Chapters Transcript Live Robotic Gastric Bypass Surgery Gary Korus, MD performs a Robotic Gastric Bypass Surgery, live from Penn Presbyterian Medical Center. So in this operation were actually ate a small pouch out of the part of the stomach. And then we're gonna bypass part of the small intestine to help give her the tools to help her lose weight. So I think we are gonna have to take that stuff down just so we have the harmonic scalpel. Yeah. So this instrument that we're gonna use, this is a harmonic scalpel. The tip of this vibrates at five. But I think it's about 5000 times a second. And we're freeing this up because we're gonna need to flip this tissue up. Don't know if you had heard me say earlier, but this is scar tissue probably from her C. Section. So the energy from this creates heat and it seals the vessels. Okay, so this fat is called the momentum. It's kind of an apron of fat. This is part of the colon, the large bowel, large intestine and Nate's gonna tell us how we're gonna find at this point that we're looking for this transition, you know, anatomically it should be going up. What? So this is transmits musical and so Jason you let go and grab this. Is she flat? Yeah, so it's where we go from the retro peritoneal duo to the intra peritoneal to june. Um so this is small bowel that we're holding here and you see how it's fixed there. So that's a ligament of rights and we'll look at a second. Sometimes you can see the interim esoteric vein next to it. But I'm going to put this on the holder for a second. So here you can see this mobile peristalsis even though she's under anesthesia and we're touching it moving it you know it's okay. So let me try. It says here and if we look on this side sometimes you can see the infirm esoteric vein kind of. We saw it better in the case last week. But anyway so we're gonna march down. So here the medicine terry the military is the tissue that carries the blood vessels up to the intestine. This is pretty short so we wouldn't be able to bring this up to the pouch. So Usually go down about 60 cm. So I figure about 10 20 30 40 50 60 60 10 Please. So now we're gonna divide the bowel here so we can start to do our the bypass segment. So this device we're gonna put in is gonna seal the bowel on either side and cut in between Yeah loaded loaded. We got it. Okay. Okay thanks. So the first the first version of this device were the first gi staplers were developed Jason. They were developed in the soviet union and they weren't automatic or pre loaded. They had to put in each staple individually and then reload it. So here we want to make sure that this shaft of this is perpendicular to this. Uh this is you see product placement. So for the libyan. Yeah exactly. So here and then we'll look at the back side just to make sure we're not skiving and that looks pretty good. You can have a Maryland ready please. Yeah have a clip, clip. Hey my clip. Hey my clip. Thank you. That's hard. Hi sean. Yeah. Yeah. So usually if there's one side there's another. Yeah. Okay can I have a debating? So now we're gonna measure that. I did measure kind of hand over hand. That area is a little less critical this one I actually measure out and basically I use a ruler. I have the local paper just hold it sideways facing me. Great. Okay police. Okay umbilical dips in the belly. This is 75 cm long And I'm going to do 150 centim limbs. It'll be too length of this And years ago they used to make these much longer like double, even triple and they were much more malabsorption. I've but people got a lot sicker. They were much more dehydrated. The original illegal bypass mate. About a third of those people did. Well a third actually had the operations reversed. A third developed cirrhosis because of the bio salt absorption, the disruption of that. So Nate here is one of our medical students working with Jason also. He's one of our residents. Yeah say Yeah Nate. What are those white lines on, the small bowel tv no. See these lines here, those white lines, what do you think? Okay Jason. What do you think? What's that? So No it's actually they're like deals lymphatic ECs so it makes you wonder what you had for dinner last night. Yeah. Mhm. Actually, we have them for the last two weeks before surgery. They're actually a very low calorie diet. Like 1000 calorie a day diet. There's some evidence that that depletes glycogen stores in the liver and may actually shrink the liver. So it makes the liver more pliable easier for us to move and move out of the way. You'll see when we work up top. Now that sometimes a large liver can be a problem. So that's 75. Okay, so this thing, this white thing I'm moving is called an umbilical tape years ago. They used to use it to tie off the umbilical cord. That's why I'm assuming that's why