Approach to Marginal Ulceration Following RYGB Surgery: Laparoscopic Excision of the Marginal Ulcer and Retrocolic, Retrogastric Rerouting of the Roux Limb with Truncal Vagotomy and Hiatal Hernia Repair

CHAPTER 1

So, this is her esophagus. It looks pretty normal - a little bit patulous - but otherwise normal. So here’s the pouch. It’s kind of inflamed, but it looks better than it did last time I looked at it. And this is her GJ anastomosis right here - where the ulcer was. This is the gastric remnant. Okay, we're not supposed to be looking at this. That mean she has a hole where she shouldn't. So this explains that she has a gastro-gastric fistula. That's her p - that's her pylorus. Alright, so if we come back, you'll see that... So that should not be gastric remnant? Well, the remnant should be there, but we shouldn't be looking at it because it should be bypassed, and it's not bypassed currently. So the problem is that she has a hole between her remnant and whatever that is. I think that's the small bowel, but I can't really tell. There’s - there's a hole there though. This is her pouch here, which is still kind of inflamed because it's been connected to the remnant. And I’m not really sure - so that's the abnormal hole up there? That’s it right there. I'm not sure where her small intestine is. I think it might be right next to this, her Roux limb. I think it's right here, hold on. There it is. Okay, so there is her - this is her small bowel. And that's her Roux limb, and it's also kind of inflamed - looks kind of nasty. It’s very red. Those red streaks are not normal. And it looks like, which is what I think I saw before, is that either there was an ulcer that eroded into the remnant, and this was the base of the ulcer and it just eroded into the remnant, or it was a - or it was an anastomotic leak that leaked and then joined the remnant. So one or the other. It is a pretty big connection, yes, so it's a good picture. But in any case, that's Roux limb, and that's remnant fistula. Alright. Exactly, and here's the - here's the pouch now. You get a better view of it as we're coming out. Alrighty. Good. So the measurements - start with the xiphoid. You're going to come - measure 15 centimeters down from the xiphoid, and then another - another three. So 18 total. And then I usually come over about here for my - between - around 5 centimeters - for my camera port, so that's my usual camera port. I come up 9 centimeters for the 12-mm port - or in this case it'll be 15. So neither of these prior 15-mm ports are anywhere near where I would make mine. Now there's a possibility we’re open, so in her, I'm going to run the port this way. Okay. So we can convert easily if we need to. And then I put the next one 9 centimeters above, and we'll also run it that way so that if we need to convert, we can. Okay? Nasty mess under there. Okay, so that's her Roux limb there. And that would be her JJ anastomosis most likely. Okay. She still has her gallbladder - that’s - that’s rare in a bypass patient, but she has actually only had one major operation. Okay, so put a 5 millimeter in here, and we're going to move it up a little bit - so put it right about here. Yep - that will give us a better view. 5 - that’s good. I'll watch you come in. Yep. There you go. Okay, that’s good - now go straight in. Excellent. Perfect. Let’s put a 5 here. And that one, we're going to go in, and you're going to aim for the left lower quadrant once you're in. So once you're through the fascia, you'll turn and aim to the left lower quadrant. That will get you where you want to be with respect to the falciform and the liver. Oh - well, you angled - you don’t want to go through the fascia angled - go straight in through the fascia, perpendicular to the abdominal wall, which is right - like that - okay. Alright, now aim towards the left lower quadrant. Yep. Come through the rest of it. Good. Excellent. Okay, and then finally, you're going to want to put a liver retractor in because we're definitely going to need one here. And… That looks just right. Yep. And that one you're going to aim towards the spleen as you go in. Don't let it slide up on the abdominal wall - and what happens in - in - when you're going in laterally, is it'll slide up, and it will end up way up here. You want to actually have it go in right there. There you go. Perfect. Excellent - okay, good job. Can we have the lights out, please? And we'll take the liver retractor.

