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28. Kimura W, Nagai H.Study of surgical anatomy for duodenum-preserving resection of the head
of the pancreas. Ann Surg. 1995;221(4):359–63.
29. Nelson L, Moon RC, Teixeira AF, Galvão M, Ramos A, Jawad MA.Safety and effectiveness
of single anastomosis duodenal switch procedure: preliminary result from a single institution.
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30. Lee-Bion A Jr, Menahem B, Le Roux Y, Contival N.Single anastomosis duodeno-ileal bypasssleeve gastrectomy: surgical technique. J Visc Surg. 2019;156(4):343–7.
31. Gebelli JP, Gordejuela AGR, Ramos AC, Nora M, Pereira AM, Campos JM, Ramos MG,
Bastos ELS, Marchesini JB.SADI-S with right gastric artery ligation: technical systematization and early results. Arq Bras Cir Dig. 2016;29(Suppl 1):85–90.
32. Finno P, Osorio J, García-Ruiz-de-Gordejuela A, Casajoana A, Sorribas M, Admella V,
Serrano M, Marchesini JB, Ramos AC, Gebellí JP. Single versus double-anastomosis duodenal switch: single-site comparative cohort study in 440 consecutive patients. Obes Surg.
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33. Tacchino RM.Bowel length: measurement, predictors, and impact on bariatric and metabolic
surgery. Surg Obes Relat Dis. 2015;11(2):328–34.
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dose of cyclosporine in children after liver transplantation. N Engl J Med. 1990;322(11):733–8.
A. C. Ramos and E. L. D. S. Bastos
Chapter 23
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Robotic Duodenal Switch andSADI-S:
Technical Aspects
AaronBornstein andAndreTeixeira
23.1 Introduction
As the incidence of morbid obesity continues to rise within the United States and
throughout the world, bariatric surgery offers the most effective and durable solution to combat this ongoing epidemic. While the sleeve gastrectomy and Roux-en-y
gastric bypass comprise the most popular weight loss options, the biliopancreatic
diversion with duodenal switch (BDP/DS or duodenal switch) and single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) are the most effective
weight loss surgeries available. The duodenal switch and SADI-S offer the greatest
magnitude of excess weight loss (EWL) and the most signicant improvement and
resolution of comorbid conditions, in particular type II diabetes and hyperlipidemia.
However, despite their superior weight loss and comorbidity resolution, duodenal
switch operations typically account for less than 5% of the bariatric surgeries performed worldwide. This is likely due to a combination of factors: patient selection,
fear of long-term nutritional complications, and, most importantly, the technical
skills required to perform the operation safely. The ability to perform this procedure
using the robotic platform eases the technical demands of the operation allowing
bariatric surgeons to more freely offer this surgical option [1–5].
A. Bornstein (*)
Department of General and Bariatric Surgery, SSM Health St. Clare Hospital,
St. Louis, MO, USA
e-mail: aaron.bornstein@ssmhealth.com
A. Teixeira
Department of Bariatric Surgery, Orlando Regional Medical Center, Orlando, FL, USA
e-mail: andre.teixeira@orlandohealth.com
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
A. Teixeira et al. (eds.), Duodenal Switch and Its Derivatives in Bariatric and
Metabolic Surgery, https://doi.org/10.1007/978-3-031-25828-2_23
229
230
The robotic platform has several advantages from a technical standpoint when
compared to standard laparoscopy: improved visualization, improved ergonomics,
more precise dissection, and dexterity of the wristed instruments. These advantages
allow surgeons to perform more complex operations in a minimally invasive manner. For the BPD/DS and SADI-S, the 3D visualization and dexterity of the robotic
arms give the surgeon more control when dissecting around the duodenum and the
ability to more easily perform all the anastomoses in a hand-sewn manner. Also, the
improved angulation of the robotic stapler, as opposed to the laparoscopic stapler,
allows the surgeon to create the sleeve gastrectomy and transect the duodenum with
ease. This chapter will be dedicated to the technical aspects involved in performing
these two operations using the robotic platform [6–8].