it's called a little better now. They use clips at least. That's what I remember. Okay. Okay, so that's 1:50. Just gonna bring a little bit more up to. So it's not under any tension. So yeah, that Uh huh. Yeah. Yeah, a local takes out, I'll take a stitch. So now we're going to line this up and then make our connection, try and avoid those vessels. And yeah, so some people in describing what this is like they have heard people say it's like tying your shoelaces with chopsticks. Okay. But it's just like any skill we can teach, they taught me how to do it. So you can teach a monkey to do it? Right. This seat actually will dissolve over time and go away. But it's there long enough to hold things in place. Yeah. And you'll see when we make the connection, we use this same kind of future that will go away and again the baking that it's there long enough to hold the tissue so that the tissue can heal and seal. Yeah. I'm never going to line up. So you're right. Uh huh. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Ah Yeah. Yeah. And yeah. Okay. Thanks. Yeah. Yeah, Yeah. Yeah. Yeah. Thanks. Yeah. Yeah. Yeah. Mm. Yeah. Yes. Yeah. Same period. Yeah. Yeah. You're an entrepreneur. Yeah. Okay. That stuff, yeah. Yeah. Yeah. Yeah. Mhm. Yeah. Yeah. Yeah. Okay. Yeah. Yeah. Okay, lets just hear that's lining about. Yeah. Yeah. That mhm Yeah. Okay. Yeah. Mhm. Yeah. Yeah. Yeah. Yes. Yeah. Mhm Yeah. Little fuzzy picture. We're going to readdress the camera in just a moment. Mhm. Yeah. Yeah. Yeah. Okay. Yeah. Yeah. Yeah. Yeah. Yeah. Is it? Yeah. So we're gonna leave this future a little bit long because we're going to use it as a handle in a moment. Yeah. Okay. Yeah. Mhm. Yeah. Okay, needle back. Okay. So now the food and beverage person is going to eat later on is going to come down this way and some of the secretions and enzymes that help with digestion come down this way. So we have to create a connection that allows those juices to meet the stuff that's coming down harmonic And to take a 62 5 uh sorry, no, 10, 60 10, we don't have to burn fives anymore. So now we're going to open the bow here. So this is why this case is classified as a clean contaminated case because we're actually gonna open the bowel and later on we'll open the stomach also. I like it profession. Uh huh Yeah, mm Yeah. All right. Yeah, that's perfect. Mhm All right. Yeah, yeah, yeah mhm mhm And there, yeah, yeah mhm Right. Yeah, mhm What's that Maryland? Mhm She left this world? Yeah, because there, so that's into the bowel here and this is into the battle here. Okay, stapler. Okay, 60 10, Yeah, so this is the same stapler, the same type of state where we used earlier, we're gonna use this to connect these two. This is where I use this sutra as a handle. Okay, square peg round hole. Uh huh there. Great. Yeah, hope yeah, angles a little funny, but okay, yeah, yeah, when we use this future again as that handles, I said to kind of pull this on kind of match it up and then we'll close it. I'm gonna see if we can get them a little closer together, right? Yeah, okay, and then we'll look at the back here. Yes, thank you. Yes, that looks good. Gonna take a 9" vertical on the short, right needle driver. So this has now stapled and cut just like it did before, but now because we're in the belt it's actually formed a communication between the two. So the first thing they do is make sure it's not bleeding. We look inside it looks good. So the secretions will come down this way. It'll go across this opening that we created in food and beverage is going to come down this way. So now we have to close this hole. Snitch nine inch michael. Yeah. Yeah. So again this is the same kind of future that we're using earlier. This is the stuff that will absorb and go away but it's going to be there long enough to hold the tissue together so it can heal and seal gauge Nate. When will this be watertight? When will it be watertight? Yeah. Hopefully right away. Right. Because otherwise it'll leak. Yeah. He takes yeah. Okay. Got to try to with. Okay. Right. Yeah I put it exactly. Four. Okay so now we're going to try and roll the mucosa in here. And because this bowel is similar thickness usually we can just close it in one layer. Sometimes if there's a mismatch we would do it in two layers like with the pouch. Mhm. And again this is laparoscopic. So this is still two dimensional site enough. They've seen any robotic so robotic surgery, the camera, The scope that's in the patient actually has two cameras And each camera presents an image to one eye. So it's not true three D. But it gives you a stereoscopic view. This is like watching tv still two dimensional, you kinda have to rely on shadows and reflections and how deep your other hand is to actually gauge depth. Yeah. Yeah. Just trying to don't