Laparoscopic Malabsorptive Procedures: Technique of Duodenal Switch

Fig. 1.

Sleeve gastrectomy and beginning of duodenal switch: patient and team’s positioning.

Trocars’ Positioning

The following six abdominal trocars are placed: a 10 mm trocar (T1) 20 cm distal to the xiphoid process for the 30° optical system, a 5 mm trocar (T2) on the left anterior axillary line about 5 cm distal to the costal margin, a 12 mm trocar (T3) on the midclavicular line in the left upper quadrant between the first and second trocars, a 12 mm trocar (T4) on the right midclavicular line in the right upper quadrant, a 5 mm trocar (T5) distal and to the left of the xiphoid process, and a 5 mm trocar (T6) to the left of the midline in the lower abdomen (Fig. 2).

Fig. 2.

Duodenal switch: trocars’ positioning.

Sleeve Gastrectomy

This procedure can be performed using two methods: lateral-to-medial and medial-to-lateral approaches [3]. The patient is placed in the reversed Trendelenburg position.

Lateral-to-Medial Approach

After identification of the crow’s foot, an oblique line is marked on the anterior gastric surface with the coagulating hook, between the end of the gastric vessels both on the lesser and greater curvatures, at the level of the most distal vessels in the direction of the pylorus. The lesser sac is opened through a window made in the greater omentum within the epiploic vessels, 3 cm lateral to the marked line and close to the greater curvature of the stomach. This window is extended in a caudal direction until the marked line first and then cranially to the direction of the left diaphragmatic pillar, to completely dissect the greater omentum off the greater curvature. Coagulating hook, bipolar shears, or harmonic shears can be used. The dissection ends after the left diaphragmatic pillar is reached. All retrogastric adhesions are divided. Two first firings of the linear stapler (green/black load) are introduced through the T4 and divide the greater curvature in the direction of the crow’s foot. The linear stapler is placed with its extremity close to the terminations of the gastric vessels on the lesser curvature. A third firing of the linear stapler (green/black load) is introduced through the T3 and transect the stomach parallel to the lesser curvature. After this last firing of the stapler, the anesthesiologist pushes down an orogastric tube of 36 Fr, in order to guide the gastric transection. The stomach is sectioned from the antrum up to the fundus at the level of the angle of His using other firings of the linear stapler (T3) (gold/purple load) (Fig. 3a). The resected stomach is left in the left upper quadrant and it is extracted in the plastic bag at the end of the procedure through the enlargement of the T3. Different options are available to manage the staple line. The staple line can be left without sutures or without the use of buttressing material; the staple line can be oversewn by two converting running sutures using absorbable material; only some stitches are placed between the terminations of the staple lines; buttressing material is used for firings of the stapler [4].

Fig. 3

Sleeve gastrectomy: (a) lateral-to-medial and (b) medial-to-lateral approaches.

Medial-to-Lateral Approach

After the stomach is marked between the crow’s foot and the pylorus, the lesser sac is opened just enough to allow the introduction of linear stapler through the T4. Two firings of the linear stapler (green/black load) are fired taking the extremity of the stapler close to the terminations of the gastric vessels on the lesser curvature. After sectioning the stomach at the level of the incisura angularis, the anesthesiologist pushes down the 36 Fr orogastric tube to guide the gastric transection in the direction of the angle of His. Further firings of the linear stapler (T3) (gold/purple load) are kept parallel to the lesser curve (Fig. 3b), and all the posterior gastric adhesions are divided. Before the last firing of the stapler, the angle of His is freed from bottom to top and vice versa; the stomach is sectioned placing the stapler lateral to the left pillar and without tension. The greater omentum is dissected from the transected greater curvature of the stomach, using the coagulating hook, bipolar shears, or harmonic shears. The resected stomach and the staple line are managed as described above.

Duodenal Switch

Laparoscopic duodenal switch is a technically difficult procedure, demanding considerable laparoscopic skill, accompanied by the possibility of intraoperative complications and characterized by postoperative morbidity. Superobese (50 < BMI < 60 kg/m²) and super-superobese (BMI > 60 kg/m²) patients are often affected by arterial hypertension, diabetes type II, sleep apnea, degenerative joint, cardiovascular, pulmonary, and metabolic diseases that put them at adversely increased surgical risks. In order to decrease the morbidity and mortality, and the overall risk of perioperative complications, it has been reported [5] to separate this procedure into two steps: sleeve gastrectomy first and biliopancreatic diversion later. In this way, patients submitted to sleeve gastrectomy can achieve a sustained weight loss and reduce the severity of obesity-related comorbidities, and after an interval time between 6 months and 2 years, the procedure of duodenal switch can be performed under safer conditions [6].

Cholecystectomy and Duodenal Section

Cholecystectomy is performed and the specimen is extracted in a plastic bag through the T3 at the end of the procedure.

The duodenum can be sectioned using two methods:

Posterior approach: the antrum is held up and all the retrogastric adhesions from the antrum to the pylorus are divided by the coagulating hook. A passage just anteriorly to the pancreatic head and gastroduodenal artery is created with gentle dissection in the direction of the common bile duct. The superior and inferior edges of the duodenum are freed and a piece of cotton tissue tape is used to encircle the duodenum. The tape facilitates in holding the first duodenum upwards for insertion and firing of the linear stapler (blue/purple load) through the T3 (Fig. 4a). The duodenum is divided.

Fig. 4.

Duodenal section: (a) posterior and (b) anterior approaches.
Anterior approach: after identification of the pylorus, the anterior peritoneal sheet at the superior border of the first duodenum, across from the common bile duct, is dissected by the coagulating hook. A passage between the above first duodenum and the pancreatic head is created under vision. The first duodenum is encircled by a piece of cotton tissue tape. The tape is taken up in order to permit the introduction of the linear stapler (blue/purple load) through the T3, and the duodenum is transected (Fig. 4b). The gastroduodenal artery is usually visible under the first duodenum after this section.