Robotic Sleeve Gastrectomy for Treatment of Morbid Obesity

CHAPTER 1

My name is Hany Takla. I'm a general and bariatric surgeon. And I'm the Chair of Surgery here at Wentworth-Douglass Hospital. We're a part of Mass General Brigham. So today, we have a case of a sleeve gastrectomy that we're presenting, and our patient is 56, his BMI is 44.5. And he came in to see us about more than four or five months ago. I met with him about a month ago before his surgery. His comorbidities include hyperlipidemia and sleep apnea. He also has an AV block, a first-degree AV block. But otherwise, these are kind of his comorbidities. So we sort of, you know, made sure with his cardiologist that he's okay, obviously, these patients go through a few months of visits with the dietician to make sure that they're following the diet before and after the procedure. And then also meeting with the psychologist, and they go through the extensive bariatric program like all of our patients. So we did pick the sleeve gastrectomy for that patient in particular because he didn't really have a whole lot of comorbidities that would, you know, necessarily make us choose a different procedure. So he didn't have any reflux disease or reflux symptoms. And his upper GI was questionable whether there is a hiatal hernia or not. When I looked at it, I didn't see one. And also, you know, we'll see during the procedure usually we'd need to look at that, especially if someone's having a sleeve gastrectomy. And he didn't have diabetes. So I think these are the two main reasons why I would recommend for a patient to choose a gastric bypass. For example, over the sleeve, if their BMI is really high, if it's like in their above 60, sometimes we sort of steer them toward a SADI or a duodenal switch because they need to lose more weight. And a sleeve probably wouldn't get them there. But this patient had a BMI as I mentioned of 44.5, and he didn't have any of those comorbidities, and he wanted a simple procedure. So he talked about the sleeve gastrectomy. It sounded like the right procedure for him and that's what he chose to do. So like for all of these bariatric procedures, I have a very standard port placement. So I use usually four ports. I use them for my sleeves, bypasses, DS's, foregut procedures. So very similar port placement. And we'll explain some of the differences during the case. But after port placement, usually we will put the patient in reverse Trendelenburg position, and the idea is to be able to see the hiatus well. One of the main landmarks for any foregut procedures is to see the GE junction or the junction between the esophagus and the stomach. The reason that's important is because that's kind of the area where your vertical staple line, whether you're creating a pouch in the gastric bypass or you're creating a sleeve in the sleeve gastrectomy, that's where your vertical staple line will run just right next to the GE junction. You don't want to be at the GE junction, you don't want to devascularize it because that's kind of a risk for causing leaks and things like that. First step is to basically move the liver out of the way the left lobe of the liver. You can do that with a an Nathanson retractor. I personally have used sutures to do that or barbed sutures for the past seven years or so. Sort of the first step is to retract that and then try to identify the GE junction. So a good landmark for the GE junction is the phrenoesophageal ligament, which is basically the attachment between the left crus of the diaphragm and the GE junction. And that also has the fat pad. So once you identify that and dissect it, basically separate that from the left crus of the diaphragm, then we would start to look for a hiatal hernia. And in this particular patient we will look for it because it was questionable on his upper GI. And then after you're done with that and/or if the patient has a hiatal hernia, and you end up preparing it, then you sort of move on to identify where you're gonna start dividing the gastrocolic ligament. And I usually do that about six centimeter from the pylori. So a good landmark is one of the instruments that we use. The tip up grasper is about six centimeter in length from the metal to the metal. So you can use that to measure about six centimeter from the pylorus and that's when the stapling will start. So that's where you kind of have to divide the gastrocolic ligament to