classify share. There we go and say that's kind of dunking the mucosa. And here you can kind of hold this up to see what it looks like disposal. So we're gonna carry this to the end and then we'll tie it to that original stitch that we used as a stage stitch kind of as a post. Yeah, it looks pretty good. And now we're going to tie it out to one of these tales. Yeah. And then we'll look at the back of this. Sometimes there's a little gap in the staple line that we need to over. So so is there in a sec standing true scissor? Okay to go back got it. Okay. The baking micro line. Look at the back side of this now, it looks okay. I'm gonna put a stitch there. I think that's fine. That may just be a little bit of where I made up my entire economy. We're open about. You have an eight inch Michael or nine inch. So just put one stitch there just reinforced. But the rest of that line looks fine. Right? And take the scissors in a second. Uh huh scissor middle best. Bacon micro line. Right? Yeah. So that's that Now we've created a space here when we divided that bowel way back at the beginning? So this is where you can get an internal hernia, can get bowel that sneaks in here and gets twisted and turned um and can cause a bowel obstruction. So we're going to close this and we close this with permanent future. Because if we use the absorbable away this would fall apart. And the reason is that we're not cutting this, we're like sewing together tissue. It's not irritated or inflamed. It's like if you pinch your cheek. I may have said this to you before and hold it for a week and let go. It should still open up. Unless you've been so hard enough that You've traumatized the tissue. Gonna take a 9" tight ground on the short right needle driver. What's something that might happen if the wrong part of the stomach were cut during this procedure? Is that something that can be kind of corrected in the moment or might that require more surgeries? Different procedures. So tell us about the anatomy. So if we you know the were always very uh it's not just surgeons. I mean I don't know if you've ever heard the phrase of a carpenter measure twice cut once. Uh huh. So atomic landmarks. We do a series of checks um to make sure that we are sizing things as appropriately? The human body though is incredibly forgiving. And you you can fix a lot of things. Are there any sort of common complications that happen with this procedure? So this operation, One of, one of the common, more common complications would be when we make a connection if it leaks. We talked about things being watertight, but things can't leak. The risk of a leak is pretty small. It's usually not at this level, it's usually kind of higher up on the stomach, But it's less than 1%. Um, and recognizing it is important. Ah there are other complications that aren't necessarily related to the surgery but a long term and can be related to nutrition and that's why again, the preparation for this is so important to make sure that people are taking the right vitamins and supplements because you're most people may not be eating the same variety of foods, although once you've recovered you can eat really just about anything you may not want to. But certain vitamins also this alters the way certain vitamins are absorbed and processed. So it does mean making a commitment to taking those and some of those deficiencies can occur weeks and months and years down the road also because as I said earlier, just to kind of make the point that obesity is a disease, there are behavioral aspects of it that play a role. Also depression is very common in our patients. And a lot of times we, it's hard to kind of sort out if people are depressed because of their medical problems in their weight or vice versa. But it's one of the reasons why kind of paying it to those aspects of their care after. So it's also very important. Years ago, people did these operations, much like other operations. We do fix a hernia, take out somebody's gallbladder, you'd have surgery, see your doctor once or twice after surgery and then be sent on your way. And when these operations were done that way without the follow up people lost some weight, a lot of people gained it back and really had problems. Now this it really is taking care of these people long term in addition to the preparation surgery and the outcomes have been much better. Mhm. Long answer to the question, Sorry about how often do you perform this type of a surgery is pretty common. Six Bariatric surgeons. I think there are eight of us group. We do about 900 a year. I'd do about a I think I did about 140 last year. This is one of the operations. This is uh this used to be the most common operation. The one we're doing now, the most common now is one called a sleeve gastrectomy. That's