CHAPTER 2

Alright, that’s a nice view. Nice. Okay, liver retractor. Now this - you stick this one in through here. Excellent. Now, this is not going to go up very well yet because we've got all those adhesions, but it’s not too bad. So why don’t you fix it there. It’s actually not bad at all. Move in closer. Yeah. There you go. Thank you. So, these are adhesions associated with the pouch and the liver, which are very common, but they're actually not - they're not particularly dense. This is sort of typical. This is actually - this is actually much less than usual, okay? These are nothing compared to what we usually see, and we haven't gotten to the worst of them yet - but these are - these are really pretty - pretty benign. Okay,we're going to adjust this baby. Just going to adjust our liver retraction because now we have all the adhesions down from the liver. Right, so we do - we do the liver dissection first because that allows us to get - once we have everything off the liver - it's also - it’s an easy plane, but it also allows you to see - to get the liver retractor in so you can see better to fix the hiatus or whatever you’re going to do next. But it also allows you to put the liver retractor in better so you have a better view. So sometimes, these patients have so many adhesions on the top-side of the liver, you actually don't need a liver retractor, and very often on the revision patients, I actually use fewer - I use less ports than I do on the other patients - on the regular patients. So grab that fat, and lift it up over towards you. There you go - that’s nice. We’ll see - there we go. There’s the plane there. So we’re looking for the plane inside the crus here. You want to be careful because obviously the esophagus and aorta and a lot of important things are right in here. Move in closer so I can see what I'm looking at here. Okay. So now you’re dissecting the crus, is that correct? I am attempting to dissect out the crus, although it’s hard to tell exactly where it is. I haven't found exactly the plane I'm looking for yet. The purpose of this is to get to the vagus. Because of her ulcers, you want to do a vagotomy, decrease the acid production, and the risk of recurrence. There we go. She also has a hiatal hernia that we want to fix. I don't think she has much of a crus. That looks like esophagus right there, but I can't tell for sure. So I think - so if you look when I do this, so this is, there should be crus here - this stuff over here, but I can't - I just don't see a plane between the crus and the esophagus yet. Okay, so let go of that. Let's go on the other side. Maybe it'll be more obvious. Get this stuff down. Is that typical in redos where you have - have a hard time - it can hard identifying the plane there? Yeah, that's very typical. It’s exceedingly common. What we can always do is we can go back up to the head and - and scope her again - put the scope in, and that'll help us sort of figure out what's what and where we are, but we can also just continue the dissection until we get it - you know, until it becomes clear because usually it will become clear with time and dissection. It's all this stuff here. Because this stuff kind of looks like stomach still - kind of stuck-up here. Although, there should be crus here somewhere. See these fibers are going across - those are more like crus - crural fibers, but I just don't - I don't see a plane between them. That might be it right there. That will be the plane. And can it be typi - can it be typical that the cru - that the crura are accumulated in this situation as well, or? A little bit, so this is crura here. Now you're starting to see it. This is crura here, and... That’s esophagus back there. I think this has been dissected before. I think that's basically the gist of it. I think she had a crural repair with her first operation. Because this - this looks like a redo. This doesn't look like a - this is not a virgin hiatus so to speak. She's already had her hiatus dissected I think, which is why it's so stuck. Yeah, so you can kind of see it here and start to see the plane, and the plane should open up. It should sort of get bubbles in it so that you can follow the bubbles. And that's - that's sort of the key to this kind of dissection laparoscopically - is that the - the CO2 does the - does the dissection for you to some extent. Let's get this off. So this is just more of the lesser omentum that's sort of stuck over here. Okay - we’re getting there. Okay, alright. So pull back for a second. Let's take a bigger view. So there's this - still not entirely clear to me where our esophagus is. This does not look like the vagus. So, again, we're just dissecting out the tip of that gastric remnant. Or trying to. Okay, we're getting there. Starting to look like something something not touched so much. Okay, alright. So pull back for a second, let's take a bigger view. So there's this... Still not entirely clear to me where our esophagus is. This does not look like the vagus. So to find the vagus, what you do is you sort of pull the esophagus and stomach down, and you just kind of rub it a little and see where it catches. And usually there will be sort of a - a catch, and it’s usually right up here, but - I think it’s right in there - would be my guess. Move in closer. See if we can find a nerve-looking structure. I think it might be right in there. That looks like crus on that side. Interesting. Maybe this is the plane we’ve been looking for. I think it is the plane we’ve been looking for. Look at that! Alright. We found the plane. We didn’t find the vagus, but we found the plane so that's okay - that’s a good start. This is the plane right here. You see how nice that falls away when you're in the right plane? It's just so nice. We were just down. You have the crura tented up, right? Yeah, the crura - the crus is over here, and the esophagus is here, and we were down here before. So we were just sort of little low. The crus was kind of - it was kind of pulled up. It was scarred up over top of the - the esophagus and stomach a little bit, so that's why it looked weird. So - so now that we're inside the crus, then we can follow it up, and we have a good plane. And we’ll see that we have actually a great plane, and we'll see that all this stuff is actually just scar tissue and the - the esophagus is actually back there. See that? So it would have taken us a while to find the... The vagus through that. The vagus through all that. Yeah, but this is all just scar tissue. You can see it’s see-through, so it's safe to take. There we go. So we're going to find the vagus easily now because you'll see the - it's - it's going to be right there. You see that - that white thing coming down? Well, you’ll see it in a second. I’ll show it to in a second. You can’t see it very well yet. Alright, and what you also see is that there's - there's definitely - look over here, yep. There's definitely stuff above the crus that doesn’t belong there. There's a hiatal hernia there, you know, so it's a good thing we're here. Now there's a big - a big thing back there that - that pulsates. What do you think that is? The aorta. Correct, correct. So the aorta sits directly behind, and you see those bubbles? That's what I was looking for before. Those are really the key to this dissection is you have these nice bubbles where the - the - the pressure in the abdomen, which is 15 millimeters, is - is basically dissecting up into the mediastinum, and it gives you a great dissection. And I don’t have to do anything except just brush them away. Why don’t you bring hand in, and you can help me? You're going to stick that in and hold over on the esophagus a little bit. You’re just going to hold over like this. You're not going to actually hold - grab anything. You're just going to push like that gently. Okay, good. There you go. And then - then now we can see a little better, see? And what we see is there's a plane - looks like it's right here under this. See that plane there? Yeah, that's the plane. And we are - so that white stuff is actually the peritoneum that lays on the crus, but we're below that just because of the nature of this dissection. And it's just - it's just the way it is this particular case because it's a redo and because there's a lot of adhesions up there. I'm not going to worry about it though. It doesn't really matter that much. Again more bubbles, you know. It's a generally safe area. Follow the bubbles. Yeah, you can come in over here. So that fat that was between you and me, that fat was - so here we are, see? We’re through. Okay, so now you're going to get the funny looker - take this out - I’m going to get the funny looker, and I'll show you how to use it. Dr. Pratt can you tell us what the upper limits of your dissection is here? You just want to get - you basically only - all you want to do is free up enough that there's - that the esophagus is no longer being pulled up into - above the diaphragm. You want to get the esophagus about 3 to 4 centimeters below the diaphragm. Now, there’s the aorta. Remember - I told you. I promised you it was back here. That - that thing right there - that white thing - that's your aorta. Okay, so this device we call a funny looker. You’re going to stick it in, and you're going to - hold on - don’t want to hit something. Okay, you're going to squeeze it, and then that bends it, and then we’re going to flip this so that it stays bent. Okay, so now it’s going to stay bent, and you'll put it right into this space - just make sure you're not catching on anything - yep, right into that space, and you’ll just hold the esophagus up like that for us, and then I can finish the dissection.