that point. So the first trick is to try to get into the lesser sac, and one way of doing that is actually dividing the gastrocolic ligament at the body of the stomach. So a little bit above the antrum because at the antrum the layers of the peritoneum are fused. So it doesn't make it very easy to get into the lesser sac. I usually do that at the body of the stomach a little bit higher than the antrum. And then you sort of use the vessel sealer to take down these vessels up to the short gastric vessels. And then once you start to see the tip of the spleen, and you divide all the short gastric vessels, that's a good landmark that you wanna try to roll the stomach off of the left crus of the diaphragm. So you started doing some medial dissection as you'll see in the case until you completely clear the left crus of the diaphragm. The reason that's important is because you wanna roll the fundus of the stomach off the left crus in order to avoid any retained fundus in the sleeve. And after you've done that, if there's any posterior adhesions, you have to take those down and finish your division towards that six-centimeter mark. And at that point, you'd be ready for your anesthesia provider to place the bougie. And it is very important to be careful when the anesthesia provider's placing the bougie so that you know it goes down under vision as you're seeing it. There are different types of bougies that are available commercially now that have lights in them or you know, sort of, you know, it can identify exactly where it is as it's going down, but sort of visually you have to see it, and then you guide it to the pylorus. And typically for these you can, a lot of people use 36 French bougie. I personally use a 40 French bougie. There's not really any strong data to support, you know that a bigger sleeve necessarily reduces the weight loss. I think it's more important to avoid a retained fundus. And also sort of divide a portion of the antrum and not leave a lot of antrum in the patient. I usually use the robotic stapler. It's a smart stapler, so it basically can tell you exactly if the tissue is very thick for the height that you chose. And typically, we'll look at the antrum and try to identify how thick it is sort of visually. And with experience you'll know that whether or not you'll need a green staple height or a blue staple height for the most part I usually start with a blue staple. If the stapler identifies that it's too thick, sometimes we go back to a green staple line or staple height. And then sort of the trick with the two most important fires are the first fire and the last fire. So the first fire it's about six centimeter from the pylorus, but then also you have to make sure that you don't narrow the incisura too much because that could precipitate a leak down the line. Because that increases the pressure in that zone and it can cause a kink in the sleeve and that can precipitate a leap. So it is very important to be cautious of that. And a good landmark, even if you don't have a bougie for any reason, is the end of the blood vessels from going from the lesser curvature of the stomach to supply the sleeve. If you follow the line where these vessels end, then that would be a good landmark for where you want your vertical staple line to be. And then after multiple fires, whether that's you know, blue or white, there's an algorithm that we'll talk about during the case of how to select these staple heights is the, you know, sort of keep stapling along the bougie until you reach the sort of the area of the GE junction where you want to leave a shoulder of stomach that's about maybe a centimeter or so from the GE junction so you don't staple at the GE junction because that's also a risk for a leak. And after that's done, you know there are several things that you could do. One is that you could just do nothing and leave the staples as it is. But I personally learned to do an omentopexy where I'll suture the omentum to the staple line, it acts as a buttress, reduces risk of bleeding a little bit, and it makes the sleeve a little bit more straight, looks aesthetically better, and I think reduces the risk of postoperative nausea a little bit for these patients if the sleeve is more straight. And after that's done, I typically do an endoscopy, take a look, make sure there's no bleeding, and then we usually extract the specimen through the right-sided port.