actually the next case. We're doing scissors. So this is the end, it's going to come up to our pouch. Jason's gonna let go of that. Okay, this is Colin So we're going to divide this apron of fat just so that it's if you don't have to grab over here, if you would. Okay, and as you can you can take the harmonic with. Yes. Can you use your left hand a question about some of the blood we saw a minute ago. So is that sort of like harmless or would that become plotted potentially if it wasn't section? So so far the amount that we lost kind of on the skin at the beginning is probably more than what's there. Um I don't want to I mean, typically the blood loss for these operations is about A teaspoon or two usually. And that amount of blood is not worrisome. If it were larger, it can irritate the abdominal cavity. It was larger amount. It could potentially get infected. But that'll be that'll go away and be absorbed. Resort. Obed pretty quickly. So we grab Jason a little higher. And what do we see right now, is this sort of like a misting like? Yeah. So that is actually because this instrument generates heat, it's kind of the condensation, condensation or the vaporization because these tissues are high in water content. So that's what it's sitting. Just get both. That on my side. Okay, okay, So this instrument can seal blood vessels. I think that are up to like eight across, gives you an idea of scale a sort of more general question. How do you deal with stress on the job? And you have like a a routine that you do before every surgery to kind of prepare yourself. It is a there's there can be a lot of stress. People raise your hand up so we're off about. There you go like that that creates stress. Okay we're done. So there's stress in really everything that we do to some extent. You can release that right? Um Can we put the Thompson on the side rail on the opposite side? So there's stress really whatever you choose to do. I think that the way that you handle stress and deal with it is very individual. I have you know I ride a bike. I run I tend not to raise my voice too much so hopefully that's not one way that I release it but it's important to have ways to deal with that. Okay okay on the other side so we're putting in a clamp now on the bed that's gonna hold a retractor that's gonna help us hold the liver out of the way with it. I put it on, I put on the side road don't who's a yeah so that's and you can see how it is kind of hanging down. So we're gonna put in a retractor now to hold it out of the way, grab the camera through it local. But this is a lot of fun. I mean getting to do stuff like this and see how people do afterwards. It's pretty neat. Nice please. Nice. Can take it five next. Yeah. I have a patient actually that we saw, I want to say about two or 3 weeks ago. Um He is uh Running a 5K. In every state after losing weight. Whatever he's up to like 13. Yeah, I'll take we'll try the short short Nathanson. Yeah, so this is the peritoneum, so it's the lining of the abdominal cavity and between the skin and this. There are muscles as well. So this is the liver. Her liver actually looks pretty good. Um I'm going to have your openness on the side close. So what I mean by that is the edge of it is pretty sharp. A little bit of a rounded edge. It's a little thick uh It's a little bit enlarged by size, but the texture of it in the color of it is pretty healthy looking. Some people have a lot of fatty changes in the liver that can actually lead to liver failure and losing weight. Can help with that. Micro enemy Carlos in Carlos. I'm gonna have you take your dog out actually pull it back a little bit first. So this is the stomach that I'm holding now a little bit more good. Stop put on section for a minute. Get anything else. Okay section and take it out completely. Let me know when you're out. Okay? I'm gonna have you put the size and for now uh it's in the bag on your back table, you can loop the balloon and it goes in the mouth. Let me know when you're past the oral pharynx. So we're just gonna watch as okay. Who from this mouth through the esophagus and that tube actually balloon on the end of it that we're going to inflate and that's gonna tell us the sock going to create. So the question about earlier about the right part of the stomach by having a tube in that's going to help guide us. So the location the part of the stomach and also the size of it. Hey up there to the tube is coming down through the patient's throat into the stomach mouth esophagus and the stomach little bit further little further little further. That's fine. And from is this type of the procedure always done laparoscopically now or can you do it without the cameras and everything sort of externally? Yeah you can do it open. So that's the gallbladder