CHAPTER 3

So there's no like absolute height we have to get to. Now look at that - what's that right there? Yeah, that's your posterior vagus - nice view, huh? So that's pretty nice. Since we're identifying it, I'm just going to go ahead and dissect it out and take it since it's obviously right there. Almost looks like there's two of them doesn't it? That’s very interesting. Two posterior vagi, or they come together right here - maybe into one right here. We're going to take these babies. So I just need to get through, and we'll take a sample of the vagus and send it to the pathologist just to confirm that we got it, yeah. Alright, I’m going to take it right there. I’ll take a little bit of this stuff. And then I’m going to take it to the other side, so I get my little piece off. And you can do this with a Harmonic. You can - you can do it with a cautery. You can really take it with anything. You just don't want to injure anything else. Oops - dropped it. We're going to label this vagus? This is posterior vagus. Posterior vagus. Yep. Okay, now let’s see if we can find the anterior vagus, so keep - yeah, exactly. Pull down towards the feet there, and I think it's right here - kind of has the - all the markings. Yep. You buy that? That’s certainly under the most - the most tension. Another branch of it - I'll take that too just in case. I think it's just the artery that travels with it or vein or whatever. It’s up away from the esophagus. Alright, this is anterior vagus. Alright, here we go. So, we have both vagi. Now the only thing we don't have is this isn't completely dissected out over here so - oops, just keep the camera on it. The side here - it needs a little bit more dissection. This is just all adhesions. I'm going to go posterior now, so lift up. There you go.

CHAPTER 4

Okie dokie. So I’m just trying to make sure we're off the crus over here and that we have enough length so that it will come down into the... So, we think the GE Junction might be - right there, it looks like. So see the diff - see this looks like stomach. So we only have about a centimeter down, so we're going to do a little bit more dissection. Okay, alright. I think that’s good - that's good. Okay, come out, and put it in again this way. There you go, and I'll take the Endo Stitch in a second here. Get this stuff down first. Just freeing up the crus now enough that we can get in there. Okay, there we go. Alright, stitch please. We use a zero silk here, and what I do is I put my left hand on the aorta, and that pushes the - that pushes - you see how that pushes - you saw how before the crus - if I tried to go through this, I'd hit the aorta. So I put my left hand here to protect the aorta and to make the crus into a - something I can go around, and that way I can get around the crus - and I know I'm safe - exactly. Come straight across to this side, and then we tie that up. Yes. Specifically, when you come to the - to sort of the root part, because that anatomy can be very hard to get your mind around... Yeah. if - if you can be like as explicit as possible on that too, that's - that's good. I think that's going to really help. That's going to be really helpful and sort of - again, like - but you've been great. You've been - I mean... Alright, scissors, please. Yeah, I’ll just explain it as I go. I have a - I have a junior resident that needs it explained anyhow, so it's working out perfect. Alright, and then, so as you get further up, you’re further away from the esophagus, so it's less of an issue, but... Sometimes, it's two stitches; sometimes, it's three - kind of depends on what it looks like - you know, how many it's going to take to close this. This looks pretty good, but it's not particularly tight. It would probably recur if we left it at this, so we’ll probably put one more stitch in. If you just stitch it so that you can't see any of the esophagus through it - I mean, any of the retroperitoneum - so if I can't see the chest, then usually it's about the right tightness. But just that tight - if you get it too tight... Then they get in trouble? Yeah, then they get dysphagia, and they get uncomfortable, and it takes a long time for it to open up. In general, you want to be able to put - you can put a bougie in to do this, or the - or we could - could've left the esophagus scope in and done it with that - just makes it a little harder to do. I find it's easier to do without. And then we're going to scope her in a few minutes, and when we scope her, if we can't get it through, obviously, we just take the stitch out so… And the top one is - again, it’s a little bit smaller so... This should do it. And I find if I make the stitch 25 inches long - 25 centimeters long - that's the right amount for - for doing three stitches. I could even do a fourth if I needed to, but I think we’re just right, there. So if I do this - see, if it’s in, yeah, so I think that's - that's generally the right size. Alright, so you can come out now. Beautiful, okay.

