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https://www.laparoscopyhospital.com/SERV01.HTM
Watch the Full-Length Skin-to-Skin Mini Gastric Bypass Surgery performed at World Laparoscopy Hospital, Gurugram, India. This unedited operative video demonstrates each surgical step in real time — from incision to closure — providing an in-depth learning opportunity for surgeons, gynecologists, and trainees in minimal access surgery.
At World Laparoscopy Hospital, we are committed to advancing the science and practice of laparoscopic and robotic surgery through education, research, and hands-on training. This video is part of our ongoing effort to share high-quality surgical education with the global medical community.
For surgeons seeking structured training in laparoscopic, endoscopic, and robotic surgery, World Laparoscopy Hospital offers Fellowship (F.MAS) and Diploma (D.MAS) programs accredited by leading universities and recognized worldwide.
📍 World Laparoscopy Hospital, Gurugram | Dubai | Orlando
🌐 Learn more: https://www.laparoscopyhospital.com
Watch the Full-Length Skin-to-Skin Mini Gastric Bypass Surgery performed at World Laparoscopy Hospital, Gurugram, India. This unedited operative video demonstrates each surgical step in real time — from incision to closure — providing an in-depth learning opportunity for surgeons, gynecologists, and trainees in minimal access surgery.
At World Laparoscopy Hospital, we are committed to advancing the science and practice of laparoscopic and robotic surgery through education, research, and hands-on training. This video is part of our ongoing effort to share high-quality surgical education with the global medical community.
For surgeons seeking structured training in laparoscopic, endoscopic, and robotic surgery, World Laparoscopy Hospital offers Fellowship (F.MAS) and Diploma (D.MAS) programs accredited by leading universities and recognized worldwide.
📍 World Laparoscopy Hospital, Gurugram | Dubai | Orlando
🌐 Learn more: https://www.laparoscopyhospital.com
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LearningTranscript
00:01Hello friends, this is a case of mini gastric bypass. Here we will show you a skin to a
00:06skin entire surgery. This is Jiffy sternum. This is the costal margin, right and left.
00:19This is umbilicus. So, this is Jiffy sternum. We are going to perform this surgery by ipsilateral
00:25port position. So, this is the GE junction. Here is the Jiffy sternum. So, basically this
00:39is the GE junction anatomical landmark.
00:50And we are going to put the camera approximately 10 cm below the costal margin.
01:05So this will be ipsilateral mini gastric bypass surgery. This is camera. Now, just below and
01:16left to the Jiffy sternum, we will put our Nathanson liver retractor that is donated by R here.
01:26This is the right costal margin. And we will put our right hand port. This is at this way.
01:33This is left hand port. And it will be the right hand at the level of the camera that is in the
01:41midline. So, this is our port position. The assistant if it is required, we will put the assistant port here.
01:52This is port number 1. This is port number 2. This is port number 4. Camera will be here. This is camera port.
02:01So, we will start the procedure. And the variation will be introduced at this point.
02:19So, this is the varice needle. Now, irrigation, suction and hanging drop test will be performed.
02:47And it is sucked in. Now, insufflated tubing will be attached. And insufflation, it started at the 1 liter per minute.
03:08And preset pressure is kept here, 15. Now, if you will palpate, homogenous distension is started.
03:23And we can get the liver dullness get obliterated. On the right hypochondrium area, you can palpate to check.
03:33Because gas first goes there. And it will give you tympanic sound or sound like a ripe watermelon.
03:42And that will confirm that smoothly gas is going inside. This patient has few previous surgeries.
03:50Also, you can see some scars are there in the abdomen. And the BMI is 48 in this patient.
03:58So, we can see that liver dullness is started.
04:05Liver dullness get obliterated and tympanic sound will come.
04:10We will wait till the actual pressure reaches the preset pressure.
04:16And then other port will be introduced after introducing the telescope.
04:25So, gradually you can see abdomen is distending.
04:32And now, various needle is removed.
04:36And the first optical port will be introduced.
04:39This is 10mm port.
