Laparoscopic mini gastric bypass (MGB)

Authors

Abstract

Mini gastric bypass procedure is a minimally invasive, short, simple, and successful laparoscopic weight loss surgery. This video shows a live procedure performed by Professor Lee.

Keywords

Mini gastric bypass, MGB

Media type

Duration

22'50''

Publication

2011-04

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Audio

Subtitles

E-publication

WeBSurg.com, Apr 2011;11(04).
URL: http://www.websurg.com/doi-vd01en3093.htm

Laparoscopic mini gastric bypass (MGB)

1. Trocar placement 00'29''

We put a 12mm video port in the umbilicus and we put two bilateral subcostal working ports, one is a 12mm for the stapler and the left side port is a 5mm for my right hand’s use. And we need a 5mm for the liver retraction. I think the mini-gastric bypass is just like the Billroth II bypass. So the only difference probably is the length of the gastric tube.

2. EG junction identification 01'06''

In this case, we need to create a very long gastric tube but first similarly to the gastric bypass, we need to identify the EG junction clearly. Why are you using the gastroscope for at this time of the procedure? I am using it as a stent only so I think now we see the EG junction. So this is where I want to put the staples. When we do a gastric bypass, a very short gastric pouch is here. It’s a very beautiful endoscope here. Can you withdraw about 10cm? That’s very nice. So I’ll start from the antrum here. I think we are now in the gastric antrum side so we can have a first staple. Can you comment on why in a mini-gastric bypass such a long gastric tube is necessary? Because the loop is too close to the GE junction, and that will cause a lot of bile reflux problems so that is a problem why the original Mason gastric bypass must shift to a Roux-en-Y gastric bypass. It’s very interesting to look at the original Roux-en-Y procedure. So it causes a lot of marginal ulcer problems. So that’s why we change the Billroth II in a low anastomosis so today when we make a very long gastric tube we can do loop anastomosis but be careful to re-aspirate the gastric volume. And this is a new product, so I think this is quite nice. Dr. Lee, how far are you going with the first staple load? As low as possible.

3. Gastric stapling 04'02''

So I think it’s long enough. This is my first five. It looks good. Now can you insert the endoscope up to here? Just suck it out. Just suck it clean. Now to the second staple. Total bypass. So now I want to move the endoscope from here. My staple comes from the central part. You can use more 12mm trocars but we intend to decrease our trocars’ numbers. So now we have a staple coming again. Please insert the scope inside. You can do a SILS technique for this procedure. We just put two trocars over here. I think two more staples is enough. So we’re now going to staple the wall. You can see that the tube is just like a sleeve and the posterior wall is symmetric so we put another toward the EG junction we just dissect. So I use the curved one and push it tight. Just move to let me see. Come inside. Then I fire and now we’re going to the EG junction from here with a very good scope. We can go inside. I can see from above and see if my scope comes out. I’m over here, almost. Can I ask you a technical question? Why don’t you use another port to retract the stomach? Because we’re not in a SILS technique, it’s important with the dissection of the fat pad here in the beginning otherwise you go here, and you have too much fundus left. You do the dissection of the fat pad first to make sure where the EG junction is otherwise you’ll leave a lot of fundus over there. See there’s a lot of fundus. If you want, you can check the endoscope. It’s ok to come inside or out. I think it’s ok so I’ll fire it. I think we must be very familiar with the anatomy here so now we’re complete and the last one. OK I’m out, it’s no problem. Then I put the staple as close to the EG junction as possible. This is what we do for bypass and sleeve and for the sleeve because of the leaks we have.

