Prophylactic Total Gastrectomy for CDH1 Gene Mutation

CHAPTER 1

Hi, my name is John Mullen. I'm a surgical oncologist at the Massachusetts General Hospital and I specialize in the treatment of upper GI tract cancers. And so today we're gonna do a procedure on a young lady, who has inherited the CDH1 gene mutation that causes hereditary diffuse gastric cancer syndrome. Patients with this mutation will have about a 50% lifetime risk of developing stomach cancer. And so a standard treatment for this is actually a prophylactic gastrectomy and it's a prophylactic total gastrectomy. So that's the procedure we're gonna be doing today. Interestingly, she has a history of prior rectal cancer that required a low anterior resection and a temporary diverting ileostomy. That was seven years ago. She's been free of recurrence and presents at this time for her gastrectomy. Preoperatively, she had an endoscopy study that was totally normal. All random biopsies were negative and preoperative CT scan imaging was also normal. Steps of the procedure are fairly straightforward. We're gonna do an upper midline incision, followed by that we'll do a survey to look for any metastatic disease and feel for any tumors in the stomach. Second step is gonna be to enter the lesser sac. We're not gonna take out her omentum because she's had prior surgery and I suspect it's gonna be stuck down in her pelvis. Once we enter the lesser sac, we'll then move leftward, take the short gastric vessels and the left gastroepiploic arcade, and then we'll move rightward, and take the right gastroepiploic vessels. We'll then open up the lesser omentum, take the right gastric vessels, divide the duodenum, and then reflect the stomach toward her head. That will then expose the left gastric pedicle, which we'll divide with a stapler. Lastly, we'll dissect out the esophagus at the hiatus. We'll choose a site for division. We'll do that with the cautery, and then I like to do a reconstruction in stapled fashion. So we'll develop a Roux limb, we'll bring that up, retrocolic behind the transverse colon, and then do a stapled EEA anastomosis for our esophagojejunostomy. And then I create a 60-centimeter Roux limb and we'll do a side-to-side handsewn jujenojejunostomy. We'll then close, and hopefully everything will go smoothly.

CHAPTER 2

Knife down. So for this operation, obviously, you can do this open, you can do this laparoscopically, robotically. In my hands, I'm most comfortable doing it open and we would make an upper midline incision, obviously, extending up to the xiphoid because you need to have access to the intra-abdominal esophagus. She's had prior surgery for a rectal cancer in the past, and so we're expecting some adhesions. You're off midline a little bit. That's my side. Debakey's. Yeah, so it's to my side. So that's okay, just– Richardson. Hold onto that guy. Let's finish here. So now we're coming through the preperitoneal fat here. I like to do this with the cautery, since there's often small blood vessels in here. There you go. Now that might be - Omentum. Omentum. Let's come up higher. She may have adhesions from her prior colectomy. There's something down there. Divide through here. I think that's safe. Richardson. Great. Sure, that's hemostatic, yeah. That's it. All right, do you have a wide handheld abdominal wall retractor? And we take a look around, just make sure there's no… We might have some adhesions first. Cautery. And DeBakey. Do you have the LigaSure open there? Yeah, cauterize here. Yep, see my finger here? We're just taking down the falciform ligament now. Can I get the Bovie extended? Yes. Great.

CHAPTER 3

Okay, wide handheld abdominal wall retractor. So we're just gonna do a metastatic survey here. We don't expect any metastatic disease in a prophylactic patient who has no known gastric cancer, but on occasion you can find an invasive gastric cancer incidentally, and so important to do this survey nonetheless, looking at the liver, the peritoneal surfaces. Also given her his distant history of rectal cancer, make sure that there's no recurrence of that. Everything looks good. Some adhesions here we're gonna have to address. Some adhesions that we have to get through. Kochers Yeah, you're too high there. There we go. Now, now. No, no, it's okay. Follow it up there. You see the peritoneum, yep. So I think you can take LigaSure and come through here. Xiphoid's right there. Xiphoid, perfect. See if I can tee it off to the left of xiphoid a little bit. That's great. This here needs to be taken down off the abdominal wall. We don't have to worry so much about the omentum in the pelvis, because we're not gonna do an omentectomy, so… And grossly everything looks okay. And then I feel the spleen is nice and smooth. The diaphragm feels okay as well. Take this band here. Great. LigaSure. All right, we'll take the bladder blades for here. We gotta make sure it's under the abdominal wall. Do you have a nut? I'll let you screw yours on, and then I'll pull on mine once you're done. Okay. I can help you here. Relax that. Yep. Great. Okay, how about two right angle lollipops. It's a little more of this tissue divided. You might slide this over a touch. Thank you. And then can I have a malleable. See, let's take this down. This one should be fine on a lollipop. You have the lollipop? No, one of these, yeah. Some adhesions to the liver, which we're lysing now. Super, and then a moist lap pad. So this retractor will get the left lateral segment of the liver out of the way, so we can ultimately see the hiatus. Super.

