Authors: Vadim Sherman, MD; Philip R. Schauer, MD
case hx–11 sec
port placement–20 sec
procedural video–30 sec
Keyword(s): angle of His, LRYGB, morbid obesity, SG
SAGES Member Discussion
Great topic and the authors are to be commended for choosing such a difficult patient because rarely are videos shown that deal with the sickest patients. Excellent technique with emphasis on care of the dissection of the Angle of His. There is some blurriness and pixelation of the image during transistions, which doesn't detract from the instruction but does make it difficult to watch at times.
This video shows a stapling first technique, which is used in about 10% of cases. Gastro-colic space is entered too distally, as posterior adhesions may hinder further progression and risk injury to the pancreas, it is better to enter on the left side in my opinion. When stapling, bleeding initially is due to not having mobilized the greater curvature distal to the first stapler application which results in getting into some vascular branches of the gastroepiploic (or the vessel itself). The major problem with the stapling first technique is the inability to evaluate the adhesions posterior which means the stapler can get too lateral from the lesser curvature. The esophagogastric junction is not really identified, and a blue cartridge (3.5mm) maybe too thin to divide this area, as gastric tissue will usually get thicker near the EG junction. The admirable advantage of this technique is the ease of the greater curvature mobilization, especially near the upper part of the spleen. Suturing of the staple line should be done to decrease the risk of leakage and bleeding, especially if staple line reinforcement has not been used, tissue sealants has not been shown to decrease leaks, are expensive and may potentially increase the risk of intrabadominal infections. It is even more important in high risk patients, where leakage will not be tolerated. Extraction is better at the umbilicus, so facial defects are easier to close in the thinnest portion of the abdomen, in higher BMI patients.
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