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Laparoscopic Mini Gastric Bypass (MGB) is one of the most commonly performed bariatric surgery and slowly getting popular all over world as obesity surgery. This video demonstrate step by step technique of performing mini gastric bypass surgery by Dr R K Mishra at World Laparoscopy Hospital for a female suffering from Morbid Obesity. Mini Gastric Bypass has Restrictive, Malabsorptive and Hormonal component.
Restrictive:
A small stomach pouch is created restricting the amount of food you can eat.
Malabsorptive:
A portion of the small intestine is bypassed. Since the small intestine is responsible for absorbing the calories from the food you eat, bypassing a portion of the small intestine results in fewer calories being absorbed, thus creating additional weight loss.
Hormonal:
The hormone ghrelin has been nicknamed the “Hunger Hormone” by researchers because of its significant effect on appetite. Gastric Bypass results in a fall in ghrelin levels resulting in a reduced appetite.
For more information please contact:
World Laparoscopy Hospital
Cyber City, Gurugram, NCR DELHI
INDIA 122002
Phone & WhatsApp: +919811416838, + 91 9999677788
Laparoscopic Mini Gastric Bypass (MGB) is one of the most commonly performed bariatric surgery and slowly getting popular all over world as obesity surgery. This video demonstrate step by step technique of performing mini gastric bypass surgery by Dr R K Mishra at World Laparoscopy Hospital for a female suffering from Morbid Obesity. Mini Gastric Bypass has Restrictive, Malabsorptive and Hormonal component.
Restrictive:
A small stomach pouch is created restricting the amount of food you can eat.
Malabsorptive:
A portion of the small intestine is bypassed. Since the small intestine is responsible for absorbing the calories from the food you eat, bypassing a portion of the small intestine results in fewer calories being absorbed, thus creating additional weight loss.
Hormonal:
The hormone ghrelin has been nicknamed the “Hunger Hormone” by researchers because of its significant effect on appetite. Gastric Bypass results in a fall in ghrelin levels resulting in a reduced appetite.
For more information please contact:
World Laparoscopy Hospital
Cyber City, Gurugram, NCR DELHI
INDIA 122002
Phone & WhatsApp: +919811416838, + 91 9999677788
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LearningTranscript
00:00hello friends this is a case of laparoscopic mini gastric bypass this is
00:10a 47 year old woman with BMI 45 she has already undergone laparoscopic
00:18cholecystectomy before and now we are performing the MGB mini gastric bypass
00:26now if we accrys of amlicas will be used for various internal supra amlical port that
00:34is for telescope left epigastric port for the stapler that is horizontal
00:41stapler line and then one left hypochondrium one right hypochondria and
00:48one left anterior axillary line so this is the standard port which you
00:56can find out the detail about my lecture of the MGB is present and here we are
01:01using the various needle that is 20 centimeter various needle will be
01:06introduced to the amlicas assistant will lift it and you will point it towards the
01:11anus keep it in perpendicular to the abdomen wall now you can take a syringe
01:18this is irrigation test suction test and then hanging drop test lifting it up after
01:36that you can attach the various needle here we are using a striker pneumoflator that is
01:4445 liter insufflator and bariatric mode striker microprocessor insufflator has
01:51different modes so bariatric mode will be used and in this patient approximately 45
01:584.5 liter gas was used to reach to the preset pressure 15 and then this is a
02:05supra-ambleical port that is for telescope and this is the 10 millimeter port which
02:12we are using for telescope
02:24once the telescopic port is introduced then you can introduce the telescope and have a
02:28inspection of the abdominal cavity insufflator tubing will be again attached and the flow rate will
02:36be increased to 20 liter per minute and now once you entire everything was fine little adhesion of
02:43the momentum were there to the right hypopondrium near the gallbed area now this is the right
02:51hypochondric port that is for the purpose of the stapler and this is for your left now this is the left
03:02hypochondric port that will be your right during the surgery for ligature or harm and these ports are
03:10working ports now you can lift the momentum with the epigastric port and the right hypochondric port
03:18will have the this liver retractor and left hypochondric port you will hold by right hand with the ligature
03:29so there is a instrument which is lifting the liver here we are not using nathanson liver retractor
03:36and at the level of the secondary gastric vertical you should lift the lesser momentum and then you can
03:42make a elemental window this is a window created and after that you can enlarge the window and have
03:49a inspection and find out any adhesion below the stomach mini gastric bypass is a very simple and
03:56easy surgery and most of the time it is a job of just staplers and once you have a basic concept clear
04:03this surgery can be performed within half an hour to 45 minutes so this is the ligature which has made
04:10a window and we can see it's a good case there is no much adhesion and now this is the epigastric port
04:16will use the stapler to get a horizontal line that is you will use for making the gastric tube and this
04:25is the first cartridge which you have to fire and this is the horizontal line after that you can push the