04:42We will use a striker telescope.
04:46And the 30 degree 10mm telescope to perform surgery.
04:56Now, the maximum flow rate will be increased to 10 liter per minute.
05:01And telescope is introduced.
05:06So, we can see that there is adhesion or not in the previous scar.
05:11But luckily there was no much adhesion.
05:14And everything was fine.
05:22Now, the second port is for the Nathanson liver retractor.
05:27And this port will be the left hand of the surgeon.
05:32So, we will put first the left hand port.
05:39And take a grasper just to do the some diagnostic.
05:44And then the epigastric port is introduced.
05:56A 1-8 traumatic grasper has been introduced.
06:01And it was fine.
06:02Everything diagnostic was done.
06:05And then the epigastric port is introduced.
06:08Just left to the Jiffy sternum.
06:10Port was taken out.
06:12And Nathanson liver retractor will go percutaneously.
06:17And now Nathanson is going to be clamped with the stand.
06:30And that stand is attached with the OT table.
06:33So, it is fixed now and it is retracting the left lobe of the liver.
07:00Now, this will be the right hand port.
07:14Right now, it is 5 mm, later we have to increase it to 12 mm for the stapler.
07:29So, now we start the surgery.
07:36We can see the Nathanson liver retractor is lifting the liver.
07:42Left lobe of the liver as you can see.
07:44This is a fatty liver.
07:45Of course, you will have a lot of load of momentum in the bariatric patient.
07:52It will be like that.
07:54This is the lesser curvature.
07:55This is the greater curvature.
07:59If you will pull the momentum down, you can look at the spleen there on the top.
08:05That is a spleen on the top visible.
08:08And you can watch the first and second gastric pedicle.
08:12And approximately 10 cm below the GE junction.
08:15You have to make a retro-gastic.
08:17Actually, it should be 12 to 16 anywhere you can make.
08:21Bigger is the tube, gastric tube.
08:23It is better.
08:24And that will prevent the biliary reflux.
08:27So, here retro-gastric tunnel has to be formed at the lesser curvature.
08:35Meaning, gastric bypass is a straightforward and simple surgery.
08:40And it is a realistic procedure because 80% of the excess weight will be lost at the end
08:47of one year.
08:50And unlike sleeve, it works even for carbohydrate eaters and grazers.
08:56So, the father of this surgery was Professor Rutledge.
09:00Unfortunately, he expired in the March this year.
09:06Professor Rutledge was very known to me.
09:08He was also a faculty of the World Laparoscopy Hospital.
09:14And he was regularly taking classes here online also.
09:19And he was also telling that always that India is his second home.
09:24He has presented his new surgery Mini Gastric Bypass MGB-2 at our VALS conference which was
09:32conducted by us in the February this year.
09:37So unfortunately, he is not with us now.
09:41But his surgery will always be there.
09:45So we can see here, this retro-gastric tunnel is almost formed.
09:55And after getting this, you will be able to see the posterior wall of the stomach.
10:00Retro-gastric cushion and omental bursa will also be visible.
10:05So, we can see the posterior wall of the stomach.
10:09Luckily, this patient has no much adhesion in the posterior wall.
10:15And that is good thing.
10:19Because many patients who have gastritis, they have a lot of adhesion.
10:26So, now this is a stapler.
10:31And this is horizontal row of division.
10:35And that will be 45 mm.
10:39You can fire three times.
10:40And then you can pull the stapler handle.
10:43And this is the horizontal row of division is done.
10:46Little oozing is there.
10:49That is fine.
10:50You should not use any energy to stop it.
10:55And then you can check again the posterior wall.
10:58And this is okay.
11:01Now you can start taking the vertical row of division.
11:06And you have to go up to the GE junction.
11:10In mini-gastric bypass, there is no much leak chances at the level of the GE junction.
11:17Because it is a low pressure, unlikely to sleeve gastrectomy.
11:25You can use all purple color cartridge or blue color.
11:35So this is the first vertical row of division.
11:40And we have to go all the way to take this gastric tube.