A. Bornstein and A. Teixeira
23.2 Biliopancreatic Diversion withDuodenal Switch
23.2.1 Patient Positioning andPort Placement
The patient is placed in the standard supine position with both arms out at right
angles on padded arm boards. A footboard is used, and a padded belt is placed
across the lower extremities to secure the patient to the table. Peritoneal access is
obtained using either a Veress needle followed by an optical trocar or optical 5mm
laparoscopic trocar in the left mid-abdomen near the mid-clavicular line. A 0° laparoscopic scope is used when accessing the abdominal cavity using either approach
and then exchanged for the 30° laparoscopic camera to place the remaining trocars.
The trocars are placed in a smile shape across the abdomen: 8mm right anterior
axillary line a few ngerbreadths below the inferior edge of the liver, 12mm right
mid-clavicular line near the level of the umbilicus, 8mm supraumbilical midline,
12mm left mid-clavicular line near the level of the umbilicus, and 8mm left anterior axillary line a few ngerbreadths beneath the ribs. The liver is then retracted
toward the anterior abdominal wall. This can be done in several different ways at the
discretion of the surgeon; routinely, I will place a 5mm subxiphoid trocar and place
a laparoscopic toothed Alice grasper at the superior aspect of the hiatus, thus retracting the liver off of the stomach. Alternatively, a full length 2–0 Ethibond suture
placed through the superior aspect of the hiatus and brought out through the abdominal wall on either side of the falciform ligament also works very well.
After the liver has been retracted, I run the bowel laparoscopically starting at the
terminal ileum to a point roughly 250cm proximally, and a suture is placed in the
mesentery to mark this point. The suture is also brought through the superior portion of the greater omentum which prevents the bowel from falling down into the
pelvis. This can also be done robotically depending on surgeon preference. A marking pen is used to mark the bowel proximal to the suture in order to ensure no twisting of the mesentery when the bowel is brought up to the duodenum for the
anastomosis. Once the suture is placed and bowel marked, the patient is placed in
23 Robotic Duodenal Switch andSADI-S: Technical Aspects
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231
10–15° reverse Trendelenburg, and the robot is brought in from the patient’s left
side for docking. The instruments used for a duodenal switch from the patient’s
right to left side are as follows: fenestrated bipolar grasper, assistant trocar/robotic
60mm SureForm stapler, 30° robotic camera, vessel sealer/robotic monopolar scissor/large needle driver, and tip-up grasper or cadiere. After the robot is docked, I
begin with the duodenal dissection.
23.2.2 Duodenal Dissection
Beginning along the greater curvature of the pre-pyloric antrum, a plane is created
between the antrum anteriorly and the pancreas posteriorly using the vessel sealer
and the fenestrated bipolar grasper. The distal antrum is retracted anteriorly using
either a cadiere or tip-up grasper. This plane is continued down to the duodenum,
and a retro-duodenal tunnel is created in order to ensure a 1–2cm cuff of mobilized
duodenum. It is important not to be overly aggressive during the retroduodenal dissection which could lead to duodenal stump ischemia and subsequent stump blowout or injury to the gastroduodenal artery posterior to the duodenal bulb which
could lead to signicant hemorrhage. Once the retroduodenal tunnel is completed,
a Penrose drain is placed through the tunnel in order to facilitate placement of the
stapler during the transaction of the duodenum. Following the completion of the
sleeve gastrectomy, the robotic stapler will be used to transect the duodenum at least
1cm distal to the pylorus. However, I do not transect the duodenum until after the
sleeve gastrectomy portion of the procedure has been completed. It is easiest to
bring the stapler in through the left mid-clavicular 12mm trocar as opposed to the
right mid-clavicular site. I prefer to place the anvil side of the stapler through the
retroduodenal tunnel given its thinner prole. The previously placed Penrose drain
is retracted anteriorly to better expose the retroduodenal tunnel and ensure appropriate placement of the stapling device. Once the stapler has been placed, the Penrose
drain is removed to ensure it is not incorporated within the staple line. I prefer to use
a white load cartridge, but a blue load is perfectly acceptable when transecting the
duodenum. I do not routinely oversew or reinforce the staple line of the duodenum.
23.2.3 Sleeve Gastrectomy
Starting along the greater curvature of the body of the stomach, the lesser sac is
entered by dividing the branches of the gastroepiploic arcade using the vessel sealer.
