Laparoscopic duodenal switch
by Mitch Roslin

Video Atlas of Laparoscopic Surgery: Bariatric Surgery (Volume 1)

by Rana C Pullatt
About Video

This video demonstrates the technical nuances and tips in performing a duodenal switch. Surgical procedure: Six ports are used for the procedure and are placed as seen in the illustration. The surgeon initially stands between the legs of the patient for the Sleeve portion of the operation and then moves to the left side of the position for the creation of the common channel. The surgeon then performs the duodenoileostomy from between the legs. The procedure begins by creating a sleeve gastrectomy in standard fashion. The lesser sac is entered; the angle of His is dissected till the left crus is seen. The pars flaccida is opened to look at the right crus to make sure no hiatal hernia is visualized. As opposed to sleeve gastrectomy the dissection of the stomach is conti­nued till the pylorus is elevated. A 40 French bougie is placed into the stomach and advanced to the antrum hugging the lesser sac. A sleeve gastrectomy is performed using the bougie as a guide. The first fire is done with a black cartridge followed by a green cartridge and then a gold cartridge is used for the upper stomach. Care is taken, as in a sleeve gastrectomy not to encroach on the GE junction or on the incisura angularis. The entire sleeve staple line is over sown using a 2-0 PDS suture. A cholecystectomy is then performed in patients who have a gallbladder. The duodenal dissection is begun on the right side of where the common duct passes superiorly. This will eventually serve as the target for where the stapler will exit during duodenal transection. Pyloric dissection is continued inferiorly till a plane is developed beneath the duodenum. The duodenum is then transected using a blue load stapler creating a 3–4 cm duodenal cuff. The omentum is then divided to create a pathway for the Roux limb. The surgeon then moves to the left of the patient. The terminal ileum is located; 125 cm of the small bowel is measured from the terminal ileum. The bowel is rotated in an anticlockwise direction and at the 125 cm mark on the antimesenteric border an enterotomy is made. Another 175 cm of the bowel is then counted upstream by rotating the bowel in anticlockwise direction and rotating it superiorly to the patient’s right to keep the proper orientation. The bowel is then divided with a white load at this point approximately 300 cm for the ileocecal junction. The left hand of the surgeon is positioned on the proximal biliopancreatic end and the right hand is positioned on the eventual Roux limb. An enterotomy is then performed about 6 cm from the end of the biliopancreatic limb to allow for enough space for eventual firing of the stapler both proximally and distally to create a H shaped anastomosis for the eventual enteroenterostomy. The Roux limb is then rotated in an anti-clockwise direction in close proximity to the biliopancreatic limb. This will eventually line up the enterotomy on the biliopancreatic limb to the initial enterotomy created on the bowel 75 cm from the ileocecal junction. Once these are lined up the anastomosis is created in a H shaped fashion by firing the stapler proximally and distally and the common enterotomy is closed perpendicular to the initial staple line to prevent narrowing of the anastomosis. The surgeon then moves back between the legs of the patient and the Roux limb is brought up in the correct orientation without twisting. The end of the Roux limb and its mesen­tery face medially. A 2 cm duodenotmy and an enterotomy are made after stay sutures are placed in the ends. The anastomosis is done in 2 layers using 2-0 PDS suture. The anastomosis is completed using methylene blue and the procedure is thus complete.

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