This is the post op report, I'm copying and pasting it because it's faster.
Cindy said it's on of the most detailed that she has seen! (Makes me feel a little better because his bedside manner is horrible, but he's a good surgeon)
Operative Report by Dr. J Lau at 08/28/24 1752
Loyola University Medical Center
Robotic Assisted Duodenal Switch with Upper Endoscopy
PREOPERATIVE DIAGNOSIS: Morbid obesity, ICD-10 code E66.01. Obstructive Sleep Apnea
POSTOPERATIVE DIAGNOSIS: Same, ventral hernia
PROCEDURE: Robotic Assisted Duodenal Switch and Upper Endoscopy
DATE: 8/28/2024
ATTENDING SURGEON: James N. Lau, MD
ASSISTANT: Matthew Cheung, MD (Resident)
ANESTHESIA: General with endotracheal intubation, 60 cc's of 1/4 % Marcaine
ESTIMATED BLOOD LOSS: 50 cc's
FLUIDS: 2000 cc's of crystalloid
URINE OUTPUT: not measured
SPECIMEN: greater curve of stomach
FINDINGS: Ventral hernia with omentum within it. No hiatus hernia noted.
INDICATIONS: Sara is a 38y year-old with a BMI of Body mass index is 66.4 kg/m²., who has significant comorbidities of obstructive sleep apena. She has failed multiple attempts at medical management of morbid obesity. In addition she meets 1991 NIH Consensus Conference criteria for bariatric surgery. Risks and benefits of the procedure were discussed with her, and she was desirous of surgery. The risks discussed included but were not limited to death, pulmonary embolus, DVT, anastomotic leak, stomal stenosis, bowel injury, bowel leak, bowel obstruction, liver injury, splenic injury or removal, (cbd or gallbladder injuries,) gastric leak, gastric-gastric fistula, ulcers, hernia, bleeding, infection, myocardial infarction, cerebrovascular accident, renal or pulmonary failure, vitamin deficiencies or malabsorption, potential for weight regain or lack of weight loss, persistent nausea or vomiting or excessive weight loss. she understood that the procedure is irreversible and entirely elective.
PROCEDURE: The patient was taken to the operating room and placed on the operating table in the supine position. Bilateral lower extremity sequential compression devices were placed. 5000 units of subcutaneous Heparin were given IM prior to the patient coming to the operating room for DVT prophylaxis. Appropriate intravenous antibiotic prophylaxis was administered prior to incision. General anesthesia was induced and the patient was endotracheally intubated. The abdomen was prepped and draped in the usual sterile fashion. A surgical timeout performed.
Following 40 French VISIGI tube placement, a small stab incision was made with an 11-blade at Palmer's point. A Veress needle was used to gain entry into the peritoneal cavity through this stab incision. The abdomen was insufflated to a pressure of 15mm Hg with carbon dioxide gas. An 8mm trocar was used to enter the peritoneal cavity in mid-abdomen above the umbilicus. The DaVinci was introduced through this trocar. A visual sweep of the abdomen confirmed no iatrogenic injury on gaining entry. The Veress needle was removed.
A 12mm right and a 12mm left paramedian and a left subcostal 8mm trocar were placed. A bilateral transversus abdominis plane block was performed with 30cc of 0.25% bupivacaine. An extra 8 mm Incision and trocar were placed right subcostal for AirSeal insufflation. A 5mm stab incision was made below the xiphoid process and the Nathanson liver retractor was placed. The patient was then placed in the reverse Trendelenburg position. The left lobe of the liver was retracted with the Nathanson, exposing the hiatus and stomach. There was a left of umbilical ventral hernia with omentum within it. This omentum was not removed and the hernia was not addressed at this time because of the high recurrence rate with her weight. The Da Vinci Xi system was docked.
The bipolar energy device was used to divide the gastrocolic ligament immediately adjacent to the greater curvature of the stomach beginning at the lower body. Continuing cephalad the short gastric vessels were divided along the greater curvature of the stomach. The fundus was completely mobilized off of the left crus. Great care was taken to avoid injuring the spleen and devascularizing the distal esophagus. We carefully examined the hiatus anteriorly and posteriorly and noted there was not a hiatal hernia present.
We then identified the terminal ileum as it entered the cecum. Utilized a umbilical tape to measure a 300 cm total alimentary limb of ileum. We left a stay suture marking the ileum 200 cm from the ileocecal valve for later ease of identification and placement of our ileal ileostomy. We then marked the alimentary limb at 300 cm for duodenal ileostomy after the sleeve was prepared.