CHAPTER 2

So for this, all of these bariatric cases, I like to go in with the Veress needle. The previous case it didn't work out very well so we sort of went in with an Optiview. But ideally if I can I try to insufflate before I go in with Optiview. So we're doing a sleeve gastrectomy, so it's kind of similar port placements to the gastric bypass just a little higher because we don't have a JJ, so we don't really need access to the mid or lower abdomen. Just feeling my way through. Then I'll pull back the Veress needle until we get, so that's - eight is a good pressure. So I need anywhere between, you know, zero to two to five to eight, like anything less than 10 I think is a good pressure, like opening pressure, for the Veress needle. So that means that we're intraperitoneal. So just let it insufflate. Can I get a marking pen? And for the port, so it's kind of similar. So a handbreadth below the costal margin is where I want the camera to land. So somewhere there, not dead midline. So just to the left of the midline. So a handbreadth is like here, so maybe somewhere there would be the camera, and then a handbreadth would be another eight port, another handbreadth, another eight port, and then the stapler port will probably go here. But I like to go in and look with the camera first before I put these ports. It's not like set in stone because every patient's anatomy is a little different. I'll take a look. Just next to it. In the shade. All right, can we turn the room lights off? So the Optiview, so I'll sort of adjust it, make sure that the camera's centered where the tip of the obturator is, and I'll sort of hold firm pressure on the camera and then rotate the trocar. You can see here anterior rectus sheath, rectus muscle, posterior rectus sheath. Probably the yellow behind it is falciform. You can see here, I can see this is omentum, this is peritoneal cavity. So there's a cushion from the CO2. That's why I like the insufflate first. Once we're past the abdominal wall, then sort of let it be and then basically take a look at where the Veress needle is inserted to make sure - you can see here there's, it's underneath the omentum so I'll just kind of pull it back and make sure it looks okay. I'll take local. So you can see, just inspecting, make sure everything is where it's supposed to be. That's the liver. So now a handbreadth next to that, just to the right side. Again, I used two right hands for all these bariatric and foregut procedures. That's how I was trained. Some people use two left hands, which is okay. So this is gonna be an eight millimeter. I used to before use two twelves for sleeves. But I think for the most part, especially with the newer short form stapler, kind of, you can get whatever angle you need to from the left side. So just kind of putting firm pressure, rotating the trocar. These are muscle splitting, so just once you're past it. So there. You have the remote center, which is that black part. So you want that to be in the abdominal wall. I'll take a look over here. So another handbreadth lateral. That's also an eight port. That's the assist port. Now we're gonna put the 12 port. So the 12 port is kind of also a handbreadth, but you wanna go maybe a little more lateral. And the way I sort of position is I see where it's gonna go. And then look at the antrum of the stomach, which is gonna be here because you want - that's your first fire. So you want it to be a straight line between the antrum and the port, which is kind of right about there. Take a grasper. Okay. So now we're gonna close that 12 port because again, the 12 ports, that's the inner diameter. The outer diameter is 15 because it's made of metal. So it's always good to close these. You're using a laparoscopic 12. Might not close them because they're just 12 millimeters. I will take the sponge and the V-Loc. Just the liver stitch and the sponge. So it's a barbed suture to retract the liver. All right, Elena, can we do a reverse T, please? Yes. So the sleeve, because we're not doing a a jejunojejunostomy, so you can do max reverse T-burg so that you can see better. That's good. If we can lower the height down. Can we slide down a little? Yeah. Good. And if we can do a little more reverse, just a tiny bit. Okay, that's good, that's good. All right. All right, Shannon, we're ready.

CHAPTER 3

So same thing as the last case. We're just targeting the hiatus and then just using the arm four as an assistant, and arms one and three as the working arms. Hold on one second. If you can gimme the number three first. Okay, if you wanna advance. Yeah, that's good. If you bring it back just a little. The same thing, I use the sponge, and just kind of put it in the left upper quadrant.

CHAPTER 4

And the first step is to try to expose the hiatus by retracting the liver. I see this vein is like the inferior diaphragmatic vein. So that's one of the veins that you know you could injure with that liver stitch. So, if you can't see it very well, then I would just go just below it. You don't have to go, you can go above it if you can, if you have enough diaphragm above it, this suture takes a little bit of time to get used to. Liver's also very soft. So I'm gonna see where it wants to land. But again, I mean the easiest thing to do when you're first starting these cases is to just do a Nathanson retractor. It says 18 inch, 2-0 absorbable, barbed sutures, and probably the first load will be blue, guys. The next bite will be in the diaphragm. So we're gonna lift up the left load. And the idea from this suture is just to... We call it a liver hammock just to hold the liver up, not necessarily, doesn't have to be too tight. So muscles of the diaphragm, it's gonna be very superficial 'cause the pericardium is right behind me. As long as I can see the needle, that should be okay. As I'm tightening it, I try to get my tip up away. Let's hold the liver up a little bit. Usually if the falciform ligament is in the way like this, you can probably take a bite of it to just help hold it up. I'll suture this to the abdominal wall right below the costal margin - costal margin's here. All right, I'll take the vessel sealer, number three.

