightly longer for various reasons.

No, no, no, no, we're doing it, no, at my institution, yes.

Most centers are now moving to a fast track enhanced recovery.

Provided the patient lives in a reasonable surrounding, okay?

Well, that's the problem.

This patient is coming from Norwich, which is about two hours away.

So, you know, we have criteria for discharge.

The problem, every time you do enhanced recovery, you have to audit the results

and make sure your readmission rate is not too high.

we probably send home the next day

around a third of our patients

we are aiming to send 50%

to the patient but still

we have not achieved that

that's in the public sector

in the private sector where patients have to pay

by their own pocket

most patients go home the next day

excuse me?

they pay on their own pocket and?

they go home the next day

they don't want to pay extra day

so it is safe to send patients home the next day

according the patient as well and now everyone agree on that mini bypass they've got the advantage

of there's no any extraction site like you're having a sleeve gastrectomy so they have a very

less pain um okay can you quickly uh wiggle the tube a bit to make sure i'm not caught into a

stitch thank you perfect say again make a huge use of the bougie to make sure i don't uh i don't

close

don't stitch it on

it's very embarrassing when you put a stitch a bit deeper

and you end up catching the

bougie, it's very embarrassing

ok, we're trying to

and in check can it die

through the nasogastric tube

I will do a leak test

a leak test with a blue

with air

I'll flood the anastomosis with saline

and I'll do a leak test

the reason for a leak test is so I can

wash out at the same time

I'm going to cut the needle, please.

Needle back.

So the other technical aspects at this stage.

Okay, thank you.

I will, of course, check, see if I want to put any two layers just to bury this part.

And then I will do an astromosis.

Hold it, please.

Grasp it, please.

Actually, no, sorry.

I'll go this.

So the things I will do, I'll also put a stitch on the afferent limb to make sure there is

no acute angle between the biliopancreatic and the alimentary.

the main case is where

if this angle becomes too steep

then this limb gets obstructed

so it is a good

practice to hook

this part of the limb to the

stomach

some people do that for anti-reflux, I do it simply

for improving, make sure the anastomosis

doesn't twist, I know that some surgeons

also hook the efferent

limb to the remnant

so there are various techniques

at this stage, so I'll have another stitch

This is simply over and over, just to bury the suture line, just to make it look pretty.

There is no need to do that. Most of us do additional procedures for peace of mind, for habit, for superstition.

Like my old surgeon said, it's a sacrifice to divinity waiting for heredity.

Yes, I agree. That's a good way of saying that.

Thank you. Another stitch, please. We need two stitches in total.

It's not brilliant, isn't it? Thank you.

Can I have the table down a bit, would you mind?

And when did you switch from traditional gastric bypass to this procedure?

Well, I've not switched completely.

We started incorporating a mini bypass in this institution one and a half year ago.

We have not done a complete switch.

I think the Rome Y has got a huge role in revisions,

especially if there is a significant reflux.

It does remain the procedure of choice.

Let's say probably at the moment the co-inter-split between Rome Y closer to Prisacama

and Mini is about 50-50.

We have ongoing research projects also with the Rome Y gastric bypass.

us and so we we need also to complete the randomization and for some of the

trials we're doing so it's let's say we have another another option and it's

something we have been able waiting for many years without you without you doing

it I just wanted to see the long-term outcomes and the longer terms are very

good so we decided to take it on as an institution and I think you know there

There are lots of technical elements of this operation which have to be addressed and then

especially if a run by gastric bypass surgery has moved to this operation, there are elements

they need to be...

Oh, it's a bit loose this one.

It's okay.

It's still all right.

Cut it, please.

Okay.

Still got a bit of stitch there.

I have to put another stitch there and then I will finish off this pathetic stitch there.

So what I'll do before putting the additional stitch to secure the anastomosis, the anti-kink

stitch i will leak test it thank you so oh what's this what's the needle check the port check the

portrait here is thank you the back is please so man we're doing a leak test so the tube is there

just across the anastomosis i used the back is to clamp the bowel ready when you are so use a

6 ml of air and the cricoid compression to blow the gastric tube and the anastomosis thank you

perfect blow up so yeah no bubbles we're happy so we'll aspirate and remove the tube thank you

so i like that leak test because pragmatically you are also doing a final washout

at the same time did you leave any drain no no i don't leave drains okay so leaks are not a

problem with this operation I said the operation the problem could be staple

I'm bleeding but I just suspected that it'd be okay always says when you do

this with the sucker don't careful to explain I've seen lots of many spleen

injuries caused by their the sucker it's okay that's fine that's fine come back

please so put the last stitch now and then we're done stitch please so I'll do

Come in, please.

Got a camera?

So, again, anti-mesenteric around there.

Okay, just leave it, leave it, leave it.

Then around there.

And how is your experience with the Pettersen or post-operative?

So, we, well, we have no,

we have no idea with the mini bypass,

and it's questionable if you can have it.

Yes.

I know that some surgeons start to do a closure or at least an attempt to close the defect.

I don't think the data at the moment is suggesting that we have to close it for meaning.

For Rome Y, yes.

For Rome Y, we advocate a closure, and our society is now producing a statement

where we advocate closure for the Rome Y, for the Peterson, but not for this.

I know it's an odd topic.

I guess we'll have to see what happens when we've done a large population and then followed them up for a long time.

Okay.

So, again, this stitch, not everybody does it.

I had a couple of patients where the anastomosis got kinked, and then they had a slower recovery.

So I prefer just to anchor this. It's only one stitch.

And how did you solve it?

Sorry? How did you solve it, the twist?

Yeah, that will, that will, that will, oh, the twist, I had to take the patient back

to theater to put this stitch. Ah, okay.

So that's why, that's why, that's why now I'm more keen to put a stitch. I know that

there are some surgeons, they also will stitch this there. I normally don't, don't think

this is the case so procedure is complete we have a loop anastomosis um 150 centimeter from the trites

with a long gastric pouch and we've done the anterior eye to senior repair

um and so far so good so patient will go to intensive care because of the obstructive

sleep apnea and it will be discharged rather day one or day two depending on how he's progressing

and now only no drains.

Is that okay?

Yes.

Allora complimenti e grazie anche da parte di Giorgio Palazzini.

Devo dirti che ieri abbiamo avuto 2000 accessi

all'internet dal mondo.

I dati di oggi ancora non ce li ho,

però l'Odias qua è sempre piena come tutti gli anni,

quindi direi che è una bella esposizione.

È un congresso meraviglioso

perché si concentra sulla tecnica.

Especially in bariatrics, now everything is focused on metabolism, on research, and we forget the technique, so I am a great supporter of the Congress.

Great compliments. Do you think you can transmit something else or is this all in the program?

We have a slip later. If you want, if you have space, we can transmit it. It's not a problem.

I agree with the professor.

Again, congratulations and thank you.

Thank you. See you later.