CHAPTER 5

So this is where the - the remnant will stick to the pouch, and it sticks because there's a staple line there - and staple lines tend to always stick. So look up closer to this - yeah, and the plane is going to be right in here - right in that area, but it’s going to be very hard to see. So what we'll do is we're going to come - pull the camera back - we're going to actually come across the Roux limb. Come - come back. So here's our Roux limb. It's an anti-colic, anti-gastric Roux limb. So we're going to have to take down the adhesions of the Roux limb to the remnant stomach. Although, remember - there's a fistula there somewhere. Right. As we saw. So, as we're coming across this, we may get into either remnant or stomach - either one. But we're going to come across the Roux limb early because coming across it actually gives us a huge benefit in that the Roux limb will then become necrotic and change color, and then we can figure out where we are. And we can - we can identify between Roux limb and other structures. So it's actually a very nice thing to do early on in this dissection. Looks like they probably connected the omentum to this on the side to prevent an internal hernia. Down here - oh, there’s a nice band. Okay. So we have the patient in reverse Trendelenburg still, and that helps us because it puts all this stuff on tension - you know, so you don't need someone else to hold it. You can just do it, you know? What I'm trying to do is separate this, which is omentum, over here from this, which is the mesentery of the Roux limb. There's a plane in here somewhere. So the reason this keeps sounding like that - you hear the LigaSure's unhappy with me. So, next step is to come across this. Let’s see, we need anymore of this stuff down? It’s pretty much down. This is where it’s stuck. Okay, look down further. Look down here. Make sure this is detached here. Get this detached from the - there we go. It’s the other side of the mesentery we need to detach. We have omentum on this side. Alright, I’m going to try to put this straight across. Okay, so there's the mesentery on the end, right? And this is straight across. Let go of what you're holding, and show me the whole Roux limb - where you were holding and everything. Okay. Alright, so that should get it. I’ll take it right there. It’s a little tight, but that’s okay. Scissors, please. Alrighty. So, that's good. We’ve come across the Roux limb.

