CHAPTER 1

My name is Ozanan Meireles, and I’m a bariatric, minimally invasive and foregut surgeon at the Massachusetts General Hospital. I’m an assistant professor at Harvard Medical School and the case are going to be doing today is a- the most performed bariatric procedure in the world right now, which is laparoscopic sleeve gastrectomy. Actually, the name is laparoscopic partial vertical gastrectomy. We say sleeve because the gastric conduit that's created looks like a sleeve, but we're putting no foreign body on this procedure.

So, the procedure takes about an hour and is performed in a fashion where we separate the stomach from its adjacent ligaments, both freeing up the greater curvature and the fundus, exposing the left crus, identifying the gastroesophageal junction. And then, once that dissection is performed, we’ll be tailoring the gastric conduit to be the same caliber of the esophagus, which some surgeons prefer to use bougies, others prefer to use gastric scopes. On my personal experience, having a gastric conduit that’s the same caliber as the gastroesophageal junction both prevents post-op reflex, dysphagia, and weight regain. I’m anticipating this case is going to be as standard as possible and that's it.

CHAPTER 2

So knife. Xiphoid. Remember, we were talking about the xiphoid the other day? You felt that one- yeah, feel this one here. It shouldn’t- it’s not at the tip of the xiphoid, it’s by- you know, the angle. Yeah, by the confluence, right here. Okay. Incision. Thank you.

Alright, so let's have the- let’s turn the gas on. Already got it. It’s fantastic, okay. Perfect. Would you just stabilize the port for me like this. Thanks. Yeah, so this case is being done in French position actually. That's my preferred way to do foregut surgery because the surgeon’s going to be aiming towards to the- our target is going to be right here on a hiatus. Kick out, split the legs, or French position, but it's just a different way to do advanced foregut laparoscopy.

Hold this for me, please. Knife. Alright, so hold over here. Knife. So then, the fossa form is a little big here, so we going to go... See, right here. So we’re doing a liver biopsy right now. I think. Yeah, you got it. Nice. Lovely.

Knife, please. So the reason I go three time- I don’t think I ever told you, but the muscles here collapse back very easily. Talking about like for example, how I already lost my- that’s it, there you go. So much better. And so you put them on a diet of like? About 2 weeks on a low calorie, high protein... The idea is because the- yeah, so the very first organ to decrease in size when you start losing weight is actually the liver because like- yeah, almost half of the weight of the liver storage is glycogen. Yeah. So let's put patient in reverse T-burg, and room lights off.

CHAPTER 3

So what happen is, as you are suddenly running out of glucose- right, and you need to generate glucose, so that goes through the liver storage first. Likewise, if you're gaining weight, the very first organ to increase in size is the liver.

So this is a standard sleeve gastrectomy patient. We can see the anatomy here. That's the lesser curvature, here. That's the greater curvature, here. And that's where going to be the lines. Going to be the lines on the gastrocolic ligament starting from here, going to go all the way up, where then we’re going to be taking down the gastrosplenic ligament with the short gastric vessels. And then finally, then the angle of His, which is there, to free up the entire stomach. Then we're going to be dissecting, remember- the Belsey’s fat pad to expose the gastroesophageal junction. Of interest, this is the- where is the pylorus, and that’s where the antrum begins, so everything from here over there is the antrum we’re going to try to preserve.

So, we start going contralateral of the incisura angularis. Perfect. Alright, so lift it up a little bit more. So this is omentum, and this is gastrocolic ligament. Let’s see, do you have a good angle there? Do you want the table down a little bit? Can I have the table down, a tad? The other way, the other way- facing the curvature, facing the stomach. Yeah, there you go. Perfect. Is that good, or would you like more? Open wider. That’s good right there. Push it- now open wide and push it in. There you go. So I like this technique to enter the lesser sac, because what we’re doing is we're pulling the gastrocolic ligament up in the stomach, and as we do this, without actually breaching through our cut right here- see this is already open, could potentially go inside, but I prefer to keep going. Push it in. There you go.