CHAPTER 4

Okay, first step is to get into the lesser sac. So, do we have our nasogastric tube in position? Maybe, but we might need to go a little bit further at 55. Jeff, can you advance the NG tube just a little bit? Yep. That's great. Perfect. You can stop there. So it's best Zhi, if you grab both the stomach and the omentum in your left hand there. Got it. All right, I grab her transverse colon. It seems to me that this is cleaner here. I think that's promising. Right angle. Smaller right angle. Yep, and we can take the LigaSure there. Let me just regrab my transverse colon. I'll regrab the stomach. The key here is to not be too close to the transverse colon mesentery. The last thing you want to do is inadvertently devascularize the colon. Since we're not doing a comprehensive node dissection in this case, because it's a prophylactic gastrectomy, we don't need to be too concerned about our station four lymph nodes here, although those will come with the gastroepiploics. We're gonna be staying pretty close to the stomach proper. We're not gonna be doing a D2 lymph node dissection, since there's really no indication for it. She'll end up with a D1 lymphadenectomy, as part of this procedure. Cautery to me. I'll open that up, Zhi. Can I have a little bit of slack? Thank you. I got that, yeah. Okay, I think we can… We'll do here. Yep, why don't you march down there. Cautery. I like to do some of this with the cautery. So as we get down toward the gastrocolic trunk here, have to be very careful about putting too much tension or avulsing any vessels. The right gastroepiploic arcade is gonna be in here, and the middle colic is gonna come up here. And so we want to be very thoughtful as we dissect in here. Bleeding in this location is a nuisance because it's venous and can be somewhat challenging to address. So better not to have it at all. These are where the station six lymph nodes live. That's part of a D1 lymphadenectomy. But as I said, because this is a prophylactic case, we don't have to get too far down on our gastroepiploic pedicle. So this case is not gonna be a good illustration of a D2 lymph node dissection, but… She's obviously a little heavier set than some patients. So the anatomy here is not instantly visible. There's a fair bit of fatty tissue here. Okay, I think you can come through here, Zhi. Let me have a look here. Let's see where our duodenum is. Okay, so keep marching down here. Still dividing omentum here. We're gonna come up to the first portion of the duodenum. And that will be our infrapyloric dissection. You can see, actually you're getting a good look there at the gastroepiploic arcade, the right gastroepiploics. Those come off of the gastroduodenal artery. We'll probably divide those fairly high just again, because we don't need a thorough node dissection in this case. Right angle. Bovie. And DeBakey. Yeah, grab. It'll come through here. It's surgeon's preference how much of this you do from the outset. If things are going well, sometimes I just keep going on the right side before I go around and take the short gastrics and do the work on the left side. Sometimes I will save the right gastroepiploics for later and do the short gastrics first. It doesn't matter, it all has to get done sooner or later. So, I think if you've got momentum in one direction, it's reasonable to just keep going. We're gonna need an endo GIA 60-millimeter tan load. Yeah, the short one is great. Take the cautery. Let's lyse this. There's an adhesion here to the first portion of the duodenum to the caudate lobe, which we're gonna just lyse, just to mobilize the duodenum a little bit. Zhi, go ahead and just open up the lesser omentum there. Can we have the longer right angle now, Josette? I'll take the longer DeBakeys as well. I'm sort of cheating here and going to the suprapyloric dissection. And again, the order in which I do things is variable. Sometimes from case to case, it just depends on…

I might LigaSure that. Because that could be the right gastric. The right gastric comes off of the proper hepatic. Obviously, that needs to be taken in a total gastrectomy. It's typically quite small. Station five lymph nodes are in that pedicle and there's typically not a lot of nodes in station five. Autopsy studies have actually shown a median of about one lymph node in most D2 dissections. Let's turn our attention back here.

CHAPTER 5

So, finish here with the omentum. Going back here now, just to the infrapyloric dissection, kind of working from above and below, making sure we're in the same plane. Wanting to divide the duodenum at the same level, appropriate level. We can thin that out a little. You can feel the pylorus right here. And the first portion of the duodenum is here. Obviously, we do not need to take a big duodenal margin because again, there's an expectation that there's no invasive cancer here. We will send it for frozen section, but... So now I'm gonna get around the right gastroepiploic pedicle here. It's a pretty big wad though, so I think maybe… Trim it. Why don't we trim it. Hold this up here, Zhi. Do you have a DeBakey, please? Thin this out a little bit. If I'm gonna divide vessels, you know, with a vessel-sealing device like the LigaSure, I don't like to have a lot of tissue in the jaws, and so, though you could do a sort of a mass ligation, you know, of the nodal and fatty tissue with the vessels, I sort of like to get a little bit of a better look at the vessels and less tissue in the jaws. Of course, in doing so you run the risk of pesky bleeding, but…

So here you're getting a pretty good look at the gastroepiploic vessels there. And we can angle right here. Exactly. I might have caught a small vessel. Let's see. Okay, so I think we should be able to take these pretty easily now. We have a nice view. I would do three sequential burns: two at the bottom and then a final one up top. Great and that just released the gastroepiploics. That's quite a give in the tissue there and now we just have a small amount of fatty tissue here to address. Let me take a look at this side here. DeBakey. Grab that tissue there. Let me see my tips. One more little vein here. So this will complete the infrapyloric dissection of the duodenum, taking the right gastroepiploics.

CHAPTER 6

We can move right now to the suprapyloric dissection. We've already opened up the lesser omentum. We've taken our right gastrics. There's a small vein here I'd like to get so we don't have bleeding with the stapler. Can I have the smaller right angle? It's pretty - hugging the wall there, isn't it? Well, it may just be best to take it with the stapler. It's like inseparable from the wall there, isn't it? Yeah, that's fine. Okay. Okay, let's just make sure we have enough of an opening here to pass our stapler. I think we do, and that will then allow us to elevate our specimen.

CHAPTER 7

So we'll take the endo GIA 60-millimeter tan load. I like the tri-staples. I use the tan load on small valve because of the smaller staple heights than you get with the purple or the black loads. Maybe put a… This stapler roticulates nicely, and so you can easily… I think… There you go. So… I feel the pylorus in my, between my thumb and forefinger here, and when I'm confident that we're distal and I'm happy that the duodenum is laying flat, and you can see the tips. Okay, fine. Close the stapler. You happy with that? Happy with that, yeah, and you're gonna fire that slowly. We're gonna fire. Beautiful. So in dividing the duodenum now, we have the distal stomach completely freed and we can reposition our retractors now to expose in better ways, both the short gastrics and our left gastric pedicle, so we'll change this out for a malleable.