04:31busy little bit and you can introduce the busy in this gastric tube and then you can start taking the
04:38vertical staple line you should must be clear that below in the retro gastic area there should not
04:44be any adhesion when you are using the staple and any adhesion should must be separated from the
04:52adhesion with the either harmonic or you can use ligature so these vertical staple line will keep on
04:59continuing and once you fire it once after that always inspect and do the adhesiolisis and then progress
05:06again you should not fire blindly because that may cut there may be the bleeding also started so once
05:15it is the second staple is fired then you will just lift the stomach with the grasper and just you can
05:22have a view there in that view you can see the retro gastic area that everything is fine there is no
05:28much adhesion so now the third cartridge also can be introduced and this is the third staple cartridge
05:35here if you can see retro gastic area little adhesion then with the harmonic you can do adhesiolisis
05:44so this is fine now this is the third cartridge which will be introduced as near as possible to the
05:50gastric buji so that you have advantage many gastric bypass has a two component one is restrictive and
05:58another is malabsorptive and restrictive component depends upon how nicely you are making the gastric
06:05tube and malabsorptive component how much intestine you are doing the bypass here we have every firing
06:12we use wait for few seconds and then fire as you know mostly fire four firing is required to reach the 60 mm so
06:20every firing you should wait for few seconds so that you will have a very good uh means without any
06:27bleeding a good staple line will be there now again you will lift it and you can have an inspection in
06:33the posterior gastric area retro gastric area to see for any addition so this is the grasper again lifting
06:40it and your telescope can enter into this retro gastric area to visualize that there should not be much
06:46adhesion so this is the ligashore again doing additional isis once you reach to the upper part
06:54then you should must be careful that sometime the spleen is getting adhered with the fundus part of the
06:59stomach and sometime this retro gastric fat cushion has adhesion so with the ligashore or harmonic you
07:06should try to separate these adhesions and you should make a blunt dissection with the window so that you can
07:11reach up to the diaphragm the petroleum over the left crust also sometime has to be mobilized to reach
07:18there so this is slowly going on and you will keep on lifting by left hand stomach and right hand and
07:25telescope should enter into this retro gastric tunnel you should also take care that ligashore should not
07:31create any collateral damage and stomach should not be burned again slowly slowly slowly slowly
07:38bluntly you will enter and shiny fascia of the crust and then you can start seeing the diaphragm once
07:46you reach to the diaphragm that means now your stapler also will go beyond the fundus here we can see
07:52that this diaphragm is visible and this is the window created and now that's that is the enough this is
07:58the diaphragm and window is created now you can do little suction and you can apply the other cartridge
08:04this this is again 60 mm tri-stuple cartridge and again you can apply and again you can fire
08:12mini gastric bypass has a much less complication compared to ru and y gastric bypass and it's a
08:20promising surgery the sleeve gastric tummy has as you know that problem of again weight regain after few
08:27years so mini gastric bypass doesn't have this problem and this is now the staple which is cut
08:34and now that we have reached up to the fundus but in many of the cases as you can see a small portion
08:39of the tag of the fundus from the gastrosophageal junction is already attached in those situation
08:45you should never try to clip it or ligate it better always to fire one more stapler because if you will
08:52unnecessarily try to do it with the clip or with the knot titanium clip or the knot there may be leak
09:00so always check a better new cartridge load the new cartridge and then you will fire it
09:06so this is now the previous one is removed and this is the other cartridge is introduced
09:13and this small dog here will be cut out
09:22so it is now over and it is done
09:25after that little suction irrigation can be performed and absolutely no bleeding is there
09:31after that you will go and you will try to find out and lift the momentum up and pull all the
09:38small bubble walk over to the small bubble to reach to the first part of jejunum
09:43at near the ligamentum trees so a lot of fat of course will be in the morbid obese present so just
09:51you have to push it towards the at that time the table to be tilted so that you can pull the
09:57intestine loop and here we can see it is reaching up to the ligamentum trees how you will know that
10:04further jejunum cannot be pulled because it is the end of the fourth part of diodonum and a start of
10:09a jejunum so this is the first part of the jejunum and ligamentum trees will be nicely visible
10:16in some time if it is not then also you should try to visualize it transverse colon and all the
10:23greater momentum should be lifted up and then slowly you will pull it to make it sure that this
10:28is ligamentum trees and here we can see this is fine and after that you can start walking over to the
10:35jejunum so we will take 2.5 meters so you will walk over and this should be done in such a manner that