11:45The length must be 12 cm or little more because you should not make a teeny pouch.
11:53Unlike RYGB where we make a very teeny pouch.
11:59That's why this surgery is also called one anastomosis gastric bypass.
12:05That is O-A-G-B or you can say loop gastro-genestomy also.
12:11So this is first row of the vertical row was taken.
12:15And after that we will check again posterior adhesion and luckily no adhesion.
12:20Now we will put a gastric calibration tube.
12:22This is the 36 French gastric calibration tube.
12:26Which is introduced by an ascetist.
12:30And that will come in this gastric tube.
12:32So that further stapling line will be straight.
12:35And you can make it 36 French.
12:50So this is the second cartridge.
12:55And the bougie is already in the place.
12:56That's why you can see left side this circular bulge is due to the gastric bougie.
13:04That is gastric calibration tube.
13:14As we know the length of our cartridge here is 60 mm.
13:22So in vertical row of division 2 or 3 cartridge, 3 average is required which you have to fire.
13:44You can use either Aslan Flex 60 or you can use tri-stapler by the Covidian or Panther or Lotus.
13:54There are many Indian companies also.
13:56Now they have come with a very good and economical stapler.
14:01Now this is the third cartridge.
14:11And if you want to use a little bit further.
14:21And of course you can use similar things.
14:24Now from the very first at the time I've found on the other side of the cartridge.
14:26And as a little bit further.
14:29And you can use the first cartridge.
14:32That you can use type of thing.
14:33You can use the first cartridge.
14:34Now the other cartridge is 1.
14:36So the cartridge is visible.
15:24Before firing you should wait for couple of minutes so that fluid will displace.
15:30Here we think that there is a small portion is still uncut so we will use fourth one also.
15:36You should not apply any clip or any knot and don't try to save the number of cartridge
15:45because leak chances will be more if you will try to do some other technique of knotting
15:50or clipping on the remaining part of the stomach.
15:56And now we can see that entire stomach a new gastric tube is formed.
16:02You may say it is a new oesophagus.
16:04So, it is over and now a stomach is remaining stomach is detached and nothing is attached.
16:24This is omentum that is fine.
16:29So it is good now you should inspect your little bit bougie should be little bit pulled not
16:36completely and lift the gastric tube and check that there is no any bleeding if there is any
16:42oozing we can do suction.
16:46So, just try to remove the blood which might have collected into the sub diaphragmatic area.
16:55So, this is our gastric tube.
17:09I will not say pouch because it is basically a tube unlike RYGV where we make a teeny pouch.
17:17We can see the bougie here we will perforate the posterior wall because here we will do the
17:24side to side anastomosis with the jejunum with the posterior wall of the stomach.
17:34So little bit fat is there that can be separated.
17:37So let us now go to the ligamentum trees and start calculating the jejunum.
17:45So all the omentum has to be pulled up.
17:49And we should try to find out the first part of jejunum.
17:57This is little time taking job because you will have a lot of overloaded omentum.
18:04And generally MGB is done anti-colic.
18:07You don't have to go retro-colic.
18:09Just like traditionally in the old time gastro-jejunostomy was performed retro-colic.
18:15But MGB by laparoscopy is done anti-colic.
18:18So this is we can see if you will pull the jejunum then it will not get further pulled.
18:26That means this is first part.
18:34And then you have to calculate 2 meter of the bubble lobe.
18:37So this is 10, 10 centimeter.
18:41Every time 10, 10 centimeter you can calculate or you may calculate 55 centimeter or 44 centimeter
18:5250 time.
18:52That is up to you.
18:54So here we are calculating 10, 10 centimeter every time.
18:57So this is 1.
18:59This is 2.
19:00Here it is 3.
19:01Two atraumatic bubble grasper should be taken.
19:02This is 4.
19:03You should not use normal grasper to walk over to the bubble.
19:08This is 5.
19:09This is 5.
19:10This is 2.
19:11This is 2.
19:12This is 3.
19:13Here it is 3.
19:14Two atraumatic bubble grasper should be taken.