So then we do dissection both cranially and caudally, and it saves a lot of time. Of course, you have the luxury of the stomach coming out, so can you go pretty close to the stomach. I’ll feed that for you. Hold closer to the stomach. There you go. Closer. Okay, let’s see if we can go one more. Lift it up in your hand. Left hand. Okay. Active blade facing in. No, no, you have a vessel right- there you go. Take another one. So let me actually regrab, let go. Do me a favor, just- see this thin little red area over here? Just get a tiny little bite of the harmonic there. If I have a good angle or not. Let’s see here. Yep. You got it. Close it. Perfect. Okay, good. So bring it up. So let’s get one more bite, but let’s go away from the stomach. Open wider. Pull away from the stomach as you do this. Okay, that’s fine. So that’s it- just one more bite here, away from the stomach. Close to my instrument. There you go. Now lift it up and away from the stomach as you pull it. Fast. Okay, good. Alright, perfect.

So now, let’s go proximal. Close- see the vessel is about to bleed right there. Okay, good. Nice, okay. Lift it up as you do this. Okay, so what's going to happen is- hold this, and you and I are going to be bringing our target over here, so you can have a better angle for our harmonic. Lift it up. There you go. Okay, so what happened is because- so let’s do this. Let’s move it to the left. There you go. Fast. And the quickest you go through this part and get it to the best angle for the surgery, you stop suffering. Not suffering, struggling.

Yeah, so let’s do this. Yeah. We’re going to reposition the liver retractor if you need it, but you're going to be getting out of this pretty soon. So... Let me see one thing here. So, what’s going to happen is that’s going to be the angle we’re going to be operating, so it looks pretty good for me from here. So if we need to move the structure more over there, we do that, but there's no need to reposition this right now. Fast. If it’s transparent, go fast. Now, slow down. See, it’s getting much better, isn’t it? See, for a laparoscopy, you can never have like a hundred percent perfect port placement for all the steps of the operation, so you just save for the most critical ones.

Get this vessel first. Actually, right there, that’s the take off of the left gastroepiploic. Not the take off, but when it starts you go all the way over here for the gas- cancer operation. That's going to be resected the entire length. Okay, now keep pulling more with the left hand. That’s the angle of His, right there. Actually, the gastrophrenic ligament, which makes the angle of His. I’m going to check in a min- right now. Just keep going, since we’re making progress. Pull more with the left hand. Let me ask you to hold, right here. So let's just open this layer of peritoneum here. Small bite. Fast. Nice. Push it in. You’re going to feel it. There you go, and you’re going to be tractioning with your left hand. There you go. You’ll be tractioning a lot. So hold right here. So lift it up a little bit.

So those are the phrenics right here. Let's be careful. So once you engage your blade, right here between the stomach to the left, lift it up and get all of this in one single bite. No, no. Don't get the phrenics. Push it in. Okay, lift it up. Fast. Nice, good. Careful. Careful. Careful. So let’s get a bite right here. Let me just… Fast. Alright, it’s looking better here, so hold this. Actually, more posteriorly. Hold right here. Hold that 0-G right there. Let’s just make it... If I could- the stomach first. Let go for a second. Okay, so hold this. Pull to the left. Hold right here. Pull more to the left. There we go, so what we’re going to do is kind of focus this on it. There you go. Fast. Nice. Nice, okay. Careful, good. Close the stomach over there. And that part is going to stay, so a little bit away from the stomach. Okay, good.

Bite. Push all the way through, next to my instrument. You can get a better bite, so I want you to push all the way through. I want you to feel the crus, right here. There’s a lymph node right there- grab a bite. No, see what’s bleeding right now? Let’s get a big bite, right there. This is nothing. So our goal is to see the decussation of the crus, here. So what I want you to do is I want you get your blade right here, between what I’m going to be holding, the lymph nodes. Push all the way through. To the right, you are going to be away from the stomach and this part may stay. There you go. Are you okay with that? Yeah. Okay. That’s the crus. So we’re pretty much done. Do you mind if I take the Belsey’s? No. Okay, perfect. Alright.

So what I'm dissecting right now is the- what we call the Belsey’s fat pad. Then expose the gastroesophageal junction, so they're going to show me what’s the gastroesophageal caliber, so I can actually calibrate the sleeve- the gastric conduit. See here. Alright, Julie, this is nothing. Alright, let’s take a look. Alright, so we can see the esophagus. Let me see, you can actually see the phrenoesophageal ligament. Go in with the camera. Camera up. To the left, a little bit. So what I want you to do is grab this fat for me. Okay. Camera up a little bit.

