C. COPAESCU Gastric sleeve gastrectomy

yes we are again in the air let's say okay okay thank you we start again with a sleeve resection

but this time we are using eric on johnson and johnson instruments we have a harmonic case here

on my right hand the trockers are placed similar with the first procedure yeah okay there's

something with the instrument please okay thank you very much was not calibrated testing process

thank you very much okay so the trochers are placed in the same position as i showed you

in the previous surgery we used routinely six trochers one at the umbilicus an optical troca

One a little bit above in order to see very well the esogastric junction, 10 centimeters

above.

One at the epigastric area for the liver retractor in the left and right abdominal quadrant for

the left and right hand of the surgeon two of 12 millimeters and another one of 548 as i said

we are now entering in bursa mentalis the lesser sock is opened and the beginning of this procedure

This procedure will be initiated by the level of angle of the stomach because here it's

supposed to have less posterior adherences than in other places, gastro-pancreatic or

gastro-gastric adherences.

Now, we are going downwards on a caudally direction, staying close to the stomach and

going towards the pylorus, keeping the line parallel with the antrum, which is going to

be freed.

We have here the pylorus, there is the end of the dissection, all this fat that is going to be an obstacle for a good firing is going to be dissected.

now we can see very well the posterior aspect of the stomach with as you all

know harmonic case is a very nice instrument for delicate dissection and

it's a very rapid one very efficient may ask a question please I'm listening to

you okay and the BMI of a patient the BMI of a patient is 44 it's again a

woman 46 years old BMI very convenient for this operation as a sole procedure I

can tell you especially in in women we have to free all these utterances and we can do very easy

with a hook with monopolar we can do with a harmonic as well with other energy device

my left hand is hanging up the stomach to the abdominal wall and my right hand

is dealing with this very nice energy instrument okay by this moment we can

see the pancreas behind the stomach here and the stomach is freed in its inferior

part enough I want to clear the image please clean the front lens and give me

an external view please in the meantime okay okay we are again inside I hope

that you have a better image than before yes this is good even before but now is

yeah yeah because of the steam that is yes producing by the instrument we have

have to clean all the time.

Now, again, I want to check if there

are some additions in between the two parts of the stomach,

I mean the anterior and the posterior part of the stomach.

And this may facilitate a very proper firing of the staper.

So this is something that anyone who

who deal with the gastric sleeve resections

should check about, especially at this point

when we cross the border.

There is an important risk here because

of the gastro-gastro-adherences to get in between the jaws

of the staplers, not two layers, not towards posterior

and anterior, but four because of those adherences I was referring about.

So this is very important to see if it's something to delineate here,

and I'm happy with this situation.

Anyway, I will start with the gold one.

Now, my second aid on my right side, on the left of the patient,

it's grasping the stomach at the line of the angle of the stomach

and it's pulling to the right, that's enough

it's pulling to the right and it's opening like a book

this space where we are going to dissect more towards the angle of his

okay going up going up thank you very much we just opened a valve to let the

steam to go out the image is a little bit bluer than in a previous case when

we use another energy device but I can tell you that this harmonic case it's

It's very efficient.

I like this new generation of surgery, energy, then again, my left hand is grasping a little

bit the stomach, not too much tension because we will be at the risk of detaching the utterances

of the gastro splenic ligament to the spleen and then we can injury the capsule

of the spleen and then we need additional hemostasis to an organ that

we have to leave intact step by step not too big steps because you see bleeding

may occur now I am using it okay the other option not the rapid one but the

slow one of the harmonic okay probably the pulling was too hard so not enough

time for the hemostasis okay again let's see if we have something more no it's

okay again going up going up small steps we have a very important landmark at the

12 hours of the our screen this is the inferior phrenic vessels yeah so we see

that there will be the end point of the dissection I am telling you this because

because sometimes there is a lot of fat here

and we cannot see very well the landmarks

and we are going to be orientated in our maneuvers

by that vessel, it's very important.

