One Anastomosis Gastric Bypass (OAGB)

Aaradhya Sharma

https://www.laparoscopyhospital.com/SERV01.HTM  One Anastomosis Gastric Bypass (OAGB), also known as Mini Gastric Bypass (MGB), is a bariatric procedure designed to assist in weight loss and treat obesity-related comorbidities. This surgical technique has gained popularity due to its simplicity, efficacy, and favorable outcomes compared to other bariatric procedures.  Historical Background  The OAGB was first described by Dr. Robert Rutledge in 1997. Since its introduction, it has undergone several modifications and improvements, enhancing its safety profile and outcomes. The procedure has evolved into a viable alternative to the more commonly performed Roux-en-Y Gastric Bypass (RYGB).  Procedure  The OAGB involves creating a long, narrow gastric pouch along the lesser curvature of the stomach. This pouch is then anastomosed to a loop of the small intestine, typically 200-250 cm distal to the ligament of Treitz. The procedure results in both restriction of food intake and malabsorption, contributing to significant weight loss.  Surgical Steps  Creation of the Gastric Pouch: Using a stapling device, a vertical gastric pouch is created starting from the antrum to the angle of His. Identification of the Jejunum: The jejunum is identified approximately 200-250 cm distal to the ligament of Treitz. Gastrojejunostomy: A single anastomosis is created between the gastric pouch and the jejunum, forming the gastrojejunostomy. Advantages  Simplicity: OAGB is technically less complex than RYGB, with a shorter operative time. Effective Weight Loss: Comparable to RYGB, OAGB provides substantial weight loss and improvement in obesity-related comorbidities such as type 2 diabetes, hypertension, and hyperlipidemia. Lower Complication Rates: Studies have shown lower rates of internal hernias and marginal ulcers compared to RYGB. Outcomes  Weight Loss: Patients typically experience a 60-70% excess weight loss (EWL) within the first year post-surgery. Long-term studies indicate sustained weight loss up to 10 years.  Metabolic Improvements: Significant improvements in type 2 diabetes, hypertension, dyslipidemia, and obstructive sleep apnea are observed. The procedure induces changes in gut hormones, enhancing insulin sensitivity and glucose homeostasis.  Complications  Nutritional Deficiencies: Due to malabsorption, patients are at risk of deficiencies in iron, calcium, vitamin B12, and fat-soluble vitamins. Lifelong supplementation and monitoring are necessary. Bile Reflux: There is a potential risk of bile reflux gastritis due to the continuous exposure of the gastric pouch to bile. Dumping Syndrome: Some patients may experience dumping syndrome, characterized by nausea, vomiting, and diarrhea after high-sugar meals.

Transcript

00:00Hello friends, today we are going to see how to do one anastomosis gastric bypass surgery.

00:07This is a very popular bariatric surgery in which first you have to make a gastric tube

00:14and then minimum length of this gastric tube should be approximately 12 centimeter

00:20and after that you will calculate the jejunum from the ligamentum trees that should be 2 to 2.5

00:33centimeter depending upon how fast you want resolution of the comorbidity and reduction of

00:40the weight and after that you will do loop gastrojejunostomy. So, this is a very popular

00:47surgery and nowadays it is also called realistic bariatric surgery. It is reversible also, it is

00:56cheaper and it is 60 to 80 percent of the excess weight loss is there at the end of one year.

01:05So, it is basically a malnutrition surgery and difference between the RYGV is that you are

01:13making a gastric pouch and you will make a roux limb to do gastrojejunostomy but here you do not

01:19have to make a roux limb. Here you will do the loop gastrojejunostomy. It is also called mini

01:26gastric bypass. Professor Rutledge has performed this surgery and after that slowly it is becoming

01:33popular all over world. And this surgery can be performed less expensive means cheaper than

01:42the sleeve gastrectomy because number of a stapler required is little less than the sleeve gastrectomy.

01:50So, let us see how to perform this surgery. We can see here this gastric tube and the loop anti colic you have

01:58to make retro colic gastrojejunostomy is not required in this surgery and it has a lot of advantage.

02:08So, we can perform with the 5 port and patient will be positioned in the supine position first

02:18and during access you will be left. This is the umbilicus inferior crease, this is supra umbilical port.