CHAPTER 6

We're going to let that die, and while that's dying, we're going to work on our - our gastric remnant. So pull back the camera. Let’s assess our remnant - how big it is and everything. Pull back the camera. Look over here. This is the pylorus. Alright, we follow it up. This is our antrum. We’re starting the body here, and we’re going to have to take it sort of across here - probably right about there. Once - we’ll have to come under in a second actually. We could start doing that now, except it's really stuck. It’s easier to do from the bottom, so we'll get across it in a minute. So ideally, we’ll come across sort of like this with the stapler, and we’ll leave all of this. You always want to leave enough in an ulcer patient to reverse them - especially a smoker like her, because you don't know that she's going to stop smoking forever, and if she starts smoking again and gets more ulcers, I'll recommend a reversal. So I try to leave enough stomach so that I can reverse her if I need to in the future. Now we're talking. There’s some staples stuck up in here, so it’s not burning particularly well. There we go. Okay, let’s come back down here. And we’re going to try and see behind the stomach now, over here a little bit. See if we can create a space so we can cut the stomach off. Now we have the Roux limb off, the next step is to cut the stomach, and that will give us access to the pouch. And then we'll complete our dissection of the pouch. Now if we convert to open, this is usually the stage where we end up converting, because this dissection is very difficult. You're right on top of pancreas, the splenic artery is right underneath here - I've had the splenic artery actually up and involved in some of these ulcers, and you know, you just have - you know, you have an erosive disease, and it erodes into things - and it can erode into the splenic artery. We’ve actually had a couple patients that we saved who came in with splenic artery erosions. Those were not done laparoscopically. And those were done with Doctor Watkins in the room. I mean, we're talking - you know, horrible, horrible cases where patients are basically bleeding to death in front of you. And you go in, and there's a huge hole in the splenic artery - you know, it’s looking right at you. It’s not pretty - I can tell you that. I actually think that staple line might be on the pouch. Oh yeah, that might help - move that up little bit. Working in the upper abdomen - so lift that up right there. Move the camera in closer. Staple. Alright. Alright, we’re going to go around the front now again, I think. Let's go over to this side. So you can see our Roux - our - our Roux limb is now dead, so we know - we can see where the pouch starts and where the anastomosis is, which is right here - you know, which is always nice to see, because that way you know where you're headed - makes life a little bit easier, yep. So we need to come across the remnant now. So we need to get into the lesser sac from over here in order to place our stapler, and we need to continue our dissection posteriorly here if possible. Little bit more of the stuff here. So I was very careful when I came in here to look at the left gastric, which is right here. You want to make sure you're always below the left gastric. So before I began this dissection, I paid careful attention to the left gastric artery, which is again - there's the left gastric vein. The artery is traveling right next to it. So, you always want to look for that. That is a blood supply to your pouch - if you cut that, your operation’s over. Then you have to do an esophagojejunostomy or an esophago- gas - an esophagogastrostomy, but basically, you don’t have a pouch anymore. At least not one with a blood supply, which is usually a criteria for healing - last I checked - exactly. To say the least. Here we go. Alright. Okay, so that’s good. Okay, so let go. So next thing we're going to do is come across the stomach because that's going to give us a great view of where we - you know, of all this stuff and where we need to go, okay? So you're going to hold this up like that. And I just want to make sure I have enough room to get through here, and I can get into the same plane. Seems like a pretty clean plane. Not getting a great view of it. But there’s - yeah, there’s stomach wall, so pretty sure it's a safe plane to come through. This is a little - still little stuck here, but I think if I take it off, it will end up in the stomach, which is fine like I said before - but, it's a little stuck there. It’s right where the ulcer is, so we need to come down a little bit - but we have a black load, which is the thick tissue load. I'm going to reticulate it down two notches here - slide it in along my grasper. That way I’m sure to get in the same plane. Okay, I'm gonna try to... And we're gonna take this here, nice and slow. It's called a tristaple, which means it has three different sizes of staple. So it's wider. Make sure we're not stapling across something. That looks pretty good. Clip, please. Except this corner, which I told you was going to bleed. And it is. But not too bad, actually. Much better than I thought. Good, okay. Okay. Are you holding that up? I don't see it. Oh, there we go. Thank you. I'm gonna grab this staple line up here. Pull this back towards me. And one more black load. Right. A little bit of a reticulation. There we go. Alright, there’s our spleen, and there’s some more adhesions. Let’s keep doing it. Please. Okay, this, I believe, is our pouch, okay? It’s the back wall of the pouch there, which is good because it means we’re as far up as we need to go there. We still need to get the remnant off. Lift it up towards the ceiling. There you go - good. Move in closer with the camera. The remnant up out of the way, yeah. If you don't divide that stuff, it’s just - it just makes this like ten times harder. You can do it - you can lift it up and come underneath it, but it's just brutal. There’s no point, and this works well. Okay, it’s hard to tell where the plane is. Okay, I think we're going to have to come anterior now. Okay, let’s come anterior. So this is our pouch. So our remnant is going to die now too, which will give us another indicator. So grab that and pull it out to the side. There we go. It’s always nice when there’s fat in between because that makes the dissection easier. But in general, the rule in this dissection is it's fine to get into the remnant - just don't hurt the pouch. So that's all I do. I just - I - I concentrate on, you know, getting it down and not hurting the pouch. So your entire dissection here