CHAPTER 5

The next step is to try to figure out where the GE junction is. A good landmark is this fat pad and the fundus, just to kind of expose the left crus of the diaphragm, and see if there's any hiatal hernia. So that's the fundus there. And this is the fat pad. This is the phrenoesophageal ligament. So just kind of dissecting it off the left crus there. Just kind of clearing that phrenoesophageal ligament identifying the left crus, which is right here. All this anterior dissection is gonna help the posterior dissection 'cause we gotta completely rotate the fundus of the stomach off of the left crus. So that we don't get any retained fundus. So anything that you do now is gonna help later on in the case. Just pushing that left crus away. So I don't see a significant hiatal hernia here, which is good. All right, so now we cleared it. So basically this is left crus of the diaphragm. Fundus of the stomach. Fat pad where the GE junction will be. I'm just kinda trying to define it a little bit more. That's a big advantage for robotics in these cases. Actually really get high into this area, and see it very well, and define all the planes very well. It is, in a high-BMI patient, it's very hard to get like good exposure like this laparoscopic. I think I have a very good - dissection here. So I'm happy with that.

CHAPTER 6

All right, so now you can go back and basically try to get into the lesser sac to take the gastrocolic ligament down. But typically I do six centimeter from the pylorus. Some people do less, I think you know, having a little bit more antrum doesn't hurt anybody. I think it also reduces the risk of leaks so you're not very tight at the incisura. So this is the pylorus there, you can see that's the prepyloric vein of Mayo over here. So I'm measuring six centimeters. So the tip up grasper from the tip to the metal here is about six centimeters. So that's about six. So this is where I need to start dividing the stomach here. So I'm just gonna mark it maybe where that vessel is. And then I'll let that be for a minute. And I'm just gonna try to get into the lesser sac. Now the reason I get into the lesser sac the body of the stomach is because that's where the peritoneal layers are not very fused. So usually the peritoneal layers are fused at the kind of higher up in the short gastric area and at the antrum of the stomach. So I try to avoid getting into that because it's just harder to get in there. So here in the body of the stomach, the layers are not super fused so it's very easy to get into the lesser sac. Sometimes you just gotta pull it up apart a little bit. Let the CO2 do some of the dissection for you. There you go. That's lesser sac. So I try to stay close to the stomach but you know, hopefully not burn it too much in case we need to abort this for any reason. Don't have to oversew this.

CHAPTER 7

The reason I stay away from the gastroepiploic is, you know, if you go very close to the gastroepiploic, it can actually cause a thrombus there and that can actually precipitate to a portal vein thrombosis, which could happen in these patients. So we try to, you know, be away from it a little bit. So after I've done a few bites, now I'll go south towards where my marking was. The easiest way is to actually use the tip up grasper in my right hand to lift the stomach up, and then use your other hand to manipulate the omentum. This part was always very challenging to do laparoscopic as you relied on your assistant to lift up the stomach and use those two hands, and it wasn't super easy all the time. So you'll see pretty soon that the at where the antrum is, the layers are gonna start to be fused a little bit. So that's where I'm getting at now. Now I'm gonna put my hand behind the antrum, and so now you can see clearly where the vessels are. You can see our instrument behind it so that you're not burning the stomach or the antrum, and pulling the omentum. One more. So if you look here in the back you'll see the two layers of omentum are fused and the stomach gets really close. So that's why I'm saying you have to be a little careful, maybe separate it in layers and do it this way. So this is where my mark is, the initial mark, the six centimeter. So that's where I'm gonna try to get to. Let's see how it's fused there. And start to separate those two layers here. So this should be the main trunk of the gastroepiploic. So that's why I'm staying a little bit away from it, just trying to define, you can see these vessels going from it to the posterior wall of the stomach. That's where my staple line will start. So that's why I wanna make sure I dissect it well so it doesn't cause bleeding as much as possible. All right, so that's pretty good there. So again, six centimeter from there is about here. That's where I'll start dividing the stomach. Just look and see if there's any posterior adhesions to take care of. Might be some here. I'll just take care of those now. We don't have to do them right now. We can complete dividing the short gastrics but since we see it then we can just do it now. Okay. All right, so marching towards the short gastrics, I'll hold the stomach with my left hand, omentum with my right. And this is where also the omentum will become fused in two layers right about at the junction between the body and the fundus of the stomach. That's how embryologically these layers develop. Always like when I'm using all four arms, usually you'll find me parking the instrument that I'm using at the top of the screen like that vessel sealer, and park it on the top of the screen, and then use the other instruments. Don't wanna be parking it down here or in your face so that you can see. I will keep going around the short gastrics here. Let's see the spleen in the background there and some adhesions on this side. Let's keep going on the short gastric side then I'll go back, and go medial and I'll explain that. But that's the fundus there still, I see a couple of vessels here. I think I can take them one at a time. I will use that sponge sometimes to sort of help retract a little bit like that. That gives you a little bit of better exposure. Helps you drag the tissue a little bit gently. I can see the vessel. I don't wanna do a partial fire 'cause that can cause some bleeding. So I'll just get to the vessel first. And then around that corner. I think I took most of the short gastrics here. Once I feel that I - I freed the stomach from the tip of the spleen, then I'll go back, leave that sponge there.