02:25Nathanson liver retractor may be required and you may do without this. This depends upon your requirement

02:34and depending upon the size of the left lobe of the liver. One right hypochondrium and one left

02:41hypochondric port is used. So, here we are doing access by various needle. This is the small stab wound is

02:50given over the inferior crease of umbilicus and 20 centimeter variational is used. You may ask your

02:58assistant to lift the abdomen and keeping variational perpendicular but oblique to the body of the

03:05patient it is introduced. After that you will do irrigation test

03:11test followed by suction test and then hanging drop test

03:22just to make it sure that we are inside the abdomen and then we will attach the tubing of insufflator.

03:30Here we should select the bariatric mode and initially flow rate should be 1 liter per minute

03:39and after 1 liter of the gas you can increase the flow rate to 3 liter per minute and according to the

03:46size of the percent the minimum amount of gas required is 1.5 liter and maximum 6 liter to reach the actual

03:55pressure at preset pressure of 15. Now, this is the supra umbilical port

04:01which you will introduce

04:12and that will be for the telescope

04:19right now camera person is in between the legs but once the all the port you will introduce after that

04:26you may go to in between the leg and camera person may come right to you it may be performed standing

04:33right to the present depending upon the you know height of the table the sense should be a stir up position

04:42this is one right hypochondrium and then one left hypochondric port

04:48here both the right and left hypochondric port should be 12 mm

04:5112 mm so that you can put your stapler using any of the port initially when you will take a horizontal

05:00stapler then you can keep in the right and then left here we can see this is an attention liver retractor

05:07which is introducing into the epigastic port and first you will put 5 millimeter port and then this

05:14nathanson liver retractor has to be introduced percutaneously and it is lifting the left lobe of the liver

05:25now approximately 12 centimeter below the gastroesophageal junction you have to make a window in the lesser

05:35curvature so that you can first take horizontal row of division

05:40direction and here we do not have to remove the short gastic on the greater curvature we have to work in

05:49the lesser curvature here and first we have to make a small tunnel that is retro gastic tunnel

05:56so that we can introduce our stapler to do the horizontal row of division

06:02direction so we can see that left hand you should have the grasper and right hand has a ligature

06:10to make a dissection over the lesser curvature on the momentum to make a retro gastic tunnel

06:24care should be taken that you should not be near the

06:28secondary gastric particle or bleeding should not happen in this situation and little stomach should

06:35be fully deflated it should not be distended and now we can see this tunnel has been formed

06:42and posterior wall of the stomach is started visible

06:47this is the posterior wall of the stomach which we can see

06:50cow dead lobe of the liver is also above and right to you and this tunnel is formed

07:07now the first stapler here should be the blue color because we are not firing it over the antrum

07:13so this will be you may use white or blue both you can use and this is the horizontal row of division

07:30here you should not take the entire 60 mm you may take 45 or 30 mm is enough

07:38and after that you should put a bougie that is 36 frames gastic calibration tube your anesthetist will put

07:52and then once this horizontal row of division is over then we have to do the vertical row of division

08:00so this bougie is introduced and now to do the vertical row of division you may put the stapler on the left

08:14hypochondrium but before that if there is any adhesion in the posterior wall of the stomach

08:20that should be cleared because if the patient has you know history of gastritis and a smoker or alcoholic

08:30you may have a lot of adhesion in the posterior wall of the stomach that also should be taken care of

08:36and this is the vertical row of division which you will fire the blue cartridge

08:52and it is slowly dividing generally what we do that after every firing we wait for 20 seconds

08:59and then slowly we continue we do not fire all of them in one go so this is the first vertical row of division

09:11and after that again you can wait for few seconds and then you open the stapler so that there will be no

09:19any oozing now we will load the new cartridge that is again blue color and again it will be fired vertically

09:42up to the angle of his we can see some adhesions are there near the spleen those adhesions should must be separated

09:53so that once you fire you should see the tip of the stapler especially once you go at the level of

10:00gastroesophageal junction here you do not need to make a big dog here because it is not a restrictive surgery

10:09so there is no high pressure zone so in this you do not need to have the big dog here

10:21so this adhesion near the spleen is getting separated

10:29so that your stapler can work better we can see here surgeon is standing in between the leg

10:35left hand has a grasper right hand has a ligation so you have to lift the stomach

10:43grasper is lifting the stomach as you can see and slowly these adhesions are getting separated

10:50care should be taken that any tear on the spleen should not happen because if a spleen started bleeding