The dissection is then carried cephalad along the greater curvature up to the angle
of His ensuring that the left crus is clearly identied, no redundant fundus is present
posteriorly, and no evidence of a hiatal hernia exists. The inferior portion of the
greater curvature dissection is then completed ensuring that a few arcade vessels
232
remain between the duodenal dissection plane and the greater curvature dissection
to help avoid any ischemic complications as it relates to the duodeno-ileal anastomosis. After the dissection is completed, the calibration tube is advanced into the
stomach with the assistance of the anesthesia provider and positioned along the
lesser curvature of the stomach with the tip of the calibration tube in the antrum. The
calibration tube is then placed on suction to help maintain its position within the
stomach. The SureForm robotic 60mm stapling device, brought in through the right
mid-clavicular trocar, is used to create the sleeve gastrectomy starting with a green
load cartridge at the antrum followed by blue loads for the remainder of the gastric
sleeve. It is important to note that the overall size of the sleeve gastrectomy created
for a duodenal switch is slightly larger than that made for patients who undergo
sleeve gastrectomy alone. This is done to help limit any risk for postoperative dysphagia or oral intolerance.
A. Bornstein and A. Teixeira
23.2.4 Duodeno-Ileostomy
After the sleeve gastrectomy and duodenal transection have been completed, the
suture used to mark the small bowel is located, the loop of the small bowel is brought
up to the duodenum in an antecolic fashion, and a posterior suture line is created
between the ileum and the duodenum using a suture of your choice; I prefer a 3–0
PDS or Stratax. For those surgeons who prefer a double-layer anastomosis, this
suture will be carried around anteriorly after the inner layer has been completed.
Generous enterotomies are created in both the duodenum and ileum using the
robotic scissors ensuring that the anastomosis is wide, so as to avoid any concerns
for anastomotic stricture. The enterotomies are sutured together using a 2–0 or 3–0
suture, commonly Vicryl. The suture used to create the posterior suture line is then
brought anteriorly creating a two-layer anastomosis.
23.2.5 Ileoileostomy
After the duodeno-ileostomy (DI) has been created, attention is then turned to creating the ileoileostomy. This begins by transection of the small bowel just proximal to
the DI anastomosis using a white or blue load of the robotic stapler; this will serve
as the biliopancreatic (BP) limb of the anastomosis. During this portion of the operation, the robotic stapler is typically brought in through the left mid-clavicular
12mm trocar. Alternatively, a small window in the small bowel mesentery can be
made using the robotic scissors and the stapler brought in via the right mid- clavicular
12mm trocar. The small bowel is then counted 125cm distal to the DI anastomosis
and sewn to the distal BP limb in order to approximate the bowel loops needed to
create the ileoileostomy. The approximated small bowel is then retracted toward the
right upper quadrant to allow space for the robotic stapler to enter through the
23 Robotic Duodenal Switch andSADI-S: Technical Aspects
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left- sided 12mm trocar to perform the anastomosis. Enterotomies are created in
both the biliopancreatic and Roux limbs using robotic scissors. Using a white load
of the robotic stapler, the anastomosis is created. The common enterotomy is closed
in one or two layers depending on surgeon preference. I typically prefer to close the
enterotomy in a single layer with a 3–0 PDS or Stratax suture in a running fashion.
Once the common enterotomy has been closed, it is time to address the mesenteric
defects.
233
23.2.6 Hernia Defects
There are two hernia defects created during this procedure: Peterson’s defect made
from the antecolic DI anastomosis and the mesenteric defect from the ileoileostomy
anastomosis. I do not routinely close Peterson’s defect after a duodenal switch;
however, I will close the mesenteric defect. I typically close this defect with a running 3–0 PDS or Stratax suture. I bring this suture onto the bowel as well to help
avoid any kinking of the ileoileostomy. The use of absorbable or permanent suture
for closure of the mesenteric defect is dependent on surgeon preference.
23.2.7 Anastomotic/Staple Line Leak Test
I typically test my DI anastomosis and gastric sleeve staple line with a combination
of methylene blue dye administered via the calibration tube followed by air insufation. For those who are concerned about the potential for anaphylaxis to the blue
dye, air insufation with 1L per minute via the calibration tube is also adequate
after the gastric staple line and DI anastomosis have been submerged in saline irrigation. Another option is intraoperative endoscopy and air insufation leak test, but
I nd this unnecessary and more time-consuming than the other previously mentioned techniques. Next, I typically place a 19 Fr drain through the right lateral
trocar site and place it in the subhepatic space near the duodenal dissection bed in
order to monitor for postoperative duodenal stump leak and pancreatic leak. Lipase
is sent from the drain on POD2 and the drain removed prior to discharge if normal.
