Instrumentation: One 12mm visualizing trocar, one 12mm and three 5mm trocars, Nathanson liver retractor, extra-long instruments including atraumatic graspers, an electrocautery hook, needle drivers, laparoscopic shears, laparoscopic bipolar sealing device e.g. LigaSure (Covidien, MN, USA), linear cutting stapler. Surgical technique: The patient is placed supine on the operating table with both arms out. Pressure points are padded and a safety strap is applied across the thighs. Sequential compression boots are placed. General anesthesia is induced and, after intubation, an orogastric tube is inserted for gastric decompression. Prophylactic antibiotics and subcutaneous heparin are administered. A Foley catheter is not routinely placed. The surgeon is positioned on the patient¢ïïs right and the first assistant on the left. Monitors are on either side of the head of the bed. The patient is placed in reverse Trendelenberg. The abdomen is entered under direct vision using an Optiview trocar (Ethicon, NJ, USA) and a 10mm 0-degree laparoscope in the left upper quadrant. Pneumoperitoneum is established to 15mmHg. A 10mm 30-degree laparoscope is introduced into the abdomen, and additional trocars are placed under direct vision as depicted [1]. A percutaneous Nathanson liver retractor is placed in the subxiphoid region to retract the liver ventrally. However, in this case, the liver is sufficiently retracted by adhesions. Adhesions around the sleeve gastrectomy are carefully divided. A limited kocherization of the duodenum is performed by dividing these adhesions and then mobilizing the duodenum medially. The most distal vessels on the greater curve of the antrum leading down to the duodenum are divided with the LigaSure device to allow full exposure of the medial aspect of the first part of the duodenum. The plane is then developed behind the duodenum approximately 2cm distal to the pylorus. The orogastric tube is removed. The duodenum is then divided with a single firing of the EndoGIA 60mm white load stapler (Covidien, MN, USA). The patient is placed in neutral. The cecum is identified and 200cm is measured from the ileocecal valve. This is marked with a single interrupted 3-0 PDS (Ethicon, NJ, USA) suture. This loop is brought up to the proximal divided end of duodenum, taking care to ensure the bowel is not twisted and reaches without undue tension. The efferent limb descends on the patient¢ïïs right; the afferent limb ascends on the left. The antimesenteric border of ileum is approximated to the divided end of duodenum with another interrupted 3-0 PDS suture. Enterotomies are made with the hook electrocautery, both marking sutures are cut and then a wide stapled duodenoileal anastomosis is created with a single firing of the EndoGIA 60mm white load stapler. A handsewn closure of the common enterotomy is performed in one layer with 3-0 PDS. The anastomosis is not routinely tested. All trocars and the liver retractor are then removed. Fascial defects from any port greater than 8mm below the umbilicus are closed with 0 Vicryl (Ethicon, NJ, USA) suture. Skin incisions are closed with a 4-0 Monocryl (Ethicon, NJ, USA) subcuticular suture and sterile dressings applied. Variations: A grossly dilated sleeve may need to be resleeved. If a hiatal hernia or crural laxity is present, this should be repaired. The duodenoileal anastomosis may be handsewn. Postoperative course: Patients are started immediately on a thin liquid calorie-restricted diet. Electrolytes and hematocrit and monitored postoperatively. Postoperative pain is managed with patient-controlled analgesia and ketorolac. Patients are started on a standing regimen of antiemetics and famotidine, with hyoscamine as required. Other medications are crushed prior to administration. Early ambulation is encouraged. Patients are admitted to a surgical step down unit on postoperative day one only. Esophagrams are not routinely performed. Patients are discharged home once tolerating an adequate volume of oral intake and once flatus returns. The patient presented in this video was discharged on postoperative day 1.
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