10:57then it is difficult to stop that bleeding in this part of the

11:01the area because it is quite high and that is why we should use 45 centimeter instrument

11:09and telescope also should be suprahumbleical

11:15so now this is the second cartridge which is firing

11:24as we can see that after every firing we wait few seconds

11:28so that this compression will create plastic deformation fluid will displace and the tissue

11:35will be better and it will be a stapler line failure will not happen

11:43so slowly you will keep on firing till the end and you should must check

11:48that entire stomach is cut if any little area of the stomach is still left

11:54then you should use the another cartridge you should not apply any knot or clip

12:01to prevent any leak so we can see that it is done but still little bit tissue is remaining

12:11so in this situation you can load the third cartridge so that it will not leak

12:17and this is the third cartridge and tip should must be visible in the last cartridge and then we should fire

12:33so we can see it is almost touching the diaphragm and the both the jaw of the stapler cartridge

12:40stapler is visible and then this is the last firing which will complete our vertical row of division

12:50and the gastric tube will be ready a small gastric tube should not be there because that can create

12:57the biliary reflux and this is requirement for one anastomosis gastric bypass in rygb this requirement

13:10is not there because already you have a rule limb that will prevent the biliary reflux

13:25so we can see diaphragm is visible and this is the last cartridge which is firing

13:42and now the gastric part of the surgery is over

13:56and the body of the stomach is detached from the gastric tube

14:00after that now we have to go to the ligamentum trees for that we have to lift the entire omentum

14:14and transverse colon and find out the origin of the duodenum so this omentum and transverse colon is

14:24getting pulled getting pulled and this is the bovel grasper you should you lose long jaw grasper

14:34you should not use short jaw grasper that will be little traumatic to the bovel

14:41because percent is obese so you will get a lot of momentum of course

14:45and you have to walk over to find out the first part of the jejunum

15:01this is the ligamentum tree and we can see now further pulling of the jejunum is not there

15:20so that means we have reached to the correct point and after that you have to walk over to the bovel

15:27so that at least two meter of the bovel should be there so this is now we can see this is the

15:35first part and now it will be calculated

15:39so this is one sorry here this is two

15:47this is three

15:48this is four every time five centimeter will be calculated this is five and here is the six

16:01all the bovel loop we should keep on the left side this is seven so that torsion should not happen

16:07here is the eight

16:19this is nine

16:23then ten

16:25eleven

16:28twelve

16:32thirteen

16:35fourteen

16:35fifteen

16:38fifteen

16:40sixteen sixteen

16:43seventeen

16:49eighteen

16:53nineteen

16:54twenty

16:58twenty

16:5921, 22, 23, 24, 25, 26, 27, 28.

17:2927, 28, 29, 30, 31, 32, 33, 34, 35, 36,

17:5937, 38, 39, and 40.

18:16So 40 means approximately 2 meter every time we have a 5 centimeter and then this gastric

18:25tube is getting perforated.

18:33The bougie should be visible and after that anti-messentric border of the this jejunal

18:41loop has to be perforated care should be taken that it should be full thickness perforation

18:51and you should enter into lumen may be only cirrhosa should not be only open entire lumen

18:57should be open and posterior valve should not be damaged.

19:02And now this estupler is getting introduced one jaw will enter into the jejunum another

19:08jaw will be in the gastric tube.

19:17And then here side to side anastomosis will be done and that will be gastric jejunal storming.

19:29Now how long this anastomosis should be there?

19:33This is controversial some people they use only 30 mm some people 45 mm and some they do complete

19:4260 mm if you will make a long anastomosis chances of dumping syndrome is there.

19:49But some people they say dumping syndrome is good because that way patient will not overeat.

19:55Now you can see anastomosis is over and the posterior valve of the anastomosis is visible.

20:02And that is good there is no any bleeding and it is dry.

20:09After that you have to close this gastro jejunal storming site the perforation and that should

20:15be full thickness and out to in and into out.

20:21Here we are using simple 2-0 vicryl but you may use the barb suture either V-lock or a stratafix.

20:34Outcome is same there is no any difference if you will do the good anastomosis then leak

20:40is less in the OHGB compared to sleeve because it is a low pressure zone.

20:47In the sleeve gastrectomy above is the gastroesophageal junction sphincter also fegal sphincter below

20:55is the pylorus.