You have noticed that I replaced the position of my aid

in order to open the book as wide as possible, the book.

behind the stomach okay small steps any bleeding at this point may determine

additional difficulty to our dissection sometimes the stomach should be emptied

with the help of the anesthesiologist by suctioning its liquid from inside now

let's see the landmarks here is the spleen okay now I will ask the

cameraman to switch the trockers the optical trockers and he will enter

the staplers, especially at this very sensible point where most of the fistulas are going

to occur.

So in order to prevent fistulas, we have to be very careful about the nutritional support

of this area and the way of stapling this tissue.

And if you notice, I am not using energy very close to the stomach that is going to remain here on the gastric tube.

I am now cutting the tissue that we have to detach far from the esophagus, far from the stomach that is going to remain here.

Now, we have our landmark, which should be freed.

We have to cut all these posterior aspects of the stomach because otherwise a remnant

and stomach here, the redundant one will remain, and this will limit very much the weight loss

process.

So we have to dissect very well the posterior aspect of the gastric fundus, especially in

this area and this is something that differs very very much from our initial

experience in performing gastric sleeve now we are much more let's say

aggressive here in dissecting the stomach in freeing the left cruise and

And now please check with me the landmarks.

Here is the left cruise.

Here is the esophagus behind of this white bordering landmark,

esophagus.

And here we have the angle of his.

This is exactly what I intended to dissect.

No more, because the procedure will

will become ischemic from the tissue

that we're going to leave here for the gastric tube.

Sometimes when a very big fat here is present,

we have to detach.

But I am limiting that gesture as much as possible

because energy is not good for that area.

Now, I am preparing to fire, this is the stomach, this is the big stomach, responsible for the

weight gain of the patient, and the camera is now introduced again through the umbilical

optical troca, so we will have a very nice perspective of the inferior part of the stomach.

Now, I am using a gold cartridge, and I appreciated that the thickness of the stomach is going

going to fit with one peristrip veritas that I played here.

So sometimes I am placing veritas

on both jaws of the stapler or the cartridge,

sometimes only on one both.

The idea is to fit as much as possible the height

of the tissue with the type of the stapler. It's a gold one with veritas on

one jaw. In between the actioning of the handle of the firing machine, we have to

wait some seconds in order to leave the world, to go out from the area.

As I presume...

Excuse me, do you have any Bougie inside, or only a nasogastric?

At this moment, I don't have any Bougie inside, and I will tell you why.

The bougie will be introduced just now with my help because at the first firing, the bougie

as is a rigid one, I want the blue one please, okay, will not be orientated to the pylorus

but I was very carefully fashioning the stomach

as this part of the stomach to be wider enough

for a very good emptying.

Now, because of my first firing,

the bougie was orientated to the pylorus,

and now I can go up with blue cartridge

parallel with the bougie checking about how the cartridge is closed crossing a

little bit the previous line checking about the contribution of the stomach on

the posterior aspect on the anterior aspect which has to be equal one we can

You can see now that here it's a wider distance than on the posterior aspect, so I'm opening

again the instrument and I'm pulling a little bit to the lateral part of the abdomen, checking

again posterior, anterior, the previous stepper line, and now I'm happy with this position.

bleeding and now I'm going to introduce the stapler through the stapler through

the right 12 to the left 12 millimeter trocker and the camera the telescope is

a 45 degree telescope is introduced through the upper optical port in order

to see very well how we can tailor this very narrow tube now I do appreciate

that the distance in between the staple line and the gastric the smaller

curvature of the stomach it's okay but all the time we have to check the other

side please come with me and we will see how parallel is the stepper line with

the posterior part please go with me okay so I have to reopen and go much

more posteriorly because there's not in a proper way

They catched the gastric wall, and I'm reclosing, and again, trying to get a little bit from

the previous stepper line, trying to be parallel.