CHAPTER 8

And sort of try to roll the stomach to the left side. Sorry to the right side of the screen. You can see some adhesions here still. These adhesions prevent the stomach from rolling to the right side, which is important so they can actually see the anatomy. Just gonna take it. Again, just trying to advance my tip up, pushing the belly of the stomach to the right, lifting the fundus up. And I'm gonna actually start here. I think the left crus is behind this. So I'm just gonna go into that plane, and try to roll the fundus of the stomach up from there. South left crus there. Another technique is to hold the fundus up with the tip of grasper, and use the fenestrated to sort of do the dissection. Lift the stomach up if you can. So I know stomach is here, spleen is there. So right now this is what I wanna take. It's probably the short last short gastric here. Now we're gonna check and make sure that we can see the left crus. You can see this is all fundus that was back there. And that's the spleen there. That's just part of the fat pad that was... So that's that. So now we're gonna try to make sure that we dissected the fundus off the back there. You can see we did.

CHAPTER 9

All right, so this is the left crus of the diaphragm. It is right here. Inferior diaphragmatic vein. This is the fat pad, this is - the GE junction is right here. I'm just gonna clear this fat a little bit 'cause that's where I want my stapler to go. So I'm just gonna make sure I have enough room, and I don't wanna staple fat 'cause it could cause bleeding. So maybe over there. You wanna leave at least a good like centimeter shoulder next to the GE junction. So my good landmark is the fat pad. So I'll always staple like right here just giving a shoulder between the GE junction, a little bit of shoulder, stomach, about a centimeter. All right, Elena, can we advance the bougie, please? All right, and then hold on one sec. Get it - advance it a little more. Okay, one second. So now we're just putting that 40 French bougie, just trying to guide it into the pylorus there. All right, Elena, can we put it on suction, please?

CHAPTER 10

Okay, all right, I'll take the blue load in number one. So usually we sort of pick the load based on sort of sense of how thick the stomach is. This is a whole you know, algorithm, but usually... So the key with the first fire is that you don't wanna be too close to the incisura, which is right here because you don't want a narrowing of the sleeve there. You wanna be six centimeter from the pylorus or five, and then you also wanna leave a little bit of room from the crutch of the stapler. You don't want it to be too snug there because once the stapler closes it's actually gonna squeeze the tissue more. And the reason I picked a blue stapler just based on, you know, experience how you think the stomach thick, you can start with a green load and see how that goes. But most of the time for this thickness of stomach, the blue is okay and actually the sort of the SmartFi technology will tell you if the tissue's too thick. And also you don't want to be too close to the bougie. You're gonna wanna leave a little room next to the bougie. I'm gonna fire this. Let's see. It's like pausing for compression. That means that there's some tissue edema, which is normal. If the pauses are more than two pauses, then I'll keep with the same color of the blue load. If it fires like this, there's only one pause, then I'll downsize the staple height. So I'll take the next one is gonna be white. And I'll straighten the the stapler, and then I want my assistant hand, I guess, to sort of make sure that the fundus of the stomach is not rolled up in the top part. So I'll just hand it to myself where I divided those short gastrics. And sort of laid out flat. And I might know my trajectory for the stapling is gonna be right here. Now we could argue all day about, you know, using white loads on the stomach, but over the years, you know, I've tried a lot of different things for these staplers, but so far this has been an okay transition using these blue, and then white loads without staple line reinforcement. But I do an omentopexy too, which also - so again, same thing, I don't wanna hug the crotch of the stapler, just leave a little room as it squeezes the tissue. A good landmark is also where these vessels end, that's where you want your stapler to be. You don't want to be encroaching too much on the bougie. And then I close it, just let it compress for a little bit. All right. And it's normal to do compression at the beginning because these are crossing staple lines. So the first fire, and this it's firing basically here. And this stapler is good because it measures the thickness of the tissue as it's firing, and it fires the staples, you know, sort of slowly. So it keeps measuring the thickness as it's firing. All right, another one. I like to put the anvil in the back. It's easy to maneuver it. So for this - I'm not pulling too tight on the stomach, just kind of letting it lay flat. Just let it compress for a minute. So now this part gets a little, you know, important because you don't want to have any retained fundus. So you wanna make sure that you go this way and not leave fundus in the back. Again, I don't want any of the fat pad there, it's straight. So I'm gonna close it. Let's give it a minute. I usually check the blood supply for the sleeve too. So Elena, we're gonna need to give IV ICG in a minute. I'll let you know. Three CCs, 7.5 mg. Thank you. That was maybe after the next fire. I'll let you know. I'll take the fenestrated for a sec. So this is almost the second to last fire, so I really wanna make sure that I don't have any retained fundus. So that's why I asked for the fenestrated to make sure I sort of flatten this out, sort out what I need to do here. So to see a clear path, I'm gonna go across that vessel, so just anticipate that it might bleed a little bit. So I'll put my tip up like that just to find where the fundus of the stomach is. All right, I'll take the stapler, I will try to get the stapler in there, and then I'll get the tip up out. Sort of trade with the vessel sealer, and free up the vessel sealer. All right, gonna need one more white, please. You compress it and just fire. You can see there. So that's left right here. All right, Elena, you can give that IV ICG. You can see that I'm not super hugging the bougie. I'm leaving a little bit next to it.

