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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_536_Библиотеки_им_академика_М_И_Перельмана.pdf
Fig. 30.4 Dissection of
the angle of His and the left
crus. Close (a) and schematic
view (b)
Fig. 30.5 Section of the
stomach. Close (a) and
schematic view (b)
23930 Laparoscopic Sleeve Gastrectomy
Fig. 30.6 Stitch at the end of the first stapler line section
After the last stapler firing, a X stitch is performed at
the end of the section, near to the angle of His.
10. Pars flaccida is divided (in case of hiatal hernia)
(Fig. 30.9)
In case of hiatal hernia, when gastrectomy is performed, it’s necessary to repair the hiatus defect. First
of all, pars flaccida is divided in order to make a correct
dissection of the crura.
Fig. 30.7 Gastric section
240 M. Gagner
Fig. 30.8 Stitch at the end
of the gastric section. Close
(a) and schematic view (b)
Fig. 30.9 Pars flaccida division
11. Pars flaccida is divided (in case of hiatal hernia)
(Fig. 30.10)
The next step is to dissect right crus from the posterior
to the anterior part of the hiatus.
12. Posterior window behind the esophagus (Fig. 30.11)
After a correct identification of the hiatus and dissection of both crura, a posterior window is performed by
blunt dissection behind the esophagus.
13. Traction of the esophagus (Fig. 30.12)
In order to have a correct view of the hiatus, a traction
of the abdominal esophagus is necessary. A Penrose
Fig. 30.10 Dissection of the right crus
drain is placed through the posterior window surrounding the esophagus.
14. Closure of the hiatus (Fig. 30.13)
The crura are approximated by non-absorbable stitches.
Posterior portion of the crura is closed taking the whole
muscular thickness One or two stitches are usually necessary to close correctly the hiatus.
15. Final view (Fig. 30.14)
The procedure finishes with a total revision of the surgical field.
Fig. 30.11 Posterior
window behind the
esophagus
24130 Laparoscopic Sleeve Gastrectomy
Fig. 30.12 Traction of the
esophagus
Fig. 30.13 Closure of the hiatus. Close (a, b) and schematic view (c)
242 M. Gagner
Fig. 30.14 Final view. Close
(a) and schematic view (b)
References
1. Camilleri M, Papathanasopoulos A, Odusi ST. Actions and therapeutic pathways of ghrelin for gastrointestinal disorders. Nat Rev
Gastroent Hepat. 2009;6:343–52.
2. Neary MT, Batterham RL. Gut hormones: implications for the treatment of obesity. Pharmacol Ther. 2009;124:44–56.
3. Vincent RP, le Roux CW. Changes in gut hormones after bariatric
surgery. Clin Endocrinol (Oxf). 2008;69:17317–9.
4. Hess DW, Hess DS. Biliopancreatic diversion with a duodenal
switch. Obes Surg. 1998;8:267–82.
5. Marceau P, Biron S, Bourque RA, et al. Biliopancreatic diversion
with a new type of gastrectomy. Obes Surg. 1993;3:29–35.
6. Hamoui H, Anthone GJ, Kaufman HS, et al: Sleeve gastrectomy in
the high-risk patient, Obes Surg. 2006;16:14451–9.
7. Gagner M, Hutchinson C, Rosenthal R. Fifth International
Consensus Conference: current status of sleeve gastrectomy. Surg
Obes Relat Dis. 2016;12:750–6. Figure 30.1. Exposure of the surgical field.
Laparoscopic Duodenal Switch
Jacques Himpens and Roel Bolckmans
31
31.1 Introduction
Duodenal switch is a malabsorptive procedure that consists
of a combination of sleeve gastrectomy and biliopancreatic
diversion. The mechanism of weight loss after the duodenal switch is due to restriction caused by sleeve gastrectomy
and malabsorption due to reduction of the functional shortening capacity of the small bowel reduces the absorption
capacity. The common channel is usually 75–150 cm long.
The long-term results of this technique are very good with
high percentages of comorbidity reduction and weight loss.
In this chapter, the laparoscopic duodenal switch will be
described step by step.
31.1.1 Description of the Surgical Technique (Video 31.1) [1]
1. Patient, surgical team, and trocar position
The patient is placed in supine position with legs apart
and both arms in abduction. The surgeon stands between
patient’s legs (French position) (Fig. 31.1).
To perform this technique, six trocars are placed as
shown in Fig. 31.1.
2. Sleeve gastrectomy (Fig. 31.2).
In this part of the procedure, dissection of the greater curvature starts in the antrum and it continues to the angle of His
cranially. Distally the dissection ends close to the pylorus.
After this longitudinal section of the stomach is perfumed
with a Fouche tube (36Fr) located in the lesser curvature of
the stomach lumen.
3. Cholecystectomy and posterior dissection of the
duodenum (Fig. 31.3).
After sleeve gastrectomy is finished, a cholecystectomy is
performed. In this surgical field, a dissection of the posterior wall of the duodenum is the next step in order to create a passage between the duodenum and the pancreas. This
step can be performed using two different approaches:
• Anterior approach: the anterior peritoneal sheet at the
superior border of the duodenum is dissected and then a
passage between above first duodenum and the pancreatic head is created. The duodenum is taken up with a
piece of cotton tissue tape.
