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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_541_Библиотеки_им_академика_М_И_Перельмана.pdf
22 Robotic Gastric Bypass
247
Fig. 22.20 After a successful dissection of the fatty tissue, the last stapler is inserted, and the gastric pouch is nished
Fig. 22.21 The bougie is pulled back a bit, and the pouch is opened up
at the conjunction of the two perpendicular staple lines
Fig. 22.22 To ensure a correct opening, the gastric mucosa must be
visualized
Fig. 22.23 The greater omentum is lifted toward the abdominal wall,
and the ligament of Treitz is identied
248
J.-N. Kersebaum and J. H. Beckmann
Fig. 22.24 Using the grasper as a ruler
Fig. 22.25 Starting from the ligament of Treitz, the biliopancreatic
limb is measured
Fig. 22.26 100 cm aborally from the ligament of Treitz, the small
bowel is grabbed and moved toward the gastric pouch to ensure a good
positioning without tension
Fig. 22.27 The small bowel is opened up antimesenterically
22 Robotic Gastric Bypass
249
Fig. 22.28 Using all three arms, the small intestine is presented toward
the stapler
Fig. 22.29 The stapler is being inserted with the bigger side and slow
oscillating movement to avoid mucosal stress and injuries
Fig. 22.30 Using the tip-up grasper as counter bearing, the stapler is
bent
Fig. 22.31 The small intestine is approximated with the priorly formed
gastric pouch via the inserted linear stapler
250
J.-N. Kersebaum and J. H. Beckmann
Fig. 22.32 The opening of the gastric pouch is visualized, and the
small end of the stapler is carefully inserted to avoid a dissection of the
gastric wall
Fig. 22.33 Fashioning the gastrojejunostomy
Fig. 22.34 On retraction, the stapler is only opened halfway to avoid
stress on the anastomosis and a bigger enterostomy
Fig. 22.35 Closing the enterostomy with a 15cm, unidirectional 2–0
Stratax (Ethicon, Johnson & Johnson, Cincinnati, OH, USA) thread
beginning from the far left
22 Robotic Gastric Bypass
251
Fig. 22.36 We use continuous seromuscular stitches
Fig. 22.37 After nishing half of the anastomosis, a second 15 cm,
unidirectional 2–0 Stratax (Ethicon, Johnson & Johnson, Cincinnati,
OH, USA) thread is used closing up the enterostomy from the far right
Fig. 22.38 Adjusting the tension using the needle driver as a bearing
point
Fig. 22.39 The enterostomy is nished by two opposing stitches from
each side
252
J.-N. Kersebaum and J. H. Beckmann
Fig. 22.40 Proximal to the anastomosis, the small bowel is
positioned
Fig. 22.41 The mesentery is opened with the energy device. This
should neither be too close to the gastrojejunostomy to avoid a poor
perfusion nor too long to avoid a blind loop
Fig. 22.42 Dissection of the small intestine proximal of the anastomosis with a linear stapler
Fig. 22.43 Opening the small intestine for the anastomosis
22 Robotic Gastric Bypass
253
Fig. 22.44 Measurement of the Roux limb (150cm)
Fig. 22.45 Opening of the small intestine antimesenterically 150cm
aboral of the gastrojejunostomy
Fig. 22.46 After inserting the linear stapling device, the jejunal loop is
approximated toward the dissected small intestine
Fig. 22.47 Fashioning of the jejunojejunostomy with the linear
stapler
254
J.-N. Kersebaum and J. H. Beckmann
Fig. 22.48 To ensure low tension while stitching, the anastomosis is
positioned as follows
Fig. 22.49 Closure of the enterostomy using a 15cm, unidirectional
3–0 Stratax (Ethicon, Johnson & Johnson, Cincinnati, OH, USA)
thread
Fig. 22.50 Finished jejunojejunostomy
Fig. 22.51 Perform hemostasis if necessary. In this case with bipolar
forceps
22 Robotic Gastric Bypass
255
Fig. 22.52 Covering of the anastomosis with the omentum majus
Fig. 22.53 Methylene blue test of the gastrojejunostomy via the 40
Charrier Bougie with an additional gastric tube
Fig. 22.55 Positioning of the drainage under the left liver lobe
References
1. Welbourn R, Hollyman M, Kinsman R, Dixon J, Liem R, Ottosson
J, etal. Bariatric surgery worldwide: baseline demographic descrip-
tion and one-year outcomes from the fourth IFSO global registry
report 2018. Obes Surg. 2019;29(3):782–95.
