Concomitant Biliopancreatic Diversion with Duodenal Switch and Hiatal Hernia Repair: Totally Robotic Technique

Alfredo D Guerron, MD, Shaina Eckhouse, MD, Nova Szoka, MD, Dana Portenier, MD, Chan Park, MD, Jin Yoo, MD, Keri Seymour, MD, Ranjan Sudan, MD. Department of Surgery, Duke University Health System

Background: Robot assisted techniques have been developed for the Biliopancreatic diversion with duodenal switch (BPD-DS), but addressing concomitant pathology can be challenging due to limited length and mobility of the robotic arms. In this video we aimed to show our technique of single dock robot assisted biliopancreatic diversion with duodenal switch and concomitant hiatal hernia repair. 

Patient and Methods: A 46 year old male with a BMI of 61.5 kg/m2, gastroesophageal reflux disease and lymphedema elected to undergo a BPD-DS. Preoperative endoscopy demonstrated a hiatal hernia. 

Results: The procedure was performed using five ports and a Nathanson liver retractor. General exploration revealed a large hiatal hernia with stomach herniation into the chest. Marking sutures were placed at 100 cm from the ileocecal valve using conventional laparoscopy, and at the 250 cm mark the bowel was anchored to the anterior abdominal. The robot was then docked. The greater curvature of the stomach was mobilized from about 4 cm past the pylorus to the angle of His. A complete crural dissection was then performed anteriorly and posteriorly. The crural defect was repaired with interrupted pledgeted 1-0 non-absorbable braided suture posteriorly and anteriorly. The duodenum was then divided preserving the pylorus and a sleeve gastrectomy performed to create a 150 cc stomach pouch. The bowel at the 250 cm mark was anastomosed to the duodenum using 2 layer hand sewn anastomosis with 3-0 zero absorbable V lock® suture. Methylene blue was insufflated to check for leaks. The biliary limb was then anastomosed to the ileum at the 100 cm mark using a linear staple- The common enterotomy was closed using 3 zero V lock absorbable suture. Mesenteric defect was non absorbable suture. Finally, the biliary limb was divided to separate the biliary limb from the alimentary limb. The procedure took 3 hours and 28 minutes and EBL was minimal. The patient was discharged home on POD 3 uneventfully.

Conclusions: A single dock robot assisted biliopancreatic diversion with duodenal switch and concomitant hiatal hernia repair demonstrating is feasible. To our knowledge, this technique has previously not been demonstrated.

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