19:17This is 4.
19:18You should not use normal grasper to walk over to the bubble.
19:33This is 5.
19:37This is 6.
19:38This is 6.
19:397.
19:408.
19:41Right side to us is the BP limb, biliopancreatic limb or you can see afferent limb.
20:06And the left side is different limb.
20:11So, you have to keep on because we are taking 10, 10 centimeter each time.
20:19So, you have to walk 20 times.
20:23These are bowel grasper.
20:28These are completely atraumatic.
20:34Take care that torsion should not happen.
20:40And when you calculate trauma to the cirrhosa should not happen.
20:44Take care that torsion should not happen.
20:45Take care that torsion should not happen.
20:51Take care that torsion should not happen.
20:55Take care that torsion should not be affected.
21:01You should try to hold with the grasper handsome amount of the bobble.
21:27If you hold it very small amount of bobble then trauma will be more.
21:37So we are using here 2 meter bypass, minimum 1.5 meter and some author, some surgeon they
21:44go up to 2.5 meter also.
21:48It depends upon how fast you want the weight to reduce and comorbidity to go away.
21:56Cine gastric bypass is also a very useful procedure for the type 2 diabetes especially Mgb2.
22:07So now this calculation is over.
22:09After that you will perforate the anti-magenetic end of the bobble and take care that only cirrhosa
22:17should not get punctured.
22:19You should go complete full thickness and you should be able to enter into the lumen
22:24without damaging the opposite margin.
22:32Harmonic is good instrument.
22:34You may use hook but harmonic has advantage that it does not create much collateral damage.
22:56So it is now punctured.
23:09The grasper and the entire tip should be introduced to make it sure that mucosa also should be punctured,
23:20while should be visible.
23:28After that we will take again the stapler endo GI.
23:46And then one of the jaw of the carter will be introduced into the jejunum.
23:52And another in the stomach.
23:58Here this is perforated the posterior wall.
24:04It is not necessary that always you puncture the posterior wall.
24:08Interior wall also can be taken.
24:10Whatever is convenient and you should take care.
24:13There should not be torsion.
24:22And now you will do the anastomosis.
24:26How big this anastomosis should be there?
24:30It varies.
24:31Some author they take 45 mm anastomosis.
24:35Rutledge was taking complete 60 mm because he was saying that dumping syndrome is good.
24:41Because that way percent will not eat a ton of carbohydrate.
24:46You can fire three times and then you can pull it back.
24:50The cartridge and side to side anastomosis will be complete.
24:53So, you can see that mini-gastic bypass is not a difficult surgery.
25:02And basically, if you have the advanced stapler or advanced energy sources, then it can be
25:11performed very easily.
25:12And with the ipsilateral port, it can perform much easily.
25:16So, it is done.
25:21Now you can see the boozee in the stomach end.
25:24And posterior wall of anastomosis will be checked for any bleeding.
25:29And you will make it sure.
25:30Now here we are using barb suture for closure of this stapler line.
25:38The perforation of the stapler.
25:40So, we can start in to out on the jejunal end and out to in in the stomach end.
25:53And this will be two-layer suturing.
25:55We will do continuously.
25:58Barb suture is practiced more nowadays for bowel anastomosis.
26:05So, we can see this was in to out in the jejunal end and out to in it is going into the stomach.
26:13Barb suture has a loop there in the starting.
26:16So, you don't need to have the knot.
26:20Starter is not required.
26:25So this is corner.
26:26First you should start with the corner.
26:28You can start from any side from below up or above down.
26:32And we can see this loop is pulled and it will lock.
26:39Switching should be good.
26:46And after closure of this, you have to check that methimethylene blue that there should not
27:06be any leak.
27:07So, please see the entire suturing.
27:10At the end, you will like it because correct suturing is required for any laparoscopic surgery.
27:16That is why it is called that there is no future without suture.
27:22This is the full thickness.
27:29By Tekken.
27:30Not only seromuscular.
27:32Completely into out.
27:34In to out.
27:35And out to in.
