Robot-assisted Laparoscopic Biliopancreatic Diversion with Duodenal Switch

Ranjan Sudan

Indications/Contraindications

The biliopancreatic diversion with duodenal switch (BPD/DS) has more weight loss, but it is technically complex and has more malabsorptive side effects than the other bariatric operations. The first BPD/DS was performed by Hess in 1988 and is a modification of the original biliopancreatic diversion (BPD) described by Scopinaro. In the BPD/DS, a sleeve gastrectomy is performed and the pylorus is preserved. This modification is associated with reduced dumping, marginal ulcerations, diarrhea, and protein malnutrition compared to the Scopinaro operation. The first laparoscopic BPD/DS in humans was described in 2000, and the same year the first robot-assisted procedure was performed. While any patient with morbid obesity with a body mass index (BMI) of more than 40 kg/m² or more than 35 kg/m² with comorbid medical conditions may be a candidate for a BPD/DS, those with severe diabetes, severe hypercholesterolemia, or higher BMI may benefit more with the BPD/DS than other bariatric operations. It is also a good option for revisions from a previous failed restrictive operation such as a laparoscopic adjustable gastric band, a sleeve gastrectomy, or a vertical banded gastroplasty. Compliance with diet and micronutrient intake as well as lifestyle modification, and regular follow-up to monitor for vitamin deficiencies, will give the best results. Contraindications for a BPD/DS are those for any bariatric operation such as unacceptable anesthetic risk or unresolved psychological issues, but more specifically those medical conditions in which a malabsorptive procedure is contraindicated such as Crohn’s disease or end-stage liver disease.

Preoperative Planning

Detailed clinical history and physical examination helps detect co-existing medical problems and guides further investigations such as cardiac echography, sleep apnea studies, and pulmonary evaluations. Suitable medical consultations are obtained on the
basis of individual assessment of the patient to optimize their health prior to surgery. Routine laboratory investigations include a comprehensive metabolic panel, hemogram, thyroid tests, HbA1c, lipid profile, and vitamin levels. Electrocardiograms and chest radiographs are also obtained. Nutritional deficiencies are easier to correct in patients prior to their undergoing a malabsorptive operation. Patients are also asked to update their screening mammograms, Papanicolaou’s smears, and colonoscopy, as indicated for cancer screening.

In addition, all patients undergo psychological and nutritional evaluations to assess their understanding of the lifestyle changes that are necessary for the success of a bariatric operation, ability to comply with medical instructions, rule out untreated psychiatric disorders or addictions and maladaptive eating behaviors.

Surgical Technique

Pertinent Anatomy

In order to perform the sleeve gastrectomy and the duodenal switch, it is necessary to recognize the location of the pylorus and the gastroduodenal artery. The pylorus is thicker, has a slightly more pale appearance and is identified by the overlying vein of Mayo. The gastroduodenal artery lies posterior to the first part of the duodenum and provides a useful landmark where the first part of the duodenum is transected.

Identifying the incisure is important to avoid narrowing the stomach tube when performing the sleeve gastrectomy. The lesser sac is entered across from the incisure near the greater curvature of the stomach. By keeping the dissection close to the stomach, the gastroepiploic vessels are preserved, avoiding excessive bleeding. The gastrosplenic ligament is also thin in this location, facilitating division with an ultrasonic dissector. To prevent a delayed perforation of the stomach, transmission of thermal energy near the gastroesophageal junction is avoided when dividing the proximal short gastric vessels.

The ileocecal valve is an important landmark because the bowel is measured and marked from it in order to create the distal anastomosis.

Positioning

The patient is placed supine with the right arm by the patient’s side. The left arm is placed on an arm board and can be extended to provide the operating surgeon with standing room by the patient’s side, and the anesthesiologist sufficient access for intravenous lines and other monitoring devices, as needed. The extremities are suitably padded and protected to prevent pressure sores or a neuropathy. A Foley catheter is placed, but it is not necessary to place routine arterial catheters. The endotracheal tube is positioned with a low profile, ensuring an adequate distance between the operating table and the anesthetic cart, to allow the robot to be brought in over the patient’s right shoulder. A thermal blanket is used on the lower body so that it does not interfere with the operation.

There are three phases of the operation, and the operating team changes its position in relationship to the patient in each phase. At the beginning of the operation, the team stands near the head of the patient and face toward the patient’s feet. The surgeon is to the patient’s left, the camera operator is in the middle, and the assistant is to the right. During this phase, the distal ileoileal anastomosis is performed, and an appendectomy is optional.

In the second phase of the operation, the team moves to the patient’s side and face toward the patient’s head. The camera operator and surgeon are on the patient’s left while the assistant is on the patient’s right. During this phase of the operation, the sleeve gastrectomy, division of the duodenum, and placement of the alimentary limb in a retrocolic position is completed. Many surgeons will also elect to perform a cholecystectomy in this phase.

In the last phase, the operating surgeon moves to the robotic console from where the robotic arms and the camera are controlled, and the assistant moves to the patient’s left side.

Technique

Only gold members can continue reading. Log In or Register to continue