here that I'm that's a normal looking gallbladder. Um yeah. In our program about 98% of these cases are done with small incisions. So by doing it with small incisions there's number one less pain, keep going, keep going, keep going, keep going, keep going, keep going, stop. Lower the whole bed. So there is less pain that's good stop. And because the incisions are smaller there's people tend to breathe better afterwards if you have a big incision on your abdomen. You tend not to take good deep breaths and there's a higher chance of getting pneumonia and things like that because the incisions are small there's also a smaller risk of having a action and a smaller risk of developing a hernia microphone. Grasshopper to Jason. So there are a lot of benefits. And actually the visualization for the surgeon and the team is actually probably better laparoscopically with the cameras. Then if we're doing it open open it's a lot further away from you. Thank you. Yeah, pull back straight back. What is the recovery process usually look like and how long until the patient is sort of like up and moving around fairly. Normally patients we have a protocol you put in place a little over a year ago. It's comin we're gonna develop it. But we've adopted it. These patients will be up walking four hours after they leave the recovery room. They'll be started on actually sips drinking water four hours afterwards. They'll be drinking liquids tomorrow morning. This uh this one's not loaded right? It's not open all the way can have another one. Um They'll leave that most patients to leave the hospital tomorrow liquid diet and on a full liquid diet for a couple. Then pureed foods for a couple of weeks. Soft foods and then regular sits about two months until they're eating regular consistency food but we really expect them to start burning calories, exercising really starting tomorrow. Walking By the time we see them back in the office in about 10 days to two weeks. And at that point, most people are walking an hour a day. Okay. So what I'm going to do is kind of bring this behind you and then that you kind of hold down on it. Okay. Hold on, hold on, no, no, no. Keep keep that, but just lower your hand and then you'll trap this beneath you there. Let's get a better bite up here. Some pull back and down. Sure, that's good Hickman with camera. There you go. Good harmonic or than others. Is there sort of a time limit where if the surgery is longer than X amount of hours you need to have like rotating folks coming in and out a for the surgeon. Now, it's not when, you know, one might think like the airline, you know, you've got so many hours of flight time before you have to, Sorry, I'm just here. eight. That's the angle of his right there. Okay. Okay, back up the camera. Yeah, you're sick 20 CC and connected to the end with the stop cock. So if you look on the screen, this is the balloon on the end of the cat. Okay. Now I'm gonna have what to back slowly and gently until you meet resistance. Little bit of Yeah, so that's basically gonna be the size of a new stomach right now, this is all stomach here and we're going to decrease the size of stuff. Yeah. That also helps. All right. Yeah. It's going to repossess it. Okay, This is here. All right. What's that? So here, I'm trying to find the wall of the stomach and then to get behind it. So because we need to be on front by an order, it's going to be a pull back. Keep it under tension. That's good. So again, you want to keep it under tension. It's good. Have the harmonic. Mhm mm. Another grasshopper. So it's an angled scope. So we're gonna do is angle you this way so we can kind of see around, let's go to school around the corner a little bit. Mm hmm. That's like harmonic little branch. Well, let's try and get that. Mhm paul there. Okay. Okay. Going to take a 60. Not sure yet. If you wanna tan or so the color that I'm talking about to do with the stapling device and the height of the staple and we pick that based on how thick the tissue is that we think we're going to be divided? Yeah. Our scholars are going to dismiss from their auditoriums based in a couple of minutes. Is there anything like next steps wise? Now comes the fun part, but you're all going to miss. No, Just kidding. So the next step is to divide this, create a small pouch where that balloon is and then we're going to bring that bit of the small battle that we divided earlier and so it to that and then after we do that, we'll do a leak test with air under fluid, looking for any bubbles and then we'll be done the first one. How much more time will the procedure take early? It's a curse to ask a surgeon that question. Uh huh. Yeah, Probably at least 45 minutes. Created by Related Presenters Gary Korus, FACS, MD Associate Professor of Clinical Surgery