Okay. I am just checking to make sure that the GE junction has good blood supply. And once I'm done with the fire I'll look at it again. Can even see the remnant stomach has or the sleeve that we're excising has just a little bit of blood still left. Gonna look at it. Make sure it has good blood supply up to the staple line. That's pretty good. All the sleeve, and this most important part is this part. Okay.

CHAPTER 11

All right, so I'll take the Vicryl. Now the next step, I usually do an omentopexy just to kind of reinforce the staple line a little bit. I'm used to using staple-line reinforcement, but we don't have it here. Elena, can you take the bougie off suction and take it out slowly, please? The reason I do that is because I don't want anything putting pressure on the staple line because if there is any bleeding, I wanna see it. And see here as they retract the bougie, you can see a little bit of oozing there. So I wanna see those areas. That's where I'll do some of the suturing too. All right, so I'll basically just kind of do random interrupted sutures between the omentum, or any fat that I could find to sort of... One, I think it just keeps the staple line straight, and sort of is a buttress material for points that you're worried about bleeding or anything. It's just gives an extra layer. And do you guys have the scope ready? Oh, you can take it out all the way. There's kind of areas where I think there's, which is basically the junction between different fires of the stapler that makes it sit a little straighter. See some people just oversew the whole staple line with V-Loc or PDS, but I think it just kind of makes more edema and such, and I don't think it's necessary. Gives also an extra layer of security. So some reinforcement of some sort. I guess everybody does some kind of reinforcement. I might need one more of those Vicryls. So I'm just kind of searching at those areas where I think there was a transition between one fire and the other. You'll see it's like right here. Long sleeve. All right, I'll give you this back and I'll take the other one. Just a couple more. So there.

CHAPTER 12

So now we're gonna take out the liver stitch first. And I like to kinda put a stitch in the specimen. It helps me handle it and put it in the bag and actually pull it through the abdominal wall. So I'll actually use that same V-Loc suture. And I'll usually - we'll put it in the narrow or the skinny end of the specimen, which is the part which is at where the antrum was. It just gives a good handle and helps us pull the specimen out through the skin sometimes. I usually use an Endo Catch bag to get the specimen out, and I'll leave it a little bit long so that I can use it to pull. All right Kendall, I'll give you these sutures.

CHAPTER 13

So now we're in the esophagus. Gonna clear it a little bit. Going through. To the sleeve. Make sure that this is where the incisura is. So we wanna make sure we pass through it so it's not too tight. And this is the antrum, and then that's where it's occluded. You can see it on the robot too. So this is where the staple line ends. Just inspecting it, make sure there's no bleeding. Coming back. That's kind of where it ends there. Pretty good. All right, so now I'm gonna go back and empty it, all the air.