CHAPTER 8

I have her in a little bit of reverse Trendelenburg to try to lower some of her GI contents to the pelvis. I like the Thompson retractor because I do think the exposure is far better than you get with a Bookwalter or an Omni. That is of course, your preference. Thompson also comes with these really cool attachments. Gigantic malleables and… Super. I'm happy here. Okay, right angle and DeBakey. Yes, please. This is just an adhesion. Great. This is actually our, obviously, the pancreas and then the left gastric vein is gonna be evident right there. The left gastric vein is what you'll find first, and then the artery is always behind it, cephalad. So we're gonna open up the peritoneum here. This is how we start our D2 dissection. Frankly, we open up the peritoneum along the superior border of the pancreas, to begin with the station 11 nodes. But we're, again, we're not gonna do a formal D2 dissection today. This is just a necessary step to expose our… That might be a node. To expose our left gastric pedicle. Again, I don't always do this step first. I'll often go and do the short gastrics, but again, it has to get done sooner or later. And so we're making some nice progress here. So we're doing this in a slightly different order. I don't like to take these vessels en masse in the left gastric pedicle. I usually like to take the vein separate from the artery. So I do dissect these vessels out. Normally, that's necessary anyway, if you're doing a node dissection, but… We're gonna need a 30-millimeter curve tip tan. Open up the peritoneum here. More cephalad. Great and there you can see actually, the artery behind the vein. That's a nice view. I'm sorry, you're gonna have to watch the video. You'll have a better view on the video later, than you're getting in real. It's kinda like watching football. It's better to actually just stay home and watch it on your big screen TV than go to the game. Well you can take his word that it's a beautiful view right from here. I'll let you see here. Okay, do you see the left gastric vein there? Yes. Great. And then the left gastric artery is situated behind it right there. Okay? The lymph nodes at this station are station seven, right here, and if we were to go with the D2 dissection, we'd continue on to the common hepatic. Here's the station eight node, which you can usually see is a fairly large, pink node right here. And then the station 11 nodes would be here along the splenic artery. And again, we're not gonna pursue those today, but that's what we would do. We'd open up all of this peritoneum here, to retrieve those nodes.

So Zhi, we might be in a position and in fact, I think we probably can just take the pedicle as one. It's, they're so adherent to each other. Plastered against each other. Yeah, I don't think we have to… Yes. That, yeah, perfect. The ski tip. The ski tip. The ski tip. Yep. Beautiful. All right, Zhi. I like this… Let me get my... There we go. I like this curved-tip stapler. It's a really nice feature because the ski tip here, really allows you to get underneath the vascular pedicle. Whereas I take the smaller vessels like the gastroepiploics, and the short gastrics, and the right gastric with the LigaSure, I'm a little nervous about taking the left gastric pedicle with the LigaSure, and so I typically will use a stapling device for that pedicle.

Obviously you can tie it, but it's almost becoming anachronism that residents don't tie very much anymore because we've got these beautiful vessel sealing devices and staplers. You're gonna have to get right between the staples, otherwise it won't work, yeah. Great. These are just a few retroperitoneal attachments here, and I think we'll probably now go ahead and turn our attention to the short gastrics and the left gastroepiploics here. So, now we've just got a great exposure because the duodenum is divided. Start here on the free edge, Zhi. We're gonna stay pretty close to the stomach, yep. And we're gonna march right up. She's got quite a thick omentum. The left gastroepiploics are gonna come up from the splenic vessels. The short gastrics are gonna go to the spleen. There's one short gastric coming up right there. Here's a, yep. She has an unusually thick omentum here. There you go. The LigaSure is perfect for the short gastrics and - and left gastroepiploic vessels, and this is a hard area to be tying. So this has been a great advance, I think. Yeah, so the left gastroepiploics, Zhi, are gonna be coming right here. Coming up from the splenic. Yeah, so we're gonna stay here. Perfect. Maybe do two burns there. There's a vessel there. I see it. Uh huh. Maybe two on that. It's incredibly thick there, isn't it? Now we're taking the short gastrics. The key here is to make sure your jaws are completely across the vessel, you don't want to come halfway across a vessel, either stop short or take the whole thing. There's one vessel right there. I think I'm right across it. As we get up further north,the short gastrics get shorter, in terms of their distance to the spleen, and so if you're gonna ding one, it's gonna be that uppermost short gastric. So I, now I switch to a right angle to try to dissect this out. The long right angle. There's also often a posterior vessel coming off the splenic, posterior gastric if you will, and sometimes it helps to take those first, just to mobilize the stomach a little more. This is just an adhesion, but… You can see here an example, I think, of one of those posterior vessels coming up. Anatomy in every patient is subtly different. There we go. This is gonna be, there's two here, Zhi. Do you want me to take one at a time? Well, let me see if I can get you them one at - there you go. There's number one. Here's another, Oh, take the cautery. Let's just open up this peritoneum here. First, along the phrenoesophageal ligament. This gives us just a little more mobility. There's a station two lymph node. A long DeBakey. Oh, here, maybe we'll go superficial with the Bovie and then we can get the LigaSure in, well… That'll be okay. LigaSure. Again, I've kind of flopped to the other side here and I know I've skipped a little head here to the dissection of the intra-abdominal esophagus, but it seems like the right thing to do at this time, just to get a little mobility on the upper esophagus, to sort of provide us a little more exposure for those upper short gastrics. It's gonna be helpful in a big patient. Great. Okay, so let's see if we can get that last short gastric. Zhi, if you pull the stomach to you… Suction. Right angle. Great. One thing I didn't do, but you can do, sometimes it helps to put a pack behind the spleen. It brings the spleen up into the wound a little bit to present the short gastrics to you. You gotta be careful you don't ding the spleen in that process or any other. She doesn't need a prophylactic splenectomy. Almost there. You can probably have a 15 minute notice for the Lumicell. Let's see if I do this side, Zhi. DeBakey, long. Can we lower the table just a little bit. Sure. Is it as low as it will go? Okay. Can I have a short stand? Great, thank you.