is concentrated on - if you're going to - if you're going to cut into something, cut into the remnant. So stuck. I see the staple line, yeah. She doesn’t have a particularly huge pouch. I don't know who’s staple line it is. She doesn't have a particularly huge pouch, so you got to be careful stapling it because you might make it too small. You don’t want it to be too small. You do want it small for ulcer revisions though. In general, you want the pouch to be small because you don't want it to make a lot of acid. So even though you’ve got the vagotomy, we’re still going to go for a smaller size pouch if you revise the pouch, which we probably will. But you can't staple this, because it's just too scarred up, you know? It'd - so you’d be stapling through multiple layers of you don't know what. So it’s - it's actually, you have to get this down either way. Even if we're going to staple the edge of the pouch and make it smaller, we still need to get through this plane. I still haven't really seen the staple line of the pouch that I can tell. You don't let go of it. You let go of it. Regrab. So I'm trying to get you to pull down this way. There you go. Okay. Excellent. It’s also possible that some of the fistula is actually - was a leak. Remember, we said that? It could have been a leak, or it could have been something else - an ulcer, yeah, which means that if it was a leak, we may actually end up finding a hole in the pouch as we come through this stuff - as we come up here. So, we’ll find out soon enough. This is the staple line of the remnant stuck to the pouch. That’s remnant staples. And you see how the color change really helps you in the dissection. So the pouch is all splayed out here. Some people will actually open the pouch every time and revise it - just restaple it. So some people advocate that. Dr. Higa does that with every single revision. I have traditionally not done that. I have just basically restapled if I needed to and completed this dissection, but you know, everybody does stuff differently. There’s nothing wrong with doing it that way. It's just - seems hard to me. This isn’t bad. This is doable. Okay, so it let's do this now. Let's - let's come across here, and we will get into our pouch. Then we’ll have the open pouch, and then we'll be able to better sort of decipher what's what. Then we may jump - drop our - or we could drop our scope. Sometimes that helps too. But I think if we come through this, that we will be probably happiest. We could also, if we chose, come into the remnant by coming across the gastro - you know the - we’ll probably end up in both anyhow, so whatever. Can you grab this? And hold it up? Excellent, just hold that up for a second. Let me get this down a little. There we go. Now we're in something. We’d eventually get into something. Nice. Okay, so we just entered the pouch remnant/Roux limb, which are all connected here as one - one happy family. And what we’re going to do is we’re going to take the - so that's the inside of the remnant - I'm going to suck that out a little bit so we don't spill too much. And then we’ll... So there’s the remnant. Suck that out. There’s your pouch right up here, and then this is your Roux limb - this blue thing right here. Yeah. So you have the angle on this. Can you please take this device and... I want you to slide in there. And divide right between the healthy stuff and the non-healthy stuff, so right across the space right here. Yep, you have to turn it - turn it like this. Okay, slide right there. Show it to yourself. Close. Yep, and squeeze hard, yep. And then, you squeeze this - you fire that to cut. There you go. Good, excellent. Okay, just a second. Get you another bite. Now… Another bite right there. Yep, that’s perfect. Nice. Alright. Now, we want to leave a little less small bowel because we don't really want that small bowel - I don’t want - yeah, so push up towards the stomach a little bit more. Yeah, not so far with the tips - just the base. Yeah, there you go. That looks good. Yep, take that. Show it to yourself here - you're not looking at it while you're doing it, so now it came off. Okay, so try that again. Push up a little more, up - now, push up. Yep. Okay. Should be okay. Sorry, that’s my bad - I pushed it off you again. Okay. Now pull the camera back a little. Thank you. Slide it right in there. Slide it up towards the head a little. Yep. Okay. Now keep it pushed in. There you go. Now you go it. Hold on - hold on. See what we got - see how we’re coming. Okay, now it’s back to my angle. Excellent work. We got to get this off here. Okay, it’s working despite all these staples in here. That's pretty good. And I thought it was a stapled anastomosis. Maybe I’m wrong. Okay, that’s interesting. Let’s snip that one more first. It’s going to bleed of course. Okay, I’ll not be able to get through that that way. I have to use a different device. Okie dokie. Looking good. Can you get your suction irrigator in there and help me a little bit with that. Watch the tip! Okay, so suction in here - suction it out and move in a little closer with the camera. There we go. Scissors, please. A lot of staples in this. Okay, I think I might be able to get in there with this now. It would be a lot less bloody if we do. No - definitely not. Suction, irrigate in there. Scissors again, please. So, stick your suction irrigator into the stomach, and you use that as a retractor - perfect, thank you. Can’t even get through it with scissors! Do you need a new one? We may after this, but… Painful. Pretty sure I’m cutting into remnant, but just trying to - there we go. Now we’re talking. There’s remnant. Yeah, I do. Do we have the new ones - can we can try or no? Yeah, yeah, yeah, absolutely. Oh, we have the new ones? I didn't know there was a new one. You know the one that they've been advertising out the front desk. Are we allowed to try the new one? There's a large bag for the new one I'd like to use if they have it - if we can get it. Out with the bad, in with the good - yeah, the large ones. Okay. And then just stick it in, and then it's too big for me to open with one hand - that kind of sucks. It’s made for male hands. This - this you can't - you can't open it with one hand, you know? I see, now I just pull? Yep, just pull it straight back - all the way back until it stops. And then we see the cord. Cord right off - just pull it right off. Cool, that's nice huh? Alright. So I'm actually going to leave it in there, and I'm going to put it all the way in and leave it in there. If I can get it back in there. Can I get it back in? Yeah, okay. Really test your bag here.

