Mini gastric bypass / omega loop gastric bypass - general and visceral surgery

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  • Camera access; trocar placement

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    Position the camera trocar in the left epigastrium, approximately 2-3 fingerwidbreadths caudal to the left costal arch in the midclavicular line.

    Access is by means ofthrough an optical trocar (12 mm Xcel trocar) under camera view. During insertion, ensure that the individual tissue layers can be viewed.During insertion, optical trocars ensure a clear view of the individual tissue layers. Place the additionalother trocars under camera view and after placementbringing the patient into the anti-Trendelenburg position.

    Then place three more 12 mm trocars in the following order. First around 1.5 hand’s width caudal to the xiphoid process in the left paramedian region (far supraumbilical), then approximately in the midclavicular line immediately at the right costal arch, introducing the tip of the trocar in the direction of the patient’s left leg.Introduce the first trocar about 1.5 hand widths inferior to the xiphoid process paramedian on the left (far supraumbilical) and the second trocar roughly in the midclavicular line immediately at the right costal arch, guiding the trocar tip in the direction of the patient's left leg. Finally,Now insert the third 12 mm trocar about one hand’s width caudalinferior to the right costal arch medial to the midclavicular line in the right upper quadrant.,then And finally insert an additional 5mm trocar at the left costal arch somewhat cranialsuperior to the first 12 mm trocar.

    Note: A liver retractor is usedneeded only if the liver isfor extremely large livers, which is the case in less than 5% of patients.

  • Dissection at the cardial notch

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    Between the angle of His (without freely dissecting it completely) and somewhat medial to the upper pole of the spleen, detach the physiological adhesions between the gastric fundus and diaphragm or retroperitoneal space as much as possible using ultrasonic dissection.By ultrasonic dissection take down the physiological adhesions between the gastric fundus and diaphragm / retroperitoneal space as much as possible from the cardial notch (without freeing it completely) to somewhat medial to the superior pole of the spleen. This defines the cranialsuperior end of the stapled suture line.

    Note: Hiatal revision is not routinely done, but only in exceptional cases, e.g., in relatively low-weight patients with relatively low weight and substantial reflux problems. The surgeryprocedure results in creation ofcreates a low-pressure system by bypassing the pylorus and simultaneously applying tensiontraction on the pouch, thereby resulting asin a quasi-prophylactic measure against reflux. 

  • Opening the lesser sac at the superior aspect of the antrum

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    After visualizingexposing the pylorus, enter the lesser bursasac at the superior edgeaspect of the gastric antrum approximatelyabout 2-–3  cm distal to the inferior borderaspect of the so-called “crow’s foot.” (branches of the vagi to the antropylorus). On the lesser curvature aspect, visualize the posterior wall of the stomach proximally and detach adhesions to the pancreas.Expose the posterior gastric wall proximally along the lesser curvature and take down adhesions with the pancreas.

  • Fashioning the gastric pouch I

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    From the lesser curvature extending into the lesser sac, now fashion a long, tubular gastric pouch (around 20 cm) under calibration with a 30 French gastric tube, but keep the staples relatively far away.Fashion a tubular gastric pouch (about 20 cm long) from the lesser curvature into the lesser sac, calibrating the pouch lumen with a 30-French gastric tube, while keeping the stapled suture line relatively far away. First cut into the antrum with an Echelon 60 mm black (because of the thick wall in this region) oblique/transverse to the organ axis around 2-3 cm distal to the crow’s food/angular incisure. To this end, first transect the antrum about 2-3 cm distal to the crow's foot/gastric notch with an Echelon stapler with Black 60 mm cartridge (due to the thick wall here) transversely/ obliquely to the long axis of the stomach.

    Note: The pouch does not have to be as narrow as with a gastric sleeve because itthis is not a highly restrictive procedure.

  • Fashioning the gastric pouch II

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    ThenNow fashion the tubular pouch by vertical dissection along the gastric (calibration) tube, first with green, further craniadabove with gold, and then with blue cartridges, in the direction of the angle of Histoward the cardial notch, thereby separating it from the gastric remnant so there is no longer a connection with it. and separate the pouch from gastric remnant in such a way that it is no longer connected with the latter. 

    Advance the dissection while continuing to detach adhesions with the posterior wall of the stomach until the gastric fundus is finally completely vertically divided around 1 to 2 cm lateral to the angle of His. As the dissection progresses, continue to take down adhesions of the posterior gastric wall until the gastric fundus is completely transected vertically about 1 to 2 cm lateral to the cardial notch. 

    Note: Complete divisiontransection of the stomach is a deciding factor in avoiding gastric-ogastric fistulas.

  • Opening the pouch

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    After completing the gastric pouch, open it on its distal end in the region of the staple line with the ultrasonic dissector enough so that the gastric tube can be recovered.Once the gastric pouch has been completed, open its distal end in the area of the staple line with the ultrasound dissector until the gastric tube can pass through.

    Open the pouch onat the greater curvature pole of the distal obliquetransverse staple line, the caudalmost pointinferior aspect of the pouch.

  • Measuring the biliopancreatic loop

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    Locate the ligament of Treitz and measure the bilio-pancreatic loop. The bilio-pancreatic limb should be 150-–200  cm long, starting at the ligament of Treitz.

    Note: Adjust the length of the bilio-pancreatic loop for reinforcement of to decrease malabsorptionto boost or lessen malabsorption. In super-obese patients, a length of 250 cm is recommended; if the focus is on metabolic effects, a length of about 150 cm is more appropriate.if metabolic activity is the most important factor, a length of 150 cm is recommended.

  • Enterotomy

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    For the subsequent anastomosis, open the loop in a slit in the appropriate area on the antimesenteric aspect.slit open loop at its antimesenteric aspect.

  • Transposition to the upper abdomen and gastroenterostomy

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    To fashion the gastroenterostomy, first insert one limbbranch of a linear stapler into the opened jejunal loop. Then guide the jejunal loop with the inserted stapler onto the distal end of the gastric pouch and, after withdrawingretracting the gastric tube, insert the second branchlimb into the pouch. Then carry outNow fashionthe linear gastroenterostomy by firing the instrumentstapler.

    Note: The gastroenterostomy is created on the antecolic aspect and should be 4-–5  cm long to avoid afferent loop syndrome. BecauseDue of the length of the pouch, the anastomosis will be located at the level of the gastrocolic ligament or in front ofanterior to the transverse colon.

  • Closing the anterior defect

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    After inserting the gastric tube into the efferent limb, close the ventralanterior defect with running transverse knotless tissue control sutures using self-retaining suture.

    Tip: By placing the tube through the anastomosis, grasping the posterior wall when closing the anterior wall can be avoided, thereby preventing a postoperative anastomotic stenosis.Advancing the gastric tube across the anastomosis can help prevent catching the posterior wall during closure of the anterior wall, thus avoiding postoperative anastomotic stenosis.

  • Methylene blue test

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  • Hemostasis at the staple line; drainage

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