CHAPTER 9

Okay, let's reassess here, so… Twisted stomach. All right, so there's stomach, duodenum, esophagus. So right angle. So now we're dissecting out the intra-abdominal esophagus and soon choose our site for division. We just need a negative, well, not a negative margin, we just need to make sure we have 100% squamous mucosa.

There's no residual - so here's an anterior vagus nerve right here. Usually it's accompanied by a vessel. Well, I'd like to reposition this and see if we can do something here. Pull down a little bit. Okay, let's look back here again, Zhi. So these are the crural muscle fibers. This is the left crus, and over here is the right crus.This is obviously the esophageal hiatus. Long Bovie. It's always good to get a little more length than you think you're gonna need on the esophagus because it tends to retract when you divide it. And so, having a little more exposure is always best than a little less. That's pretty good. See if you can grab this vessel, and just… Great.

CHAPTER 10

So now we need to choose a site for division of the esophagus. I like to do this with the cautery and place traction sutures as we go. 3-0 silk, not the pop-offs, the long ones, and if you could have that on a rider. Maybe take this band here. That's the vagus stump. I'm getting very nice length on this. Yeah, I think what we can try now is to reposition this. I thought we had the rider. I have one. Oh, okay. Oh, one's probably enough. I wanna be sure you can use the needle holder without too much trouble there. All right, I'm gonna take the cautery, and you're gonna take the stitch. Yep, we're gonna start at 12 o'clock. Do you have the - all right. So the choice here, obviously, here's the epiphrenic fat pad here, and so you know, this is still gonna be stomach if you divide in here. So you wanna be, you don't wanna be way up here because that's gonna be difficult to sew to, so you kind of have to estimate. This still looks like sort of, probably I'm estimating, Z-line's gonna be right around here. Almost get the sense that there is stomach here, so. I'm guessing we'll probably be okay here. Okay. I use the NG tube as a guide here. There's the NG tube. And now you want to grab all layers. Yeah, full-thickness bite. Grab a scissors. And a snap. Oh, these need to be the long 3-0 silks. Oh, the long one? Yes. Sorry, I thought you said pop-offs. Snap that. Sorry, I said pop-offs, that's my mistake. So put your DeBakey there. I'm just gonna divide a little more here, and then you can put in your nine o'clock stitch. I like to do an EEA-stapled anastomosis. So these are just traction sutures to control the esophagus. You can obviously use a Satinsky clamp or whatever you like to use. Some people use an automatic purse-string device. I don't like that so much because it's bulky and it can have a fair bit of bleeding too from the cut surface. Okay, with your DeBakeys grab here. Get all layers, yeah. I can see the mucosa. All right. Did we grab it? Yep, great. So I use a handsewn, purse-string suture. We just use these, again, temporarily for traction. We'll cut them out and do our purse string. Okay, can you pull the NG tube back maybe 15 cm or so? Yes, I think it's at 55, so let me go a little bit by little bit. Yep, keep going. You can go at least another 10. Okay, I think it's at 50. Suction. Little more, yep, little more. Okay. The suction's not working. Great, so you can see that that's squamous epithelium right there, we know we're in esophagus and above the Z-line, which is perfect, it's where we need to be. Okay. And then can I have a DeBakey? But I bet if I pull this anterior lip down, you'll be able to see… No, maybe not. The GE junction is gonna be… It's gonna be a little further down here, so we'll have to see that ex vivo. Okay, cautery. Oh, thank you. All right, so we're gonna complete our division of the esophagus and then we're gonna put our six o'clock stitch in. Okay, go ahead. Put the six o'clock in. Yep. Scissors and snap. Needle back. Great, and then we'll complete the division. This is total gastrectomy for frozen section. And now we're gonna just take a look here. Can I have two pairs of DeBakeys? One for Zhi, one for me.

I just wanna make sure we are free of the Z-line. And there you are. You see the difference between the columnar mucosa and the squamous mucosa? Yeah. And there's that junction, right? You can see the difference in the shading of the tissue. And so we've got a good, you know, at least a centimeter. Okay, and that's all we need. We just wanna make sure there's no gastric glands left behind at this margin, because of course, that could develop into a stomach cancer. So that's the purpose of the frozen. And then on the other end, they're gonna cut off the duodenal staple line and they're gonna look for what gland? What gland classically tells you it's duodenum, as opposed to jejunum or ileum or something? A Bruner's Gland. A Brunner's gland, yeah, exactly. So, they'll look for 100% duodenal mucosa. Okay, you can pass that off the field. They can also look just to see if there's any cancers, you know, that we don't expect them to find an invasive cancer. They're not gonna find early cancers on a frozen, but they, I have had a patient where they found an ulcer and it was a T3 cancer. Oh wow. And then I proceeded with the D2 lymph node dissection, you know, at this point, that's my only patient who's had more than a T1 cancer.