10:44there should not be any torsion so here we start this is 5 and from 5 we will start at 1 this will be
10:52calculated so here you go this is the 1 2 3 4 5 6 7 8 9
11:1410 11 always keep it towards the left side
11:2212 13 14 15 16 17 18 19 20
11:3821 21 22 23 24 25 26 27 28 29 30 31 32 33
12:0722 23 34 35 36 37 38 39 40 41 42 43 44 45 46 47
12:3649 49 49 49 so it is reached it is reached it is every time you will pull the 5 centimeter so the 50 that is 2.5 meter of the
12:48and then you will start doing the and then you will start doing the anostomosis single anostomosis is required in the mgp and you have to be careful that you should not rotate it here accidentally if it is rotated it will be little problem so now here this is the stomach just above the staple line in the middle of the staple line
13:10so now here this is the entire wall here this is the entire wall here a window has been created into the stomach
13:16and with the harmonic or you can use hook also many people they use hook
13:21and this is the entire wall here and this is the entire wall here and you will put the harmonic inside and
13:28after that you will push the and the this is the gastric calibration tube which you can push it here
13:35and this is this is now inside and after that you can just cut the and the assistant will this buzji will be now pulled in and you should take care that sub-serosal pocket should not be formed the lumen should be visible
13:51the lumen should be visible and now here the this part of the jajunam is also cut and after that you will introduce perforate it and here you are and it should must be mucosa should must be visible
14:07it should not be here grasper should must enter after that this is the stapler and one of the jaw you will enter the jajunam
14:15and this is the face jaw of the cartridge and this is this jaw you will go to the stomach and it should be fully in that is a 60 millimeter side to side staple we will perform
14:28so this has to be fully pulled and again this end is also fully pulled and then again make it sure that both the edges should be equal and it should be even yes and it should not compromise the blood supply
14:42so you should hold it in a correct manner and this is done after that you will fire once you will fire you will get a anastomosis and here it is done
14:55now you can remove it after few seconds and now it is out after that you can put a suction and with the suction you can just lift it out and you can make it sure that this is a good anastomosis
15:16so here you can see buji is visible and lumen of the jajunam is also visible nicely so everything is fine now you can start doing the closure of the suture line
15:26so closure of the suture line has to be started a staple perforation of the staple and this is the we are using here the barb suture and this barb suture will close it
15:39so this is we will use it two layer first layer and then after that serosal layer also we will approximate it
15:46as you know barb suture has every one millimeter laser cut that gives you the self holding but then also we must tie a knot
15:55and generally we don't believe in the property of the part many people they don't tie a knot but it is better to tie a knot
16:02so this is the barb suture and here you can start the taking surgeon's knot
16:09so this is first time double wrap followed by two opposite alternating wrap
16:15so this is the first this is the another reversi
16:20so this way you can go you can catch it and then you can tie the knot
16:27here you go and then again another reversi
16:33so c reversi and again c and this is two one one that is surgeon's knot
16:40so this is the starter knot
16:42sometime in the they have already a pre-tired loop which you can use for starting the knot
16:48but in some of the company they make it some knot
16:52now this is again slowly slowly you will keep on doing the closure of the staple hole
16:58and this is slowly this is jejunum and this is the stomach line
17:03and you can keep on closing it
17:06so this barb suture is made up of polygalactane so it is self absorbing
17:14and it is not a must many people they can use vicrylo as well
17:20this is now they can continuous left hand will keep on separating it
17:26as you can see the left instrument is little bit lifting the falsiform ligament
17:31now this is again edge to edge so keep on taking a bite
17:49so one of the complication of the mini gastric bypass is the bleeding of the
17:56and another one is leak of the suture line
17:59so it is always better that methylene blue test should be done
18:02and you should be 100% sure that you have a good suturing skill
18:08now again this is going slowly posteriorly and it is sutured
18:14corner also should must be sutured adequately
18:18because if you have a bad suture line leak can happen
18:22so this is continuous suturing going on
18:26you should also take care that you should not accidentally occlude the lumen
18:31because sometime accidentally you may occlude the lumen
18:34because it is a single anastomosis
18:36so it is important to prevent it
18:39some people they put a bhoji and they introduce the bhoji
18:42then they take a bite
18:44but we are on the margins of the mucosa
18:47mucosa is averted
18:49so there is no possibility of occlusion of the stucle line
18:54and slowly it is continued
19:06left hand should support the suture and right hand to take the bite
19:12during the suturing it is important that you should not maintain a big distance
19:17and there should not be excessive pulling also that can create cut through
19:42once you reach to the corners you should again interlock and you should go once to the healthy margin also