20:56So, it is a high pressure zone and then chances of leak is there.

21:03But in OHGB generally if you properly perform leak won't be there.

21:09So this is a surgeon's knot which is given if you are using V-lock suture then surgeon's

21:15force knot is not required because in V-lock suture already you have a loop and you can

21:23pass the needle through the loop and that will be your starter knot.

21:29So, now we have the starter knot is done in vital you have to tie a starter knot.

21:39And after that slowly slowly we will keep on taking a full thickness bite to close this opening

21:46which was made for a stapler.

21:51So, this will be continuous suturing.

21:58Here the port is ipsilateral which we are using for suturing it is better you can use contralateral

22:12as well and it should be slowly closed.

22:33So, the left hand is lifting the vitrile you may close this by a stapler.

22:40So, you can pass a bhuji from a stomach and that bhuji will go to the afferent limb and

22:49then you lift it this opening and you can pass a stapler that is also possible.

22:58Waiting and see there is an elimina here.

23:04Let us enter the pole at Pika.

23:08If there is an elimina here, bye-bye.

23:13Why are winners taking place both트를 Folge

23:28So, we can see that it is an anticholic gastroenteritis stomach not retrocholic and right side is

23:42the afferent limb means your right not the patient right and left side is the afferent

23:49limb here assistant also can help you if assistant will hold the suture

24:18limb then your suturing will be little faster

24:48We also use barb suture in barb suture you have little faster suturing and there is less chances

25:00of leak compared to simple vicryl but barb suture has little memory.

25:06So, you have to be careful lifting the needle is little difficult with the barb suture vicryl

25:12Vicryl does not have a memory and if you use rapi vicryl that is white white color then it is much better.

25:26Vicryl does not have a memory and if you use rapi vicryl that is white white color then it is much better.

25:42you

26:12So, this is all actually we have not edited this part of the switch ring.

26:30So, you have to little bit wait for the entire switch ring to be complete.

26:38We have not edited this video much.

26:41So, entire switch ring is visible.

27:34So, this is reaching to the another end.

28:03And then corner suture will be taken, we should inspect the posterior wall also so that there

28:16should not be any discontinuity.

28:26And this is the closure of the corner of the perforation.

28:28So, this is the closure of the perforation.

28:30This is the closure of the perforation.

29:00And after that, you can return back by taking seromuscular white.

29:24And this is the second layer just to cover the first layer.

31:37And now with the same tail, you can terminate it.

31:44That is the starting tail of the surgeon snot.

32:14After that, we should check the leak and for this we should take 50 cc methylene blue dilated

32:32in normal saline and then you can ask your anesthetist to put it and we can see it is

32:40bulging but not leaking.

32:44So that is good that means anastomosis is okay and there is no leak.

32:52Once you are satisfied with this test then surgery is over but sometime what you can do?

33:06You can take a bite on the proximal loop and you can anchor with the stomach and distal

33:12loop with the anterum and you can do the omentoplasty, omentum you can drop over that.

33:20It is distended and there is no methylene blue leaking.

33:28So, this is the afferent loop and a pseudo muscular bite is taken and that is sutured with the

33:41stomach so that there will be no much tension over your anastomosis site.

33:49So, this is not necessary to do.

33:57This is not necessary to do.

35:07And if your suture was little long then desire because you know most of the intra-corporal

35:11suturing we should do by the 20 centimeter suture if your suture is long then tail will

35:19become long once you will pull it.

35:22that we are putting a momentum over that anostromotin site and then you can take a bite

35:32this is the efferent limb and together with this is the stomach

35:53and then you can take a bite on the momentum and you can suture it together

36:05so that entire anostromosis will be covered with momentum and that will be a type of momentoplasty

36:13so this is a bite taken on the momentum

36:22and to terminate it you may use Aberdeen termination

36:32or simply you may apply one clip as well

36:35this titanium clip will not apply the allow the suture to go back so it will be easy to terminate

36:45so we can see an entire anostromotic site is covered with momentum and then one clip is applied

36:58to prevent it going back

37:04so thank you very much for watching this video this was just a simple case of one anostromosis

37:14gastic bypass and they said the BMI was approximately 48 and we are expecting that

37:25it should have desired outcome after few months so thank you very much have a nice day

37:43um

37:57so

Category

Transcript

Be the first to comment

Recommended