CHAPTER 11

So there's a few things we can do at this point. We can sew our purse string and put our anvil in. Or, you know, we can go and make our Roux limb. I'm inclined to say, why don't we go ahead and put our purse string in. So, what we need now is a 3-0 PDS suture. Make sure you get all layers. Snap. Snap the other end so we don't pull it through. I'm gonna get off of my stand here. It's too high. Let me see if I can help you, Zhi. I'm gonna follow for you here, and then… Come around on my side. Let me see if I can hold this back here. Don't torque the needle too much. Now you're, yep, outside in, yep. Traction sutures kind of help you hold open the wall of the esophagus so he can see. Sorry, hold open the lumen of the esophagus. Make sure you get a little bit bigger bite next time. Okay. That's better. For some reason, our esophagus is a little bit shorter here, isn't it? So maybe… I'll pull back the hiatus. You pull back the hiatus, yeah. This way. Come back here and get a full-thickness bite. Don't travel too far. Yeah, better Maybe now I'll hold this. Is that helpful? A much better exposure. Maybe. I think this is it. Last one? Come back out here and… I'll put a hiatus on. Needle back. Is that gonna be okay for you to tie when we get there?

CHAPTER 12

All right, well, I don't want to tie in the anvil yet because just on the off chance we have to take more. I don't think that's likely, but let's do our jejunojejunostomy. Get our Roux limb. Now this hopefully, we don't have to mess with adhesions from her prior surgery to do this. Do you have an abdominal wall retractor? No, nothing is stuck down to the pelvis. Oh, deep in the pelvis. Right by the low anterior resection anastomosis. You can feel it down there. It might have just transected the greater omentum up here. I wonder if one option is, go ahead and find LOT there. There you go. I believe it's this one right here. Yep. Yeah, so that's ligament of Treitz. You can see the ligament nicely. It's the duodenum heading underneath the vessels there, to the right side of the abdomen. IMV is well, in there somewhere. Right there. Maybe there. Okay, go ahead and follow that. I'll take that… I want a retractor though, but this time with a right angle on it. This is 10. 20. This'll be approximately 30. Oh, okay, yeah. This is about 30 cm from the LOT. About 30. I pick an area, I'm not wed to a distance. I just pick an area where I think that there's enough laxity in the mesentery so that it will reach without tension. So there's a pedicle here, which I'm gonna leave on the afferent limb. So we're gonna march down from here and we're gonna come down here. You know, we're gonna leave that pedicle behind. We'll come through this arcade here and then we'll have to decide if we need to cut across and take another, you know, arcade. Just, you know, depending on the - Schnidt - depending on the tension, how much length we get with this. So... And we need the stapler. Stapler. Okay. Scissors. Baby Scissors. Great, now you hold this limb here. I'll hold this limb. Let's score the peritoneum. Let's take a feel there where the vascular arcade is there. Maybe you can take that. What do you think? Just with the cautery? LigaSure, yep. Cautery. Let's take this with the LigaSure. Still something going. LigaSure. Cautery. LigaSure. Can't go too much lower. Maybe take that, yeah. Bovie now? All right, one thing we can do is make our rent in the transverse mesocolon and see what kind of length we have here. I like to bring my Roux limbs up retrocolic. I think we're safe here, Zhi. My finger's here. Score underneath your finger? Yep. Maybe a little more down toward the pancreas, yep. It looks pretty good. Tension-free. Yeah. Yeah. So we're gonna need a ruler. And then you have two 3-0 PDS SH and a bunch of 3-0 silk pop-offs.

3-0 PDS? Yep. Great, all right, so that looks good. So we're gonna retrieve that now and measure out a 60-cm Roux limb. And this is to prevent bile reflux. So we have a ruler? Yeah. Yep. Let's make sure we have the right limb. Here's afferent, also known as the biliopancreatic limb. That's about a 30-cm limb there. This is gonna be… Exactly 15. There's 15. 30. There's 30. 45. 60. Okay. Now you could go a little longer. She's, you know, got a BMI of about 32 or so, you know. But this isn't really a gastric bypass. So, she's gonna lose 15 or 20% of her body weight as it is with a 60-cm Roux limb, so I think that's reasonable, certainly enough to prevent bile reflux. Great and so then we're gonna marry that. This to do our jejunojujenostomy. I do it in side-to-side fashion. 3-0 silk pop-off. You could do it that way. I think it lays nicely this way. And then that will go north. All right, so we're gonna do this handsewn for fellow benefit. Corner stitches first with 3-0 silks. This also gives the pathologist time to do their thing. I'm gonna snap this, Josette. Needle down. Yeah. Another 3-0 silk. That's plenty big. I would say maybe, you know, aim for 5 cm, 6 cm. A little - no bigger than that. Yeah, that's good. Obviously you can staple this, but since we staple everything, we'll sew this one. Can I have a bowel-toothed forceps as well? Do you want me to orient it differently? Would it be easier for you if I...? This is perfect. Did it this way? Oh yeah, it is. See, that's the beauty of the small bowel. You can just move it around. We're gonna tie these at the end or how do you wanna do that? We can tie it at the end. All right, put a little tension on this. We're not gonna snap these. I'm gonna just hold them. It's easier for me to throw stitches in if It's not tight yet. His forceps don't have teeth, Josette. Oh, sorry. Needle down. Another one. Needle down. Needle down. That might be it. That's probably good. Yeah, why don't you tie your corners. Go ahead and snap this, but we'll cut the others. These are 3-0 silk Lembert sutures. So they're only seromuscular stitches. That's the back row. The corner stitches set up the anastomosis and we keep these snapped to keep the anastomosis suspended, and… I like this way. Okay, can I have a forceps? Can you give us a couple blue towels? So now we're gonna make our enterotomies for our side-to-side anastomosis. This is gonna be the inner layer. Right here. Little bit more there, huh, just on the mucosa. Okay, 3-0 PDS. So this is a full-thickness suture. Now we're gonna take all layers. He's gonna be careful there to get all four layers of that wall and all four layers of that wall. And then we're gonna tie that. PDS is an absorbable suture, although it takes many, many months to absorb. One of the advantages of it is that it's monofilament, so it travels through the tissue without sawing through it or tearing. So it's a nice suture. I like it over chromic or Vicryl. I'll take another 3-0 PDS and then I'm gonna sew one from my side. You can cut this guy here, 7 mm or so. A little shorter. Great. And this stitch should be very close to his. I don't tie the ends together. Some like to do that. We can sew simultaneously or if you want your trainee to have maximum benefit, of course you can do it, let them do the entire anastomosis. A little shorter, yep. Nice thing about a handsewn anastomosis too, it's very hemostatic. I don't lock the stitch on the back row. Some do, but I think as it is, it's quite hemostatic and you don't have to worry about staple line bleeding or it's nice for the residents to get to practice for those rare circumstances, when a handsewn anastomosis is preferable. We gotta stop taking in two at this point. Yeah, I agree. Gotta be careful at the corners to make sure you don't travel too much and if you're gonna have a leak, this is where it's gonna be. So, very thoughtful here to not travel too much, make sure you come in at 90-degree angles. Get all four layers. Good serosal bite. Probably one more stitch around the corner. And then I like to canal on the anterior row. Probably can come back out there, Zhi. Okay. Start the canal.