2. Horgan S, Vanuno D.Robots in laparoscopic surgery. J Laparoendosc
Adv Surg Tech [Internet]. 2001 [cited 2019 Aug 11];11(6):415–9.
Available from: http://www.ncbi.nlm.nih.gov/pubmed/11814134.
3. Szold A, Bergamaschi R, Broeders I, Dankelman J, Forgione A,
Langø T, etal. European association of endoscopic surgeons (EAES)
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Fig. 22.54 Retracting the liver paddle in view to avoid tissue damage
Robotic Duodenal Switch (rDS)
Duodenal switch
andRobotic Single Anastomosis
Duodenal-Ileal Bypass withSleeve
Gastrectomy (rSADI-S)
CurtisPeery
23
Successful long-term treatment of obesity has only been
achieved with bariatric surgery. The sleeve gastrectomy (SG)
and Roux-en-Y (RNY) gastric bypass are the most commonly
performed bariatric surgeries in the United States. Very few
biliopancreatic diversions with duodenal switch, commonly
known as the duodenal switch (DS), are performed in comparison (0.9%). Several reasons may be responsible for this.
First, management of these patients is complex with a higher
risk for malnutrition and vitamin and mineral deciencies.
Second, historically the DS has had increased mortality and
morbidity in comparison to the SG or RNY gastric bypass.
Most DS have been performed either open or laparoscopically.
It is well-known that open surgery increases surgical complications, and a laparoscopic DS is an overly complex procedure
with safe results difcult to reproduce. As a result, surgical
complications have been higher for the DS as compared to the
gastric bypass and sleeve gastrectomy.
A modication of the DS has become increasingly popular and appears to have fewer metabolic and surgical complications. This modication is known by many different
names: the single anastomosis DS, single anastomosis
duodenal- ileal bypass with sleeve gastrectomy (SADI-S),
loop DS, or stomach intestinal pylorus-sparing surgery
(SIPS). The American Society for Metabolic and Bariatric
Surgery (ASMBS) in 2020 came out with an endorsement of
these procedures as an acceptable modication of the DS.To
avoid confusion, we will refer to this modication as the
SADI-S from here on out.
Because of the worsening obesity epidemic and increasing population of super-morbidly obese individuals, there
has been a renewed interest in the DS and SADI-S.Also,
robotic bariatric surgery is rapidly gaining acceptance, particularly for more complex surgeries such as bariatric proce-
C. Peery (*)
Department of Surgery, Sanford School of Medicine University of
South Dakota, Sioux Falls, SD, USA
e-mail: curtis.peery@sanfordhealth.org
dures. When surgeons are adequately trained, the introduction
of robotics into a bariatric surgeon’s practice can be safe and
increase the surgeon’s ability to perform these more complex
surgeries such as the DS, SADI-S, and revisions. This chapter discusses the utilization of the robotic platform as a tool
to safely perform the DS and SADI-S (Figs.23.1, 23.2, 23.3,
23.4, 23.5, 23.6, 23.7, 23.8, 23.9, 23.10, 23.11, 23.12, 23.13,
23.14, 23.15, 23.16, 23.17, 23.18, 23.19, 23.20, 23.21, 23.22,
23.23, 23.24, 23.25, 23.26, 23.27, 23.28, 23.29, 23.30, 23.31,
23.32, 23.33, 23.34, 23.35, 23.36, 23.37, 23.38, 23.39, 23.40,
23.41, 23.42, 23.43, and 23.44).
Food
Digestive
juice
Fig. 23.1 This is an illustration of the essential components of the duodenal switch (DS). A sleeve gastrectomy has been created and the duodenum divided in the rst portion. The small bowel is then recongured
creating a Roux limb otherwise known as the alimentary limb. The biliopancreatic (BP) limb is anastomosed to the ileum leaving a common
channel. In practice these limbs may vary in length, but the common
channel is usually 100–200cm long
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022
O. Y. Kudsi, P. P. Grimminger (eds.), Atlas of Robotic Upper Gastrointestinal Surgery,
https://doi.org/10.1007/978-3-030-86578-8_23
257