You can feel all the time in your hand how the resistance in the device is, and I'm firing

and checking about the equal contribution

of the anterior and posterior wall of the stomach

for this very narrow tube.

Now, I'm going up with a new firing.

This is the first application of the Echelon 60.

Again, checking on the posterior part of the stomach where, please go, please go up, where

we know that the gastric fundus is larger on posterior than in anterior, so to be an

equal contribution for the fashioning of this very narrow tube, we need to check both sides

all the time.

now I live for a few seconds in order to spill out the liquids inside of the

tissue and I am firing okay and checking about the hemostasis at this line I am

happy with and I am preparing another another one okay this will be very tough

on both jaws what I am doing now okay if I have an external view you can see how

I am preparing we have okay this is how we prepare veritas from synovus to cover

as a batter's material the jaws of the stapler okay easy please okay so both

Both jaws are covered.

Okay, go inside, please.

I want an inside view.

Please give me an inside view on the screen.

Okay.

The same, we have to grasp the tissue easily with soft maneuvers

because we don't see behind what's happening with the stomach.

Now we may see behind how the stomach is going to be cut.

But if I will leave the stapler in this position, of course, an important redundant stomach

will remain up, and this will decrease and limit very much the weight loss process.

So we have to reposition the stapler again on the anterior side, okay, on the anterior

side again checking about the position in relationship with the previous

tepral line anterior and posterior aspect of the stomach and now I am

firing this is actually the part of the stomach where most of the bleedings in

the post-operative period may occur with another one please and here I place all

all the time, buttress material on both sides of the stapled

line, as you can see.

Now, in the meantime, is going to be prepared

another cartridge covered with buttress material.

We may check about the hemostasis up to now.

Seems that it's OK.

Okay, and please clean up the camera, give me external view in the meantime.

Okay, clean up the camera.

I want you to provide a very nice image of this procedure, and I am nervous to answer

to your questions.

Okay?

Okay, inside view again, please.

We have again to fire at the top of the stomach.

This is probably the last firing.

Again, we have to check on the other side,

positioning the stapler as to get equal quantities

of tissue on both sides.

Checking about the ischemic gap here

here on the previous staple line, repositioning the stapler, leaving some millimeters here

close to esophagus, avoiding all the time to get the esophagus in the staple line.

And since there are some millimeters of tissue but not stomach there, I will place a clip

And this clip will help me to identify radiologically the upper part of the gastric tube.

Where is the gastric junction, the esogastric junction, in case that we have some problems with the emptying of the stomach?

So, we remember that the last medium-large clip will be here on the top.

And then we check if the line is well-orientated, looking to the left side of the abdomen, not

twisted along its run.

Now, we are asking the anesthesiologist to explain, to remove the gastric tube of calibration,

the 36 calibration tube.

And now we are checking this tube, which was fashioned from two centimeters less than two.

This is one and a half centimeters from the pylorus.

You can see that here it's a little bit wider than on the rest of the tube

to demonstrate the necessity of the emptying of the stomach.

And now the anesthesiologist is introducing a nasogastric tube

that is going to stay there for 12 to 24 hours in the postoperative course.

And with methylene blue, we will test the staple line.

In the meantime, I am asking the anesthesiologist

to rise up the blood pressure.

OK, this is the tube.

Go down.

Thank you.

Thank you.

That's enough.

You are in the antrum now.

And please introduce at least 60 cc of methylene blue.

and we are going to check how will be filled with the liquid you can do please

okay that's very good and we will check the the field the gastric tube along the

stepper line in order to see that there are twisted areas this is very important

to test how we'll be filled up with liquid in the postoperative period now

in the meantime before the tension the blood pressure will rise up I'm gonna

remove take out the stomach okay I would like a better image please I think we

We, okay, give me a clean image.

Okay, so we are going to grasp, I hope, okay,

we grasp this stomach and we'll pull it down through the abdominal wall.