So to start a canal, you come right back out close to the stitch that just came in. And so, now he's on the serosal side of the bowel. And we're gonna go to the other side here, across the street, if you will, using the bar analogy from outside the bar to inside the bar, and then from inside the bar, back outside the bar, across the street to the next bar. I like this stitch because it tends to invert the mucosa nicely. Don't travel too much, Zhi, I'd come here. All right, let me bring mine around. See if we can finish this before the pathologists give us our frozen.It's hard to get my suture out of the way. You need one more? I think one more, yep. No, no, we're okay for stitches. Just talking about throws here. And I'll come back, and you can canal to yourself. This is the jejunojejunostomy. We're sewing the jejunum together. Going across the street into the pub. And the key here is to make sure we travel appropriately on each side. We don't want to have excess jejunum on one side compared to the other. Ideally, we plan that out nicely at the beginning and have equal lengths. Makes for an easier and nicer anastomosis. Can always make up on one side of the other by traveling more or less, but better not to have to even do that. We're gonna use the 25-mm EEA stapler and we're gonna need some lubrication for that. Perfect. Thank you. One more on the caudal side? Yeah, I think so. Pull out the serosa there, and I'll try to show you here. Yeah. Can you grab it? You have lots of 3-0 silk pop-offs, Emily? Looks like we're probably there, huh, Zhi? And then you can cut these guys off here. Yep. Two needles coming back, Emily. Do you know why we ask you to cut the monofilament suture longer and the silk suture shorter? Exactly. It's not to just torture you with random lengths. Silk has a higher coefficient of friction, braided sutures, so you only need to put three throws and it will hold. It's not gonna unravel. We throw more knots in a monofilament suture because it has a lower coefficient of friction. It's slippery. So we try to cut that a little longer. Silks. All right, so now we're gonna complete the two layer handsewn anastomosis with our final layer of 3-0 silk Lembert sutures. So we placed interrupted. So we've done the inner layer with PDS. We're gonna do the outer layers with silk. I'm gonna tie them after Zhi lays them in just for efficiency. Needle down. Probably two more. Yeah. Last one. Needle down. All right, these are gonna be short now. Great, now we're gonna close our trap. Let's just do this with interrupted 3-0 silks. All right, now this is the key here. Don't hit any vessels. This is peritoneum to peritoneum. I see it. This is to prevent an internal hernia here at the jejunojejunostomy. I'll take the scissors, yeah. It's hard to see I think, for you. Nice here. Needle down. Tie it, yeah. I'll take the next one. Needle back. Now, let's see, can we do another one or? One more. Yeah, one more to me. It's such a big mesentery. Oh yeah, thank you. That's good. Yeah. Wide open. Nice and patent, yes. All right, we can get rid of these.