CHAPTER 14

All right, we can undock.

CHAPTER 15

So now we're gonna do the same thing. Just do a TAP block and extract the specimen. So this is a transverse abdominis muscle, so I'm just injecting a local mixture in the TAP plane. So just anterior to the transverse abdominis. We'll take more local. Thank you. That mixture is 30 of marcaine, 20 of lidocaine, and 10 CCs of sodium chloride. So it gives you a total of 60 CCs. You can use 30 on each side, which is nice. We don't have access to Exparel, so that's why we use it. Take mine. If you wanna head out after we extract the stomach, that should be fine. So we're doing the same on this side. Do you have any more local? Is that? That's the rest of it. That's all.

CHAPTER 16

So now we're gonna put the specimen in an Endo Catch bag. If I can find myself. Maybe turn it the other way, turn it the other way. Now I'm gonna put this part of the stomach in first, and then I'll use that suture, just kind of pull it up. Okay, close it. Okay. All right, we can turn the room lights on and the gas off guys. So now we sort of deflated the stomach. I mean, deflated the abdomen, and now we have the suture so we can pull on it. Now we use two babcocks to work on getting the stomach out through the bag. It usually helps it slide up a little bit easier so that's why I use it. And also I've seen sometimes the stomach sort of opens up, and it, you know, sprays content everywhere in the abdomen. So we're just kind of gently pulling it one side and the other. Then on the fundus side or the greater curve side. And then on the staple-line side that usually is easier to make it slide up through the bag. They're also sort of protected against spilling anything inside the abdomen that can cause an abscess or something like that. Let's see. It's coming easily so far. There you go. Almost there. Okay, I think we can probably just pull it. All right.

CHAPTER 17

All right, so that's the specimen. This portion of stomach. And that 0 vicryl that we placed at the beginning to close the port site. We're gonna tie it down. All right, I'll take Monocryl. So now just closing the skin incisions. It's the 12 port. You take scissors. Can you guys turn the gas off too?

CHAPTER 18

The case overall went really well. We did look for hiatal hernia, we didn't see one, you'll see that I did initially a lot of dissection sort of around the phrenoesophageal ligament to make sure that the patient doesn't have a hiatal hernia. It is a very important to look for those, especially if the patient's having a sleeve because the sleeve in itself is a procedure that can cause reflux. So if there's a hiatal hernia then that adds to it. So we looked for it, didn't see one. Overall, everything went well. We used the 40 French bougie, we did the stapling, we talked about the algorithm. One of the tricks for using, you know, if you're using a robotic stapler, it's a smart staple technology. So it does tell you if the tissue's too thick, but then sometimes it doesn't really tell you. So you'll see it pausing for compression. When it says pausing for compression, that means that the tissue has a lot of swelling or edema and if the stapler pauses for compression more than twice, twice or more, or two times or more, then I usually stay with the same staple height. So if I use a blue staple height, and it gives me two or more pauses, then I'll stay with the same staple height. If it gives one pause or less, or sorry, less than two pauses, meaning one pause or less, then I'll usually downsize the staple height because that means that the stomach tissue's getting thinner. And as it gets thinner then it could bleed if you use the same staple height. So I'll downsize. So you'll see me in the video I used the first load was blue, and then we used all of the rest of them white. There's a lot of arguments about the, you know, using white staple heights on the stomach because originally the white staple heights were made for vascular dividing blood vessels. But what we're seeing now is that with the changes in the software and the algorithm that the robotic platform uses, the white staple heights give good compression, and it doesn't cause as much bleeding. And one of the things that I usually do for all my sleeve patients is actually I'll check the blood supply of the sleeve with IV ICG. The reason I do that is because I wanna make sure that the sleeve has really good blood supply, especially at the area of the GE junction because that's where most of the leaks happen. In my opinion, it happens because of ischemia, and using the white staple heights in that area, you have to be cautious about it because if you're having too much compression then that can cause ischemia. And that's a big part of the reason why I check for the blood supply with the ICG to make sure that, you know, the whole sleeve has good blood supply. And I do that for the sleeves and also the gastric bypass too.