The gastrocolic ligament was then divided with the bipolar energy device along the distal stomach moving towards the antrum to a distance of 6cm from the pylorus. A 60mm Sureform blue load staple fire was used to divide the stomach beginning 6cm from the pylorus along the greater curvature taking great care not to narrow the incisura. The VISIGI was then placed along the lesser curvature and placed to suction and used as a guide to calibrate the rest of the sleeve. Multiple staple fires were used (white loads) alongside, but not immediately adjacent to the bougie to transect the specimen ensuring we do not encroach upon the angle of His. All fundus was removed, there were no dog ears, and the staple line was an even distance from the lesser curvature of the stomach anteriorly and posteriorly.
We then began our duodenal dissection. We pulled the greater curvature of the sleeve laterally and continued mobilizing the distal greater curvature of the stomach with the vessel sealer working towards the pylorus. We continued this process beyond the pylorus, mobilizing the inferior border of the first portion of the duodenum. Once the inferior border of the structures was completely mobilized we lifted them cephalad. There were some posterior attachments of the stomach to the retroperitoneum which were taken with the vessel sealer. We then identified within the retroperitoneum the head of the pancreas and gastroduodenal artery. We retracted the stomach and duodenum cephalad and bluntly dissected the duodenum away from the retroperitoneal structures. We continued this cephalad until we identified the right gastric artery. We then placed the vessel sealer at this location and brought the duodenum inferiorly. We were able to clearly identify the superior border of the duodenum and the right gastric artery. We identified that we had adequate length of duodenal cuff in order to perform a duodenoileostomy. We then selected this location for transection of the duodenum.
A white load stapler was then brought through the right lower quadrant trocar. We placed this in our retroduodenal tunnel. We confirmed the location of the gastroduodenal artery. The stapler was fired. This stump was oversewn with a 3-0 V-lock absorbable suture. Fibrin glue was then applied to the duodenal stump staple line at the distal margin in order to ensure continued hemostasis. Prior to transection of the duodenum we appreciated that the portal structures and gastroduodenal arteries were protected.
We then identified the alimentary limb previously prepared. We ran this back to the 200 cm marked with a suture to ensure the correct orientation. The ileum at 300 cm was then secured to the duodenal stump with a running 3-0 V-Loc 180 suture. This would be the back row of our handsewn duodenal ileostomy.
We then utilized monopolar scissors to create matching enterotomies in the duodenal stump and ileum. We then utilized 3-0 V-Loc 180 suture in order to complete our 2 layered handsewn duodenoileostomy. We then made a window in the mesentery of the ileum adjacent to the duodenal ileostomy on the left side. A white load staple fire was used to transect the ileum at this location.
The eferrent ileum was then clamped with the empty stapler. The VISIGI was advanced beyond the pylorus just proximal to the anastomosis. A mixture of indocyanine green and saline was then utilized to distend the sleeve and anastomosis in order to perform a leak test. There was no ICG appreciated extra luminally in both the sleeve and around the anastomosis, confirming a negative leak test. The ICG was then aspirated from the lumen and the VISIGI was removed from the oropharynx.
We then ran the ileum back to our prior placed suture that was 200 cm from the ileocecal valve, ensuring the mesentery was correctly oriented. A 3-0 Vicryl stay suture was placed in this location to oppose the blind end of the biliopancreatic limb with the alimentary limb. Enterotomies were made in the bowel with monopolar scissors. A white load sure form staple fire was used to create a stapled ileoileostomy. The common enterotomy was closed in 2 layers with 3-0 V-Loc 180 suture.
The mesenteric defects of the ileal ileostomy was closed with 2-0 nonabsorbable V-Loc sutures. The alimentary limb defect was closed over the colon into the retroperitoneal area.
We then performed an upper endoscopy to evaluate the intraluminal sleeve and confirm patency of the duodenoileostomy. The sleeve was noted to be uniform caliber and appropriately sized throughout its entire course. The staple line was located along the lateral margin in a straight line. There were no dog ears or areas of narrowing. There was no intraluminal hemorrhage. The duodenoileostomy was widely patent and could easily be intubated with the endoscope. The insufflation was then aspirated from the sleeve and ileum. The scope was removed from the oropharynx.
The specimen was placed into a bag and removed from a 12mm trocar site. The fascia of the 12mm trocar sites were closed with 0-vicryl sutures on a trans-fascial suture passer. The entire surgical field including the staple line were re-examined and were completely hemostatic. Fibrin glue was applied to the staple lines to ensure continued hemostasis. The Da Vinci Xi system was undocked.
The 8mm trocars and Nathanson were removed under direct visualization. The abdomen was then desufflated, the 12mm trocars removed, and the fascial sutures tied down. Skin was closed with 4-0 monocryl. Dermabond was applied to buttress the incisions. At the conclusion of the procedure all lap, sponge, and instrument counts were correct. A debrief was done with the entire team.
The patient was emerged from general anesthesia, awake and alert, and extubated. An abdominal binder was placed over the patients abdomen and she was taken to the recovery room in stable condition.
I was present and scrubbed or seated at the console for the entirety of the procedure.
James N. Lau, MD
8/28/2024
@Saranlhess edited your name out for safety reasons. 