That’s where the phrenics- let go. Okay, it’s right there on the bottom. Okay. See here. Show me the- he’s kind of bleeding a little bit. See there? Can I have a metal clip, please? So if you ever think that a phrenic artery may bleed, you got to do something. Okay- because that’s the first branch of the intra-abdominal aorta, and it’s a lot of pressure right there. It’s kind of- it’s sharing, actually, the supply of the cautery, so we need to take this down. So, keep traction to the right. Hold on, let me just- right here. Pull more. Traction away. Pull, pull. Okay, perfect. So let's see here. Okay, there we go. That’s the phrenoesophageal ligament. So now we see the phrenoesophageal ligament over there. We know this is the esophagus. Let’s take a look on the phrenics, where I put the clips on it. Actually, hold that. That one? Yeah. I was going to transect this, otherwise it becomes fat necrosis. Okay, pull a bit more.

So I think we are ready for stapling. Let’s take a look at the dissection- how far you got. Let’s go all the way down here. Looks pretty good, okay. Alright, so let's drop this scope, yeah? And Julie take a clean Ray-Tec please, and a stapler. Hold this, thank you. Camera up. It looks good over there. Looks good over here, as well. Alright. So the first fire is parallel to the incisura angularis, so that’s why I chose that point.

Okay, Julia, ready for you. Perfect, yeah. Let me see the light. Perfect. Excellent. Alright, you can go ahead and park the scope there, and come back. And then what I’m doing now- I’m aiming my stapling towards to the gastroesophageal junction right there. Nice view here. Julia, can you appreciate the difference on the fibers? And do you remember like when we’re doing the POEM, we talk about the vessels? Those are the vessels we’re seen. Oh, okay. See that? Yeah, it’s awesome. You see the pattern of them, they’re more longitudinal over here- was in the stomach. They changed there. Alright, stapler.

So we’re going to be holding underneath here. You’re going to go underneath here. Stomach’s not as big as- pull this. You’re good, so push it in. You’re going to be pulling it to the right. Flatten your stapler. So get it flat. Okay, you’re pulling, right? So slide your stapler to the left a little bit. Push it in. Slide a little bit to the right- like a millimeter right. Just rotate to the right a little bit. Perfect. Let’s see here, push it in. Start closing, very slowly. Good? No, actually, I want you to- it’s going to be two millimeters to the right. So… Okay? Yeah. Let’s see. Start closing. Yes. Perfect. Alright. Just a second, yep. Beautiful.

Another staple- 6 is fine. See the angle makes a difference here. If you actually had an angle a little bit, what's going to happen is you will be- start getting wider. Push it in. Yeah, I like that. Good, let’s see. Partially close right there. Stop, just for a second. So lower your stapler just a little bit, so I can grab this. Okay, good. Finish closing it. Perfect. You can go faster- the tissue is thinner. So... Wait, wait. There you go. Perfect. Alright. She’s got a smooth grasp right there. Looks beautiful. Hold that. Perfect, okay. Endocatch bag.

So lower that- get it facing us, so I can grab it. Well, you got to make that face us. Alright, start closing it. Slow down a little bit. Alright. Perfect. Alright, let me see the specimen. Kelly. Alright. You’re not going to like this either. Perfect.

CHAPTER 4

Alright, so I'm going to do the endoscopy right now. If you guys can hold the ET tube, please. Alright, so we’re going to start insufflating. I’m pulling back. Antrum. Incisura looks great. Straight tube. Our Z line right here looks good. Perfect.

I’m going to need a few spots here. So pull it away. Bring it towards the camera. Perfect. There you go. One right there. Nice. Keep holding it. One more Julie. Let’s put one right there, in the middle. There you go. Good, and then one right here. Looks good. Looks good. Looks good. Let’s go look in back, here. Let’s just put one adjacent to it. To the red dot, right there. It’s good. Perfect. Alright, good. Alright, we’re done. Perfect, okay. Alright, we’re done with the case. You guys can go ahead and level the patient, please. Sure! 4-O for us, please.

CHAPTER 5

So that was the end of the case. There was a standard partial vertical gastrectomy, which is also called a sleeve gastrectomy. There was no hiatal hernia. There was no adhesions. There were no prior surgeries. So it went as expected. Like, normally those cases take less than an hour like this one. We always do an intraoperative endoscopy to look inside the new lumen, how it looks. It should look straight, the antrum is preserved, no narrowing of the incisura, tube is same caliber as the esophagus, and that's what we go from this case. So it was- couldn’t be more straightforward this one.