Under the vision of the telescope,

we will do in a very slow way,

waiting until the liquid will be transferred from the intra-abdominal part to the extra-abdominal

part some vessels are going to be empty and this is the extraction of a rather big inside

stomach now I am closing with a fascia closure this access for hemostasis and

for keeping a proper pressure for the next step of the operation and there is

a crossing stitch which is fast very easy with this stores instrument this

fascia closure okay okay okay okay this is a mirror movement okay please put on

a stay stitch and now we have to check the whole stepper line under a blood

blood pressure of 170 we have, 170 millimeters Hg now, seems that the quality of the hemostasis

is convenient, very convenient, very convenient.

So I placed one clip here at the end of the stepper line and another one on the top as

a landmark and seems that there is no bleeding with this combination of echelon gold and blue

and the peristyle veritas from synovus okay so checking again about uh how uniform is the stomach

Stomach, thinking all the time about what is going to be happen in the posterior, in

the postoperative period when maybe twisted.

Some surgeons do attach the stomach to the peripancreatic capsular.

I don't do it because stomach is sometimes very nervous in the postoperative course.

worse one question yes please you said the lady has 43 mi 43 yes you always do

a sleeve gastrectomy instead of a gastric bypass over 40 or no no actually

actually all the patients pass a very strict protocol including multiple tests

of alimentary behavior this lady is not a sweet eater this lady oh sorry this

lady do fit with the gastric sleeve sometimes gastric bypass is necessary

but never BPD as this BMI this is our attitude okay thank you do you have any

any experience with gastric banding yes of course i placed hundreds of gastric bandings but i am not

satisfied so i removed half of them converted most of them to gastric bypass

i presume that this experience is not singular no i agree with you

united states is going to learn the lesson from europe

So, but there is future for gastric bending, I think, in a very strict program for diet.

A highly motivated obese patient may succeed with gastric bending.

Actually, about 30% of the patients with gastric bending keep their weight low at about five

five years, six years, but only 30%.

Yes.

I think the paramount...

I am happy...

Okay, excuse me.

I don't want to bother you.

Okay.

Okay, I am happy with the hemostasis at this moment.

Sometimes, as I told you before at the previous operation,

operation, the checking of the hemostasis and the behavior of the stomach at the end

of the operation lasts more than the procedure itself, but I am very, very cautious with

any possible technical problem that may appear and should be the cause of the postoperative

complications.

How is your fistula percentage?

Our leak rate is 0.5.

0.5?

This is 0.5.

We have totally seven fistulas for close to 1,500 patients operated with sleeves,

And we did identify different mechanisms for fistula producing because we reoperate the patients immediately, check about the problem, re-watching the previous movie of the initial operation, and trying to understand what was the mistake.

And in most of the cases, it was the energy involved, an ischemic gap, a twisting of the stomach, a wrong placement of the clip, and so on.

It was, in all the events, a mistake from the surgical team.

So I am very, very careful in checking what we have to do to prevent these complications.

And can I ask you what did you do with this fistula?

I just washed out the peritoneal cavity, multiple drainage, and left like that one,

without any closing the defect.

Okay.

And I think this is the attitude we have to do.

It's a very narrow tube.

Imagine to close a hole that is sometimes two centimeters.

You have no success to close it.

But we are passing a nutritional tube, and it's kept there for three weeks.

You don't do any jejunal tube?

No.

For nutrition, no.

No, no, no, no, because all the bowels are very, the small bowel is very

inflamated.

All the re-interventions are performed by laparoscopy, and I think this is

mandatory.

It's very important for them, and hopefully we lost no patients.

Some other questions?

I am happy with the hemostasis, so I am about to finish this procedure.

No, I think there are no more questions.

Congratulations for your procedure, very fast and very accurate.

Thank you very much.

We will try to perform another one in about one hour.

Okay, thank you very much.

Thank you and success in your very important event, and compliments to Professor Palazzini

and compliments to his team.

Okay, bye.

Bye.

Okay, bye.

Bye.