CHAPTER 7

Now, let’s look at this remnant first and see if it needs anything like a stitch. Yeah, that'd be good. Yep Alright, we're going to oversew this remnant just in case it gets dilated because sometimes that happens post-op in these patients, and I really don't want to perforate. It also, I think, decreases the risk of it forming a new fistula because the staple line is a little bit protected. We got to get all the way to the end - and it reinforces the staple line which goes through very, very thick tissue, so I feel better if there's a reinforcing stitch on it just in case the staples don't hold. Alright, now, we're going to flip up the colon. Bowel grasper, please. Here’s our Roux limb right here. Need to measure that. So, that’s 5, 10. It’s probably more than 10. That’s probably 10, 20, 30, 40 - pull back with the camera a little, thank you - 50 - am I counting right? 60, 70, 80, 90, 100. Oh good, that's long enough. That's lovely. Okay. So we need to take this stuff down, so you're going to hold up on this stuff. I'll take a grasper, please. This is all omentum just stuck, but it creates internal hernias because, you see, stuff could get stuck - could go through there - could get stuck otherwise. It - it's a nice length. It's in a nice location, so it should be - that should be just fine. We probably don't have to revise the JJ, which is nice because that adds a huge amount of work on to this operation. Alright, so there should be closure. That's colon - that's fine. The JJ anastomosis should be... So, interesting. Okay, so this comes down, and what you want to do is you want to follow it, and you want to say okay, where is the - where does the mesentery go? So... This looks like where the - the defect was closed, you see that? So that's the defect between the two pieces of small bowel. Okay, so they closed the hernia sac. That's nice, so she doesn't have an internal hernia there. That's very good. And this looks like - this is the extra piece of mesentery, but this is the regular mesentery. And this goes - a little kink in the pouch, but it looks good. This comes right down here and goes down here, so this is going to be your common channel, okay? So this one is your BP limb. That should go up under here. Yep. So that's ligament of Treitz, okay? And - bowel grasper - we’ll run the common channel to make sure there's no adhesions. You don't want to leave someone with a bowel obstruction after a case like this because then they’ll blow out the remnant and their JJ anastomosis, so you always want to check that there’s no internal hernias or external hernias or anything. And then we’re going to reroute the small bowel, and remember, I told you the least - path of least tension is retrocolic, retrogastric. So that’s where we’ll go. The bowel is twisted. Interesting. Untwist, untwist. Look down a little. Now we’re just looking here to make sure there's no major adhesions. I don't think there are any, but - and that she has enough long bowel - short - enough bowel to serve her, which she clearly does. Okay, good enough. She’s got plenty of bowel. I don’t see any adhesions. Okay, so we’re going to come back down here, and take our Roux limb, which is up here, and disconnect it from the mesentery of the transverse mesocolon. Okay, so we’re going to identify the ligament of Treitz, so I need you to grab right here. There’s your LOT, right? We’re going to come in just anterior to the LOT. Now there’s a big vessel just anterior in her case. Usually, there isn't, but in her case for some reason there is. So maybe we should go a little bit to one side or the other of that large vessel. Maybe we’ll just stay on your side. It seemed to be a good spot. Okay, look up. So first of all, let’s get this up out of our way. We’re going to come through here. Make a hole in the transverse mesocolon. Let go and just grab this. So - I need you to let go and just grab this front part. Yeah, that’s right - exactly. Let’s see if we have anything close to a hole - that looks pretty darn close. Let's get that bleeder. There we go. Space. Okay, so that’s where we’re going to pass the Roux limb. That's where we're headed. Looks pretty good. Actually, I’ll take the funny looker. Show me the Roux limb. Keep this right side up. See where it is or no? Is that it right there? Yeah, that is it. Okay, go through this hole. There we go, okay. Alright, let go, and let’s go above now. And there’s the Roux limb. It’s pretty nicely up there. Pretty nicely tucked. Yep, sitting right next to our stomach, so we can easily just sew our anastomosis right there. What a great blood supply. Just sew that right to that and we should be done.

CHAPTER 8

I think that’s where the staple line is - that’s what it feels like at least. I feel the question is do we want to take more of the Roux limb off because it looks so inflamed, but I think it was okay. Maybe it was just inflamed because it had that remnant bile, like, you know, bathing it daily, you know? Now these anastomoses in the revisions do have a 10% leak rate, and mostly they leak late, which means are not leaking from a technical problem. What are they leaking from when they leak 5, 7 days post-op? From the ischemia, and... That’s exactly right. From ischemia. No, the staple line will come apart in the first 24 hours if it's going to come apart. They - they die - they - they leak from ischemia, so it's just that, you know, you have a little - you have, you know, a redo operation, you're going to have limited blood supply, and it’s high-risk first for ischemia. And so the reason I think the leak rate is so high in these patients is because of ischemia. It’s one reason that it might actually make sense to do these robotically, because the robot has a - you can use a fluorescence and determine whether there's - there’s a good blood supply, yeah. So, either robotically or with a fluorescent camera, you know. You can buy them separately too, but... And I suppose if you, so - which part of the pouch do you think is the most likely to become ischemic? Which part of the pouch? Which corner? It’s got four corners this one, this one, that one, and this one. Cut these. So you’d think so, except that because you’re sewing to this corner, this is your most high risk corner. So when it leaks, it usually leaks there. In sleeves, it always leaks at the apex, but sleeves leak probably a little bit from ischemia but a lot from pressure - shorter on those, thank you. Alright, so we're going to see it come through here in a second. There we go. Come down into our pouch. I’m looking for the light through it, although you can't really see it in this case Should see the light. There it is. Okay. And I’m going to push in through the hole. Okay, look down at the small bowel. I think I’m in. Yep. Okay, and then we’ll just run that down there a little bit. Yeah, okay. Alright, now the last layer is the anterior layer. Take that - that Vicryl - Endo Stitch. We’re going to start out with one that’s really - sort of - it’s the stitch - I call it the protective stitch or the - the stitch that takes all the tension off. It’s really this sort of - take your staple lines, and you put them together. Sort of put the tip of the jejunum up onto - onto your staple line because that is your ischemic corner, right? Excellent, can you get the scissors in there? Cut these guys - yeah, just these three. We’ll leave the other tail for manipulation if there’s a leak or something. Nice. So this is kind of like a running Lembert suture. You could do interrupted Lemberts, and a lot of people do. With the Endo Stitch, you know, it just doesn't make sense. It's easier to just run it. We used to run this with a permanent suture, and we found that the permanent sutures tended to end up intraluminally, and because they were running, you'd have this knot hanging off in the loop and would get food caught on it. So we'd have to go in and endoscopically remove these sutures, and I actually had one case where we had a patient who got a bezoar on the end of it that was tethered to her anastomosis. So - so you had to - you cut it off, and then the bezoar was like this - this golf ball-sized thing that she managed to pass fortunately - out her bottom - but it was very weird. Now we do see occasional bezoars in the pouch, but - I’ve had a few over the years - but when they're attached to the stitch, it makes for a big problem, so... Tie to there. You're going to go up and scope now. Okay. Cut those. Stay high. Get it on my side. Yep. Okay.