CHAPTER 13

Okay, now to the esophagojejunostomy. Let's get our Roux limb where we want it. So we first make sure there's no twist. So you always wanna orient it. The staple line to the patient's left. Just buzz this, Zhi, a little bleeder here, maybe. This is coming off anyway. So very important, again, not to twist your Roux limb. Where the heck is our opening? There it is, okay. So, again, mesentery. Not twisted. Bring it up retrocolic. Beautiful. Okay, moist lap. I gotta get all this outta here again. Switch out to a malleable. Could we have a little more reverse Trendelenburg? Yeah, that's, that's good. Is this the one you were using before that you wanted? Yeah, yeah. Can I have like a cannoli? You know what I mean, the rolled up... Like a rolled up, yep. Wet? Wet, yep. Of a lap or a sponge? A lap. Could I have a right angle, Emily? I'm gonna open up the - a long one. Yeah. Zhi, let's just open up the diaphragmatic hiatus here a little bit. DeBakey. This is a nice thing to do if you need more exposure in the mediastinum, you can split the diaphragm. Just remember to close it. I was gonna ask if you needed to close it later. So they don't get a hernia. And be careful of the phrenic vein. Another long Allis. Is this on tension or is it okay? Hold this guy too, Zhi. Can I have the anvil with a little lube. Do you need more than that? That's good. Can I have a long Schnidt? Oftentimes I can just pop that in free hand, but it's a little bit deep. Okay. Take these guys off. Now let's get these guys outta here, Zhi, before you tie. Can I have a Metz, long Metz? And can I have a malleable, narrow ribbon malleable? Yep. Can I get a snap? Okay. Ready? Tight, tight, tight. The second this can come, slide it down. Okay. It's tight. Okay. We're gonna snap this when you're done. Question is, do we need a second purse string? I don't know, do you wanna put it? Let's see what it looks like. Go ahead and snap that guy. It looks okay to me. Long DeBakey. Can I have that long Schnidt? I wanna get some of this tissue here. Let go of the purse string. But hold back, don't twist it. Can I have a right angle? Bovie. I'm just getting a little more of the soft tissues here, to free up the esophagus. Gotta be careful about gilding the lily too much because the enemy of good - is bad. Not too bad. This is probably the vagus and you can just mobilize that a touch. Okay. Yeah, hold that. DeBakey. Cautery. Make sure we're hemostatic. I wonder if it wouldn't hurt to just run another - 3-0 PDS. Zhi, what if you ran like another one that's just… Like way, way down there, right? Yep, rider, on the rider. Yeah, so what you're gonna do, you don't have to get the actual wall, just get this stuff to tighten it up around the post. Long DeBakey. And these tissues right here. Exactly. We're just gonna run it right around. Snap. Great. Yeah, it's better. Snugs it up a little bit so that you know, last thing you want is to have any of the wall of the esophagus escape the circular staple anastomosis, then you have a leak, so having a nice two layer purse string. Oh, frozen. It's remarkable. We beat them. We beat them.

Great, thanks. Great, and you don't see any gastric mucosa at either side? I'm sorry could you repeat that, I can't hear you. No gastric mucosa… Great, thank you so much. Okay, thank you. Want me to cut this? No, let's, I like to save it. When we do the anastomosis, it'll break. Got it. Okay, so now we gotta retrieve our Roux limb. Again, I always perseverate about this, but no twists. Beautiful, okay, so what's gonna happen is we're gonna take a few of the arcades here, right angle, because this is the end we're gonna lop off. It's easier to do this now than later. We're gonna need one more 60 tan load. So we're taking the mesentery here to the distal Roux limb because we're gonna excise this at the very end of the procedure, after we've done our EEA. we're gonna use this open end. Okay, tooth forceps. Long? No, it's okay, short's good. So we excised the staple line from the Roux limb. 60 tan? 60 tan, yeah. Okay, we need the EEA stapler with lube. So I think the key is here, you want it, because you wanna be able to see the green line, you want to put it in in this orientation. So you can see the green here when that shows after you twist it. So can I have one more forceps? Great. Okay now, I'm gonna control the bowel, you control the stapler. So we're gonna decide here where I want this to come out. We need enough room to cut off this end. We want it obviously antimesenteric. Okay. Spike out. Spiking out. All right. All the way out. I'll take this off. Okay. Go ahead and there you go, you're locked. Before we do anything, let's get our big malleable in. So can I have a, oh, here it is, I left it there for that reason. Yeah, you gotta get all the… There's a lab pad back there that was helping us. You know what, we can use that. That was our cannoli. We don't want any of this tissues stuck in our mosis. Okay, can I have the narrow ribbon malleable? Suction. All right. No. Okay. Ready? Yep. Start closing. I'm in the green. Great. All right, so now you're gonna, let's just take a quick look. We're okay here with nothing extraneous included. Okay, nice. All right, so you're gonna take the safety off, crunch, hold it for a good 15 or 20 seconds, and… Safety's off. I'm crunching. Holding. That broke, that's good. Now we're gonna need some long Allis clamps. So this stapler's creating two concentric rows of titanium staples delivered between the Roux limb and the esophagus, and then it cuts the tissue. All right, Zhi. There we go. Moment of truth. Opening. Opening. This is two full turns. That's... Half, one. That's one half. Great. There we go. All right, now you're gonna wiggle that out. I'll take these guys, and we're gonna make sure we have two complete donuts and then we're gonna send only the esophageal donut. Maybe call it the final esophageal margin. This is the jejunal donut. That's fine. And then you can see that's a perfect circle there on the esophageal donut. That's important. Just going to drop the whole thing in the specimen jar. These are always impossible to get off. I send that as a final - that's dirty, that's garbage. I send that as a final margin because on the off chance they were wrong on the frozen, and there's a few, you know, gastric cells on my esophageal margin, I've got yet another centimeter or so there, so…

CHAPTER 14

I'll take the endo GIA. And so now we excise this end of our Roux limb with a linear stapler and we're done. You want me to call that final esophageal margin? Yep. Final esophageal margin. Permanent. So what we're gonna do here, Zhi. Try to cheat up against the hiatus. Cheat up a little bit, yeah. Something like… Well not that much. Can you get in further? I don't want to be that close to the hiatus. I don't like that either. Come off. How about… Coming across. Come in from the feet, yep. Can I have it? Yep. You hold this. I want you to pull it out to that side, yeah. I can see that staple line right there? But flatten out the good - yeah. Bootamous. Okay.