27:36This is the full thickness.
27:37By Tekken.
27:38Not only seromuscular.
27:39Completely into out.
27:40And out to in.
27:46This is the full thickness.
27:50This is the full thickness.
27:52By Tekken.
27:54Not only seromuscular.
27:56This is the full thickness.
27:57Completely into out.
27:58Completely into out.
27:59And out to in.
28:00The kind of pool.
28:01This is the full thickness.
28:03statement.
28:37.
29:07.
29:09.
29:10You can use the suture as a retractor to lift it.
29:40Some of the surgeons, they close this by the another stapler cartridge, by endo GI.
29:50They put buji in the efferent limb, lift the perforated area and fire one more stapler
29:57to close the opening.
30:00But generally suturing is better because why to waste the money in that.
30:06And sometime when you are firing it, the first stapler line, horizontal stapler line will
30:12give you very less tissue to do the closure.
30:16So, that is why suturing should be better.
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37:59In the jejunum you take zero muscular, stomach you can take full thickness.
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39:48Here this is a vertical stipple line, but just couple of bytes you can take over the vertical
39:55stipple line, so that in horizontal stipple line, less pressure will be there.
40:54So it is terminated here.
41:00However, in the Babs which are termination is not required, but we should not believe.
41:13The company is saying it is unidirectional, you don't need to terminate, but better is to
41:28terminate.
41:29But better is to terminate.
41:30But better is to terminate.
43:08So, this is the afferent limb and here is the anostomosis and this is afferent limb.
43:32Because already we have terminated it before.
43:58So, that is why it was not necessary to terminate again.
44:03Now, this is the second layer started.
44:05And this is again seromuscular.
44:11This is the posterior wall of the stomach.
44:20Because now we have cut the barb switcher and there is no loop now.
44:32So, you have to start with a knot.
44:35So, you have to start with a knot.
44:36So, you have to start with a knot.
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46:19This is zero muscular again on the jejunum.
46:33This will reinforce the first layer.
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49:03the afferent and efferent limb has to be catched by atraumatic long jaw grasper and methylene
49:09blue leak test will be performed.
49:18And you will see the distension without any blue color coming out.
49:22A staple line also will be checked this way.
49:27You can see it is distending but we don't have any leak.
49:39So this is, outside we will show you, here you see that through the booji, this is the methylene
49:45blue which was introduced and there is no leak.
49:52If leak is there, you must have to suture it.
49:59You can check on the upper line also, there is some oozing but no blue color.
50:15So it looks good and anastomosis is complete.
50:36Now NG tube will be removed.
50:43This is the methylene blue you can see in the saline which was introduced.
50:50Not entirely, maximum 50 to 100 ml is enough to check.
51:02That will go through the, you should not take separately NG tube, through the booji NG tube
51:07should go to distend it.
51:11And now it will be withdrawn.
51:15So, gastric calibration tube has to be slowly withdrawn out.
51:33So it is fine, you can check the posterior wall, you can check all around.
52:00Injuration has to be done, if some blood is collected in the splenic fossa or sub diaphragmatic area.
52:08Any injury of the liver also must be checked.
52:11However, Nathanson generally doesn't injure the liver because tip is bent in downward direction.
52:18You can see it is red, no blue.
52:33This is the remaining stomach.
52:39If we don't remove the stomach, that's why this is a spleen here you can see on the left side.
52:49That's why MGB is reversible procedure also.
52:53In some of the patient who absolutely not tolerate due to any reason, you can reverse the procedure.
53:02Now, by a stapler you can detach this loop and again side to side anastomosis with the remaining stomach can be performed.
53:13Now, we will cut the suture and suture will be taken out.
53:20This is your loop which was termination.
53:25That also you can cut the loop part because it is having some spike there that can trap the
53:34bobble or momentum.
53:35This is the problem of the bobble suture because sometime adhesion happens if the tip is long.
53:44So it's almost over and now we will check final inspection and telescope will be taken out.
53:50So thank you very much for watching this video.
53:53Have a nice day.
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