4. Suture reinforcement of EG junction 10'22''

Now we do some suture reinforcement at the EG junction. What’s the leak rate you would expect with such a procedure? About 1% in the EG junction. Would you imagine other means to prevent leaks not using suture reinforcements? Yes, sometimes. And indication as when to use one rather than the other? I usually use it in every patients because I feel more comfortable and if the patient is a high-risk patient like in sleep apnea, and obstruction saturation is quite low and in heavy smokers or super morbid obesity, it’s a must to use protection over here. Because the leakage is very close to the O2 saturation and also with smoking. Do you think that the leak rate and the GE junction is higher with the mini-gastric bypass compared with the regular gastric bypass? Because I don’t know of many surgeons who place reinforcement sutures on a regular basis with a regular gastric bypass. No I see more and more surgeons who use this kind of suture, at least in a randomized trial with Minnesota, the protocol asked to make the reinforcement on both sides, not only on the gastric pouch side but also on the remnant stomach side. So I think most surgeons do this kind of protection. Because even 1% leakages significant when you’re doing many patients in your practice. This is a monofilament. And actually, it has been shown that if you oversuture, you weaken your staple line rather than reinforce it, then you increase the leak rate. Probably a randomized trial answered the question. I think it must be multicentral because you need a lot of cases. Now it’s been tested in the lab but this is fine, I like it. Here it’s the left gastric artery, here’s the pancreas; so in gastric cancer lymph node dissection, you just start from here; you are always close to the artery. So now we’re back to the anastomosis. I think the gastric tube is quite long. I will make the hole bigger. The endoscope has to come outside. It looks like I did not open the mucosa. What do you need for the anastomosis? Now you’re sure that you have the hole here. Can I have a gauze inside? Can you just comment on the position of the patient as there’s much reverse Trendelenburg or is the patient flat? It is not necessary because the anastomosis is quite low so it’s very easy, you probably don’t have any tension. So is the patient flat now or? Up here, about 35 degrees I think. We just stuck the omentum in the space but sometimes in a really huge guy, you have a tension, then don’t hesitate, just do an omentectomy.

5. Intestine counting 15'05''

So now we’re counting the intestines. So this is a 10, 30, 90, 120. Originally the bypass tends 200. So I will increase 10 and every BMI increases 1. In this patient, the BMI is 50 so I plan to bypass 300.

6. Anastomosis 15'57''

So I just open a hole here. Can you prepare a white staple for me? This is a very long one. Usually with only 3cm, the anastomosis is enough. It’s a very wide anastomosis as compared to a Roux-en-Y. If you do a Roux-en-Y, usually you need to control in less than 2cm. Please remove the scope. Take it out completely. OK, now we have 3cm. You’ve had too much bleeding with the blue cartridge? Now for the intestine, I always use the white one. So now the anastomosis is here and we are crossing it. Then the operation will be complete. May I ask a further question? I saw that you were very careful to make a relatively small anastomosis, not going beyond 3cm. Is there a reason for that? Do you believe there should be some restriction after this procedure or what? Yes, it’s because we learnt from our teachers, when you’re doing the Billroth II, you will need 3 fingerbreadths. At least, you should make it 3cm. Why not 6 as you had a 6cm stapler? 6 probably increases the risk of bleeding I think. And when you use long staples, you will have some difficulties. The shorter ones are much easier to manage. So in very difficult ones, usually we use short staples. I notice that you’re suturing from the inside to the outside on the stomach side. Yes, that’s the technique used for baseball suture and it is necessary. It looks much better. I think that you can use a running suture, a baseball suture. No problem. You avoid the suturing to the posterior wall. Are you passing this loop retrocolic or? Sometimes we need a stent inside to avoid suturing the posterior wall because in laparoscopic suturing, you really don’t know if you suture the posterior wall so use this kind of technique. Everything is inside now. So there’s no risk to suture the posterior wall. Can you insert the NG tube inside for me? An 18 French nasogastric tube. You can see the NG tube pass over here so there’s no stenosis and we can check the air leak test later by this NG tube. So the last job is to check the air leak test. So I will ask the anesthesiologist to pull out the NG tube. Then can you inject some gas? Push the air inside. Suction please. And we see the posterior wall, actually no posterior wall. I think we’re done. Dr. Lee, we want to thank you for a beautiful demonstration of the operation.

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