• Posterior approach: the antrum is held up and retrogas-
tric adhesions are divided. Then a passage is created just
anteriorly to the pancreatic head. A piece of cotton tissue
tape is used to encircle the duodenum and to hold it in
order to divide it.
4. Section of the duodenum (Fig. 31.4).
Electronic supplementary material The online version of this
chapter (https://doi.org/10.1007/978-3-030-55176-6_31) contains
supplementary material, which is available to authorized users.
J. Himpens (*)
CHIREC Delta Hospital, Brussels, Belgium
e-mail: jacques_himpens@hotmail.com
R. Bolckmans
Virginia Commonwealth University Hospitals, Richmond, VA, USA
© Springer Nature Switzerland AG 2021
M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery,
https://doi.org/10.1007/978-3-030-55176-6_31
When a retroduodenal window is created, a stapler is introduced and duodenal section is performed.
5. Change of the surgical team position (Fig. 31.5).
To do the second part of this procedure, the surgical team
has to change this position. At this time, all surgeons are
placed on the left side of the patient. The patient is positioned in the Trendelenburg position.
243
244 J. Himpens and R. Bolckmans
Fig. 31.1 Position of the
surgical team and patient (a)
and trocar’s (b) placement
Fig. 31.2 Sleeve
gastrectomy. Stapler cutting
the stomach (a) and sleeve
gastrectomy finished (b)
6. Measurement of the alimentary, biliopancreatic,
and common limbs (Fig. 31.6).
From the ileocecal valve, the small bowel is measured
75–100 cm (common limb) and marked at this distance
with a stitch. From this point, another 175–150 cm is measured (alimentary limb). Proximal to this point, another
175–150 cm in direction to the angle of Treitz is marked
(biliopancreatic limb).
7. Small bowel section (Fig. 31.6)
After the correct measurement of the common, biliopancreatic, and alimentary limb, the bowel is divided between the biliopancreatic limb and the proximal end of the alimentary limb.
8. Jejunoileostomy
This anastomosis is located 75–100 cm from the ileocecal
valve is med between this part of the ileum and the distal portion of the biliopancreatic limb after the previous
section.
This anastomosis can be performed by three different
approaches:
• Hand sewn side to side (Fig. 31.7)
• Semimechanical (Fig. 31.8)
• Totally mechanical (Fig. 31.9).
After jejunoileostomy is performed, mesenteric defect is
closed with a running suture.
Fig. 31.3 Posterior
dissection of the duodenum.
Close (a, b, c) and schematic
view (d)
24531 Laparoscopic Duodenal Switch
Fig. 31.4 Duodenal section. Close (a, b) and schematic view (c)
246 J. Himpens and R. Bolckmans
Fig. 31.5 Second surgical team position
Fig. 31.6 Common (a) and
alimentary limb measurement
where the bowel is divided (b)
Fig. 31.7 Hand sewn side to side jejunoileostomy (a, b, c)
24731 Laparoscopic Duodenal Switch
Fig. 31.8 Semimechanical jejunoileostomy (a, b, c)
Fig. 31.9 Totally mechanical jejunoileostomy (a, b, c)
Fig. 31.10 Duodenoileal anastomosis. Close (a, b) and schematic view (c)
248 J. Himpens and R. Bolckmans
Fig. 31.11 Hand sewn
duodenoileal anastomosis (a,
b, c, d)
9. Duodenoileal anastomosis
To perform this anastomosis, the surgeon can be at the left
side of the patient or between patient’s leg.
This anastomosis can be performed by these approaches:
• Semimechanical (Fig. 31.10)
• Hand sewn (Fig. 31.11).
10. Leak test, closure of Petersen space, drain, and trocar extraction.
At the end of this procedure, blue methylene test is performed to check duodenoileal anastomosis leak. Petersen’s
space is closed with a 2/running suture. A drain is placed
when the surgeon considers it is necessary.
References
1. Dapri G, Cadière GB, Himpens J. 32 laparoscopic malabsorptive
procedures: technique of duodenal switch. In: Brethauer S, Schauer
P, Schirmer B, editors. Minimally invasive bariatric surgery.
Springer, New York, NY; 2015.
2. Hess DS, Hess DW. Biliopancreatic diversion with a duodenal
switch. Obes Surg. 1998;8:267–82.
3. Marceau P, Hould FS, Simard S, et al. Biliopancreatic diversion
with duodenal switch. World J Surg. 1998;22:947–54.
4. Ren CJ, Patterson E, Gagner M. Early results of laparoscopic biliopancreatic diversion with duodenal switch: a case series of 40 consecutive patients. Obes Surg. 2000;10:514–23.
5. Skogar ML, Sundbom M. Weight loss and effect on co-morbidities
in the long-term after duodenal switch and gastric bypass: a population-based cohort study. Surg Obes Relat Dis. 2020;16:17–23.