19:53so corners are very important to close adequately with the locking sutures
19:59once you reach to the corners you should again interlock and you should go once to the healthy margin also
20:05so corners are very important to close adequately with the locking sutures
20:20so here it is interlocked
20:24this is locking and again continue don't stop at this point you should must go to the healthy margin
20:33so this is the healthy margin and again this time also it will be interlocked
20:54so that it can hold properly
20:56and it is interlocked
20:57so that it can hold properly
21:01and it is interlocked
21:11after that again lift it have a look
21:14and it is required one more you can continue on the margin
21:18so here one more bite is taken
21:25so here one more bite is taken
21:39now we will return back
21:51so with the same suture
21:54you can take shirosa to shirosa
21:57and you can do the second layer
22:00Babasuchal has a self retaining
22:05so at this point you don't need to terminate
22:07once you return back then you can terminate
22:10so this is slowly you can keep on detitling back
22:17so this is slowly you can keep on detitling back
22:33and that will reinforce the first staple line
22:40and that will reinforce the first staple line
22:46so this is slowly you can keep on detitling back
22:52and that will reinforce the first staple line
22:58I'm going to show you what I'm going to show you.
23:28muscular
23:51returning back
23:58so that way there'll be absolutely no chance of leak and of course you have to
24:04do the check of the leak also by the this methylene blue so 100 ml at least we
24:13are using so this is keep on going and these corners also will be embedded
24:21buried
24:28it is taking out so this way you will continue doing it very carefully you
24:39should maintain the integrity of the zero muscular layer now it is reached an
24:51entire a staple hole is closed after that the initial tail which already you
24:57have with the same tail you can terminate the suture so although in bab suture it
25:05may not be necessary to terminate or some people what they do they take a clip
25:10titanium clip and they apply but generally we always like to tie a knot so
25:17this is now first time double wrap followed by a single wrap and you will
25:23close it once it is closed after that you will remove the suture by the scissors and
25:32then you will go ahead for checking the lumen to the seizure is cut so the suture is cut
25:42you can catch the suture as well as west tail of the suture and then you can pull it out
25:48then with two grasper you should hold either side of the lumen and occlude it
25:55with a long jaw clasper and as anesthetist will put the methylene blue dye so we can see here the dye has
26:03been introduced and it is giving you very nice distance and this distance and will be visible and you can see
26:11the methylene blue is going on either side and there is no leak and it is a distance and there is no blue color
26:18you will check the entire stepper line also you should check the stomach also you go to the gastrocephagial junction also
26:26and absolutely no blue color so if there is anything leak leak should be right now should be checked and it is fine there is no leak
26:33after that you can just give one suture on the sirosa and then on the efferent and afferent both can be fixed
26:50here afferent you will be fixed with the stomach part that is gastric tube that has two advantages that it will be parallel to that
27:00other advantage is that it will decrease the load of the strapper line because it will anchoring suture
27:10so here this we are using white grill and with the white grill you can fix it to the anchoring suture
27:17so this is some people they do it some people they don't do it but generally it is better to anchor it
27:24so that it will give you the relief of the strapper line and it is fixed here during that you should be careful
27:34that it should not tear up and it should be tension free so nicely it is pulled and it is tightened
27:42and after that c and reverse c two time you can take a surgeon's knot here also and this is done one more knot
27:52then only one knot is sufficient some people take two three knot but only one is sufficient and that will take a lot of tension and the strapper line tension will be minimized
28:08and then you can cut this suture and after that you can take the another one and another one you can fix it with the
28:18entram part of the stomach and this is a different loop and you can fix it with the entram part of the stomach
28:30and here you go and we can fix it and you can tie a knot
28:38again you can pull out you can make c reverse c
29:02and this is the knot tight end so that also will release some of the tension of the jejunum over the strapper line
29:16although it is optional not necessary now you can pull some of the tension of the jejunum over the strapper line
29:30here once this suture is done this is just the last c and then you can pull a momentum and just cover the entire anastomotic line and you can fix it with the entram part of the stomach
29:56this is also optional we do in our case so that momentum will cover the entire mgb bypass single bypass and anastomosis and that will be you can hold it and you can clip it also with the titanium clip so that it will hold and it will cover or you can tie the knot also it is up to you
30:18so thank you very much for watching this video this was just a simple case of mini gastric bypass where we try to explain everything thank you very much god bless you
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