Rutledge MGB

The Rutledge Version of Mini-Gastric Bypass: Tools, Tips, Techniques Special needs for the surgery (instruments, etc.) ========== First: Warning NO anticoagulants, NSAIDs ========== PATIENT POSITIONING: The patient is supine (not lithotomy) The table will be inclined to MAXIMUM Trendelenburg position and Full tilt to the Left Side UP The requires a simple but very important patient immobilization on the table to ensure patient safety and make sure the large patient does not move during the operation Both arms are out at 90 degrees the knees are “broken’ to an angle of 45 degrees and two Large pillows are placed beneath the knees The Heels are padded SCDs are applied and then most importantly 3 Three LARGE Leather or Polyester Straps (Seat Belts) are applied to the legs At the upper thigh the lower thigh and mid tibia Then to reassure all of the anesthesia, nursing and other attendants with all of the team watching The table is slowly and carefully moved to MAXIMUM Reverse Trendelenburg and Full Tilt Left side up Any adjustments are made Often a pillow, doughnut or soft sand bag is placed by the head EndoTracheal tube placement and Vital signs assessed Then and only then the patient is replaced to flat supine and the patient is prepped and draped in the usual fashion The surgeon stands on the patient’s Right Usually requiring a STEP Stool The Camera is immobilized by a self retaining camera holder and one assistant is on the patient’s Left side Only two scrub for the case The Surgeon looks across the table from patient’s right to left to a screen at the head of the patient located 45 degrees between the patient’s head and the patient’s left arm This means that this are must be kept free of IV poles and anesthesia paraphernalia ========== BOUGIE We use 24 – 32 French (NO Larger, No smaller) In a pinch we can use Ewald Tube Or Gastroenterologist Red Weighted Dilating Bougie NO 36-38 Bougies ========== INSTRUMENTS The instruments need are simple but should be of high quality. The Mayo stand should contain 1 scalpel of any type Veress needle 5 Ports in total Of the 5 ports; 4 ports are 12mm ports (not 10 or 11mm) 12 mm ports that can accept the stapler (12 mm) as well as the 5 mm operating instruments. Of the 5 ports the remaining port is a single 5mm port Three separate 5 mm graspers of excellent quality, at least 2 should be Locking Graspers One of the 3 three, 5 mm graspers should ideally have longer jaws to allow a firm safe locked grip on the intestine In case of emergency there should be two good quality needle drivers (in most cases not needed, but should be on the back table) Stapler, Ideally Covidien 60 mm blue or Purple although Johnson Can be used as backup No other Open Surgery instruments on the back table Skin closure is with 1 (one) single staple in each port and for this we need a single pair of Adson’s forceps with teeth and commercial staple gun No suction is on the table We use the Harmonic scalpel if possible No sutures open. but have 3-O Vicryl on sh needle available if necessary, Do Not Open =========================== A brief summary of the procedure may be of interest The surgeons approaches the patient in flat supine position from the patient’s left side. The abdomen is examined and the location of the left lateral extent of the rectus sheath approximately 4-5 finger breadths below the left costal margin is estimated. With the “go ahead” from anesthesia a 5 mm incision is made and the Veress needle is advanced into the abdominal cavity and insufflated. The surgeon moves to the patient’s right side and after insufflation the scalpel is used to make a 12mm incision 1 and 1/2 palm widths below the xiphi sternum This may vary slightly with patient size but is remarkably constant The 12 mm “Camera port” is used to enter the abdomen The surgeon uses the camera to briefly explore the abdomen and note the location of the Veress needle and the Veress is removed under direct vision The final 4 ports are now placed The locations are as follows: 1, One 5 mm port several cm medial to the left axillary line 2-3 finger breadths below the costal margin 1, One 12 mm port left mid-clavicular line 2-3 finger breadths below the costal margin 1, One 12 mm port Midline 2-3 finger breadths below the xiphi sternum 1, One 12 mm port Right mid-clavicular line 2-3 finger breadths below the costal margin Total 5 Ports In roughly a “Diamond” pattern 1 Midline 1 and 1/2 palms below xiphi sternum (the Primary But not only,” Camera Port”) 1 Left Anterior Axillary Line 5 mm grasper / retractor port 1 Right Mid-clavicular line port, used for stapler and camera at several points during the case for only a few moments 2 Primary Surgeon’s Working Ports (Right Hand and Left hand) Left hand = Midline Port Right hand = Patient’s Left Mid clavicular Line port Patient is now, with approval of anesthesia, tilted to Maximum Reverse Trendelenburg and left side up Warning poor anesthesia can lead to hypotension Anesthesia must be prepared and educated as tothe planned revers Trendelenburg positioning and drug use so to avoid hypotension when tilting the patient Poor anesthesia = No surgery Now the steps in brief for the operation The left hand grasper elevates the left lobe of the liver and the harmonic is used to dissect the lesser curve of the stomach at the junction of the body and the Antrum 5-10 minutes Stapler is passed via the Left Hand Working port into the abdomen and the stomach pouch creation is under way Using the Left Hand working port or the Right side port second stapler is fired Surgeon and anesthesia now discuss Bougie placement The bougie is advanced and retracted under direct vision ========== Surgeon and anesthesia agree on bougie movement commands: Advance Retract Tap Tap (A very tiny rapid in and out motion that aids in bougie identification) Now all staplers fired from the Right hand Working port 3-5 staples to EG Junction WARNING FEAR THE EG JUNCTION Stay lateral to EG Junction Only fools and Sleeve surgeons dissect near the EG Junction. It is not necessary for MGB and it is dangerous With division of 80-95% of the stomach the area lateral to EGJ is visualized If necessary the short gastrics are divided under direct vision with careful and meticulous dissection Case Mantra “NO BLEEDING” The division of the stomach and creation of the pouch is completed Op time 15-20 minutes ========== Attention turned to the Left Gutter Retract the omentum medially and Identify Ligament of Treitz Run the bowel 2 m Count to 60 ========== Grasp and lock the loop of bowel with larger 5mm atraumatic locking grasper Gastrotomy with harmonic Change camera to R Lateral port Enterotomy Pass 60 mm Covidien Stapler in via the “Camera” port Fire to form GJ Manipulate 24-30 mm bougie across the anastomosis Change camera back to camera port and pass 60 mm stapler in via the Right lateral port Close the GJ Case over Op time 35 minutes