23.3 Single Anastomosis Duodeno-Ileal Bypass
withSleeve Gastrectomy
The single anastomosis duodenal switch is a simple modication of the traditional
switch. It was created in order to limit the risks of macronutrient deciencies and
decrease the technical complexity of the duodenal switch, all while still achieving
similar weight loss and resolution of comorbid conditions when compared to the
234
A. Bornstein and A. Teixeira
traditional duodenal switch. The length of the common channel can vary between
surgeons but typically is 250–300cm, as opposed to the traditional duodenal switch
which has a common channel length of 125–150cm. The technical aspects of the
two procedures are identical with two exceptions: the ileoileostomy is not performed and, therefore, no mesenteric defects need to be closed [9].
23.4 Conclusion
The biliopancreatic diversion with duodenal switch and single anastomosis
duodeno- ileal bypass with sleeve gastrectomy are the two most effective bariatric
procedures with regard to overall weight loss and resolution of comorbid conditions. However, these operations are very technically demanding laparoscopically
which has contributed to their limited use. The ability to employ the robotic platform to assist in these procedures gives the bariatric surgeon more control over the
operation through better visualization, more precise dissection, and more ease when
performing hand-sewn anastomosis. By approaching these operations in a stepwise
manner, these complex bariatric procedures become less daunting and give the surgeon the condence to offer their patients the full scope of weight loss procedures.
References
1. Nguyen NT, etal. The ASMBS textbook of bariatric surgery: Volume 1: Bariatric surgery.
NewYork: Springer; 2015. https://doi.org/10.1007/978- 1- 4939- 1206- 3_18.
2. SjostromL NK, Sjostrom CD, Karason K, Larsson B, Wedel H, etal. Effects of bariatric sur-
gery on mortality in Swedish obese subjects. N Engl J Med. 2007;357(8):741–52.
3. Prachard VN, Davee R, Already JC. Duodenal switch provides superior weight loss in the
super-obese (bmi>50kg/m2) compared with gastric bypass. Ann Surg. 2000;10:514–23.
4. Gracia JA, Martinez M, Elia M, Aguilella V, Royo P, Jimenez A, etal. Obesity surgery results
depending on technique performed: long-term outcome. Obes Surg. 2009;90:15.
5. Buchwald H, Avidor Y, Braunwald E, etal. Bariatric surgery: a systematic review and meta-
analysis. JAMA. 2004;292:1724–37.
6. Van Koughnett JA, Jayaraman S, Eagleson R, Quan D, Wynsberghe AV, Schlachta C.Are there
advantages to robotic-assisted surgery over laparoscopy from the surgeon’s perspective? J
Robotic Surg. 2009;3:79–82.
7. Sudan R, Podolsky E.Totally robot-assisted biliary pancreatic diversion with duodenal switch:
single dock technique and technical outcomes. Surg Endosc. 2015;29:55–60.
8. Antanavicius G, Katsichtis T, Alswealmeen W, Assali M. Three hundred four robotically
assisted biliopancreatic diversion with duodenal switch operations with gradual robotic
approach implementation: short-term outcomes, complication prole, and lessons learned.
Obes Surg. 2020;30:3961–7.
9. Kallies K, Rogers AM.American Society for Metabolic and Bariatric Surgery updated state-
ment on single-anastomosis duodenal switch. SOARD. 2020;16:825–30.
Chapter 24
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Laparoscopic Biliopancreatic Diversion
withDuodenal Switch: Surgical Technique
LaurentBiertho, LéonieBouvet-Bouchard, andPhilVourtzoumis
24.1 Introduction
Obesity is known as a multi-factorial, complex, chronic, and relapsing disease [1].