CHAPTER 9

Okay, show me the anastomosis and then pull back to the GE junction, and show me the whole pouch. That's plenty of insufflation - I wouldn't insufflate anymore. So come back to the GE junction, that’s our anastomosis. It's not bleeding anymore, which is nice - looks very nice. And there's the GE junction. Center it - center it - oh, center it. That's where we fixed the hiatal hernia, right? Okay, and go back in for second. Show us the anastomosis one more time just because it makes us happy. Look up to the right - there you go - look up and to the right. Okay, now center. That’s beautiful. Okay, in fact we’re almost done with the case.

CHAPTER 10

Bowel grasper to my partner. Smooth grasper to me. Another one, here. So, I got to push this up. Look - look where I’m working, please. We put the omentum up over everything - will make it a lot easier. You’re going to grab right there, at the top of that defect. Okay. There you go. Now this is Peterson's defect here. So Peterson's defect - what - the biliopancreatic limb is what will come through Peterson's if anything comes through it in - in this configuration. So we close that - you have a silk, please? So this is the transverse mesocolon defect, which we will close with interrupted sutures because for that same reason, I don't like to put running permanent sutures, but I want to use permanent sutures when I'm closing a defect. So I do interrupteds on this part. So in the open cases, we only put like two of these in because they get lots of adhesions, but in the laparoscopic cases, they don't get any adhesions, so you - and there’s - you know, there’s no reason for this to stick. So you really have to put a lot of sutures in. It’s also true that the bypass patients tend to get fewer adhesions in general for like a laparoscopic gastric bypass, and I think it's just because of the weight loss and sort of malnutrition post-op, you know? But I don’t know... Because like her - I mean we came in here. She really - she has almost no adhesions, you know? Okay, so those are closed. I’m just going to double-check the JJ.

CHAPTER 11

So we're going to follow it - look at this - all the way down. That’s our Roux limb - nice and healthy, no issues. There’s our JJ - looks fine. No signs of obstruction there. Don't need to revise that at all. Could use a stitch right here. Can I have a stitch, please? So - you have anything left there? This needs to connect to this. It’s just this is - this is anti-kink stitch because this wants to kink back on here, so if we put a stitch between here and there, it'll - it'll prevent this from kinking. Alright, we are almost done. Okay, so look over in the corner.

CHAPTER 12

Further down. Tends to get stuck, huh? And then you pull it out up and down. Rock it up and down, slowly, slowly. Yeah, exactly. It’s like a forceps delivery, okay? So it's just slow, steady pressure will get it to come out. Okay, as it starts to go, I'll do this. Yep. Okay. Sometimes you have to take them out a little piece at a time. Yep, that's part of it. Oh, and that’s the other part. This is specimen. You can label it gastric fundus and - and - gastro-gastric - gastrojejunal fistula and part of Roux limb. Okay now, put this in here. How long do you think you guys need from now to close? We’re closing the port. It's going to take about 2 minutes. And then you're done? Yes. Okay. Fascial closure device, please.

CHAPTER 13

And is the bed level? Can we level the bed, please? We do have to wand, but that's going to take us about 2 seconds. Now, flip this upside down. Look at this port. Yes, please. And then get grasper. Push the colon down below me out of the way, so just sort of take the grasper and slide it. Look at the colon. Look at the colon. Okay, and just push that - push that - push that down towards the feet. Show yourself what you’re doing. Take the colon. Push it towards the feet. The omentum. Just drag all that towards the feet. You just don’t want to hit it. There you go. Okay, a little bit more. Okay. Just grab the omentum and flip it down. The omentum is not down over the colon where it belongs. It’s sitting up over the thing where I put it before to close the hernia defect. Okay, good. Now I’ve got omentum in my way instead of colon - it’s much safer - especially since I’m coming in behind the falciform - or maybe I’ll just come straight through it. There we go. Grab that, please. Closing our port site now. We only need to close the 15-millimeter port, and some people don't even do that - but I'm a little paranoid, so I like to close it. Okay. Go around the other side of the port. Yep. You got it. Okay. Show yourself the whole thing - yep, there you go. Got it. Okay. That should stop bleeding hopefully. Yep, that will stop bleeding. Okay. Watch this one coming out. No bleeding. Watch this one coming out. You can turn the gas off. Alright, you can watch this one coming out if you want. Brief. This was a laparoscopic revision of gastric bypass with partial gastrectomy, revision of gastrojejunostomy, hiatal hernia repair, vagotomy, and rerouting of Roux limb to retrocolic retrogastric location.