CHAPTER 15

Can I have you advance the NG tube? Let's feel him first. Go ahead and just slowly advance. We're probably gonna have you go to around 55 or so. Pull back. Pull back. Okay, advance. Great. That's great. What are you at there? We're at 52. Okay. You can leave it there Jeff, and secure it. Securing. First a squirt. Yep. We'll be closing in about 10 or 15 minutes. DeBakey. Is there something there, or...? It's oozing. Well… We might want a little Lembert there just to be happy. 3-0 silk on the rider. Yeah, long 3-0 silk on a rider. At like one o'clock, just put a little 3-0 silk Lembert. In that corner there? Where that little bit of blood is. You want me to go across the anastomosis? Yeah, yeah, so grab a bite of the Roux limb and then a little bite of esophagus. Oh, I should have asked for a 4-0. Needle's huge. Yeah, it's okay. Too late. Okay, we need some more long 3-0 silk, so now you're gonna approximate this to the…

CHAPTER 16

Actually you know what, first give us a long 2-0 silk. You gotta close that defect in the diaphragm, so they don't get a paraesophageal hernia. Figure of eight might do it. I would just, I don't, because there's no tension here or anything, I just… I don't know that we addressed that issue. Yeah, I guess we did. Okay. And you're gonna get the muscle too. Might need one more. Needle down. I think we'll need one more. Yeah, one more 2-0. Silk. Suction. Would you like suction? Yep. I wonder if a simple would do it. What do you think? Yeah, I can tie it. Yeah, I don't want it too tight, you know? Scissors. So let's just make sure that's not too - good and I can get a finger in there. So that's, that should be fine. Okay, now you wanna put a few 3-0 silks, long 3-0 silks, and then this is just, you know, Roux limb to here, you know. Tack it up to relieve tension. Tack it up. Yeah, thank you. Needle down. Another stitch. How many more of the 3-0's do you need? This is the last one. Just one here. Needle down. So next, we'll - we need some warm irrigation and we'll change our gloves.

And then we'll need loop PDS and then 3-0 Vicryls, 4-0 Monocryl for the skin. You can put it on here. Do you wanna change your gloves? Yes. Yep. You have my gloves there? Sweat. Okay, 3-0 silk pop.

So, important to close this trap, Angita, because you can get an internal hernia if you don't. So you just reapproximate the transverse mesocolon to the Roux limb. Needle down. Stitch. You can cut that guy. Maybe one more. The limits of that needle holder. One more. Why not?

All right, let's just look at our duodenal stump. Looks nice. Sometimes I'll tack a little fat over it. 3-0 silk. I don't usually oversew the staple line, just because you end up causing sometimes, more trouble than it's worth, but I think… Another stitch. DeBakey. Lovely. All right, I think we're ready to leave. All right. The liver's a little beaten up by the retractor, but once it drinks, it'll be fine. It's okay to level? Yeah, thank you, Jeff. We'll take the loop PDS and a Richardson. Oh, he'll take the stitch, I'll take the rich. Okay. I think you're right here, huh? Yep. Stay right here. I have done these without leaving an NG tube. You know? Really? Well, yeah, a few times. I mean, honestly, there's good data to say that NG tubes may be even more harmful than helpful, but… Do you wanna leave it in this one? You know, sometimes - old practices are hard to change, you know, because it feels like a more careful approach, but… I thought we leave it in for five days, and… Yeah, I don't do it that long. The most I would leave it is three, and honestly, well today's Friday. I mean, if they did a swallow on Sunday, you could even do it then, you know? Okay. These are pretty low risk cases because they're usually well-nourished, they haven't had chemotherapy or radiation, they don't have cancer. So, you don't have to be quite as, I think, cautious as with some of the other patients who are at higher risk, you know? Do you want to get the posterior sheath as well, or just the anterior? Both, yeah. Any questions? Yeah, it's just preference. I think it lays a little nicer instead of trying to bring it over a big fatty omentum and transverse colon. But that being said, you know, in terms of functional outcome, antecolic is just as good as retrocolic, and in fact, when they do gastric bypasses, they usually bring it up antecolic. So, but sometimes they end up having to divide the omentum, and then in this case you're - I don't want to dig out her omentum from her pelvis. They might have used it as a pedicle flap for her proctectomy, and you know, then you're getting into sometimes more than you wanna deal with. Everything - oh great, thank you. Everything good up there, Jeff? Yep. Great. Epidural's working, I heard? Oh yeah. Great. She has thick fascia. Yeah. You wanna, that's all right. We could put a malleable if you need it. Good exposure to the fascia. Maybe one more, and I'll run one from the bottom. Can I have another stitch and maybe the wide malleable? It's all the way down here. Come a little more superficial. It must be at her belly button, huh? Scarred from her prior… Oh. Nothing in there. Great. The fascia seems easier down here. That should do it, huh? Yeah. Let's see where we are. Needle's back. Thank you. We're just counting over here. Okay. This one you want to cut a good centimeter. And then we'll take a little irrigation. Just a squirt is fine. Okay. Are you doing staples or...? No, subcuticular. All right, thanks Zhi. Thanks Dr. Mullen, this was great. Good job. It went very well.

CHAPTER 17

Operation's over. Everything went very well, as we planned it to go. I didn't do it in exactly the order that I outlined at the outset, and that's common. Sometimes, when I do these operations, if I'm making progress in one direction, I don't adhere to necessarily a very strict cycle. So here we tended to do a little bit more of the dissection on the right and took the gastroepiploic arcade early, divided the duodenum early. That actually gave me a little more room, to see actually, when I was trying to take the short gastric vessels. She's a little bit of a bigger lady, and so exposure is a little more challenging. Making nice progress there, I just kept going. You know, the rest of the case really proceeded as expected. She didn't have any unusual anatomy. We didn't really run into too many troubles. Her Roux limb easily reached her esophagus. We were able to do everything as we anticipated in stapled fashion. And so I was very pleased with how it went.