Although lifestyle changes remain a key factor in the treatment of obesity, bariatric
surgery is considered as the only approach leading to signicant, long-term, benecial impact in patients with severe obesity. Several weight loss procedures are
endorsed by medical and surgical societies, including “biliopancreatic diversion
with duodenal switch” (BPD-DS), which is the subject of this chapter. The surgical
principle of a biliary bypass goes back to 1923, as described by Mann and Williamson
[2]. In 1973, Nicola Scopinaro adapted the technique to decrease caloric absorption
by adding a distal gastrectomy and performed the rst biliopancreatic diversion [3].
The distal gastrectomy was necessary to decrease the risks of ulcers, but protein
malabsorption, gastrointestinal side effects, and dumping syndrome were common.
The technique was then modied in the late 1980s, to remove as much parietal cell
located in the fundus and to increase the common channel length from 50cm to
100cm [4, 5]. This led to the creation of the BPD-DS, as we still know it (Fig.24.1).
It was later adapted to the laparoscopic approach in 1999 [6] which led to dramatic
reduction in peri-operative complication rates [7].
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978- 3- 031- 25828- 2_24.
L. Biertho (*) · L. Bouvet-Bouchard · P. Vourtzoumis
Department of Surgery, Institut Universitaire de cardiologie et pneumologie de Québec—
Université Laval, Laval University, Quebec City, QC, Canada
e-mail: Laurent.biertho@criucpq.ulaval.ca; leonie.bouvet-bouchard.med@ssss.gouv.qc.ca;
phil.vourtzoumis@mail.mcgill.ca
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
A. Teixeira et al. (eds.), Duodenal Switch and Its Derivatives in Bariatric and
Metabolic Surgery, https://doi.org/10.1007/978-3-031-25828-2_24
235
236
L. Biertho et al.
Fig. 24.1 Biliopancreatic diversion with duodenal switch
In short, the current BPD-DS technique we described in the present article
includes three specic components. First, the sleeve gastrectomy provides some
caloric restriction while decreasing acid production and accelerating gastric emptying. A 250-cm total alimentary limb is created to decrease caloric absorption. Finally,
a 100-cm common channel is formed, where food bolus mixes with biliopancreatic
24 Laparoscopic Biliopancreatic Diversion withDuodenal Switch: Surgical Technique
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237
juices, resulting in decreased protein and fat absorption and in a strong metabolic
effect. Long-term outcomes, side effects, and complications have been described
extensively in the literature [7–11], and we will focus this chapter on surgical technique and peri-operative management.
24.2 Surgical Technique (Video 24.1)
24.2.1 Preoperative Evaluation
All bariatric patients are evaluated by a multidisciplinary team, including a bariatric
surgeon, bariatric nurse, and dietician. Consultation with a dietician qualied in
BPD-DS is of utmost importance to correct eating disorders and to educate patients
on the recommended diet after BPD-DS (high-protein, very low-fat diet). Before
surgery, a low-calorie, high-protein diet can also be used to decrease the size of the
liver and the amount of intraperitoneal fat. A psychiatric or psychological evaluation is requested for patients with a history of mental health or when clinically
indicated. Screening for diabetes, dyslipidemia, and obstructive sleep apnea is performed. These comorbidities are controlled prior to surgery, especially when moderate to severe sleep apnea is detected, and noninvasive positive pressure ventilation
should be initiated before surgery.
Preoperative blood work consists of a complete blood cell count, liver enzymes,
albumin, calcium, parathyroid hormone, vitamin D, vitamin A, vitamin B12, and
iron panel. Preoperative nutritional deciencies should be detected and treatment
initiated before surgery, to decrease the risks of poorly controlled deciencies in the
postoperative period. In our practice, all patients receive a multivitamin complex
that contains vitamin B1 (Centrum Forte©) and vitamin D3 supplementation
(10,000U per day for 1month followed by 1000U per day until surgery) at least
3months before surgery.
24.2.2 Preparation andPatient Positioning
The patient is placed under general anesthesia and placed in the supine, split-leg
position with both arms open (Fig.24.2). The surgeon stands between the patient’s
legs, and the assistant to the left side, except for the sub-mesocolic part of the procedure where they both are on the patient’s left side. Before the beginning of the
surgery, appropriate antibiotic (cefazolin 2g IV for patients weighing ≤120kg and
3g for patients weighing >120kg) and deep venous thrombosis prophylaxis (heparin 5000U SC 2hours before surgery) are given.
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