NARRATOR ALEXANDER ONOPCHENKO, M.D.

Transcription

1 ROUX-EN-Y GASTRIC BYPASS SURGERY CENTER FOR SURGICAL WEIGHT LOSS AND WELLNESS ATLANTIC CITY MEDICAL CENTER, ATLANTIC CITY, NEW JERSEY Broadcast April 27, 2004 NARRATOR Welcome to a live internet demonstration of minimally invasive Roux-en-Y gastric bypass surgery, presented by surgeons at the Center for Surgical Weight Loss and Wellness at Atlantic City Medical Center in Atlantic City, New Jersey. Today you will watch as Dr. Alexander Onopchenko presents the latest technique for the treatment of morbid obesity. All viewers for today s activity will have the opportunity to interact directly with the surgeon faculty by sending their questions directly into the OR. Gastric bypass surgery represents an exciting new direction in weight loss management. When coupled with a firm commitment on the part of the patient, can produce both dramatic and satisfying results. There s nothing like the thrill of taking a person in their most productive years of life, in their 30s and 40s, who have suffered with a problem that most of them have had since childhood, imparting to them a tool, teaching them how to use the tool, and then watching them use the tool to gain control of their weight and lose weight and get a brand new life. I think there s nothing more rewarding that I could do as a physician. Hello. Thank you for joining us. My name is Rachel Boss and I m a registered nurse and the program coordinator for the Center for Surgical Weight Loss and Wellness. I d like to welcome you today to Atlantic City Medical Center s first live OR webcast. The procedure you re about to see is a laparoscopic proximal gastric bypass, Roux-en-Y, for the treatment of morbid obesity. It is performed on patients with morbid obesity as an effective and powerful weight loss tool to help patients achieve their weight loss goals and ultimately improve their health. Throughout today s webcast, we re going to give you the opportunity to submit your questions and comments to use and we re going to try our best to answer them all during the webcast. Next, I d like to introduce to you our surgeon today and medical director of our program, Dr. Alexander Onopchenko.

2 Thank you, Rachel, and I d like to add my own personal welcome to all our viewers today. This is, as Rachel said, our first live surgical webcast here at Atlantic City Medical Center. We have planned for a series of four throughout the year to highlight the services and programs that we have available here at Atlantic City Medical Center. I d like to first introduce our surgical team. At the head of the table is our anesthesiologist, Dr. Denise Mirabel*. My first assistant today is Dr. William Thierrans*. He is also the chairman of the Department of Surgery here at the Medical Center. Mark is our scrub tech and Beth is our circulator. This truly is a team effort from day 1 and certainly in the operating room it is as important as anywhere else, if not more so, that all members of the team function as such. I d like to try and orient you at this point to what we ve done so far. The patient is under general anesthesia. A little background on the patient. She s 34 years old. She weighs 239 pounds and she is 5 3 tall. That gives her a body mass index of 42. As you will hear Rachel say, that meets the National Institute of Health s guidelines for surgical treatment, with her body mass index alone being greater than 40. Just to demonstrate what is called a port strategy, this is a minimally invasive procedure, so we are doing this laparoscopically. As I said, with the patient under general anesthesia, her position is in a reversed Trendelenburg position, head up, feet down. We have instilled the pneumoperitoneum with carbon dioxide gas and we placed the ports. We have arranged five 12 mm ports in a V-shaped fashion in the upper abdomen. The fifth port is just above the umbilicus. That is through which the laparoscope is placed and the laparoscope is attached to the robotic arm. We use the robotic arm here in the operating room as one of the high tech features of the operation. The 6 th port is a 5 mm port in the subxiphoid position. We have used that to create a tract and through that tract we have now placed a Nathanson liver retractor, so that 5 mm port has been removed. That Nathanson liver retractor is being held by a stationary arm that we can manipulate the position of. On our heads, you can see we re wearing a heads-up display unit. That is allowing the surgeon and the first assistant to view the screen, view the intra-abdominal contents in a 3-dimensional fashion, rather than in a simple 2-dimensional fashion, as you can see on the screens on either side of the patient. We have started the dissection by mobilizing the angle of His, which is up here, and retracting the fundus downward. That is going to be our target for completion of the first portion of the operation, which is basically to divide the stomach into a small upper portion, and we have measured this by having a measuring balloon placed and inflated to 15 ml, and then the larger, lower portion, which will not accept food after surgery is performed. We ve also made an entrance into what is called the lesser sac, through the lesser omentum. Aesop, move back. You will hear me give the robotic arm instructions through a microphone and it will position the laparoscope accordingly. The white piece of tubing that you see is a Penrose drain that has been placed behind the stomach for later identification when we bring up the small intestine to reconnect it to the small stomach pouch that we fashion. By using the measuring balloon, we have decided how big to make the small stomach pouch, which averages about ml. We have created a small tunnel behind the stomach, through which we will now be passing staplers in order to perform the division of the stomach. You can see there are several fairly large vessels that are tracking along the lesser curvature of the stomach. The way that we re fashioning this

3 pouch is to try to make it all out of lesser curvature. That is the most indispensable portion of the stomach. One of the more common questions that I m asked is, will my stomach pouch stretch? It will stretch minimally when only lesser curvature of the stomach is used. I am leaving the stapler on before firing for a very specific reason. We try to maintain at least a 20 count application in order to try and have the stapler perform as much of the hemostasis as possible after the division begins. Now we ve started to divide the stomach. Again, we ve chosen the target as the angle of His, which is in the upper left corner of the screen. Now I m gently making a retrogastric tunnel in order to achieve that path. WILLIAM AARONS, JR., M.D. We are marching across the stomach here, if I could just get this instrument off. We are moving up, moving across underneath the stomach. We re developing a clear space through which we ll put the next stapler. Again, our goal is that upper left hand corner of the stomach. That s our target. The stapler should slide easily into the space that s created. Aesop, move in. Stop. WILLIAM AARONS, JR., M.D. What we try to do, then, is just pull down a little bit on this part of the stomach to make sure we get the pouch the proper size, we don t have any excess stomach sliding up to be left over in the pouch. As we continue to divide the stomach, basically the further applications will be 1-2 more of the same stapler. I m going to throw it back to Rachel and she ll give you a little more background on our program, in general. Before we start through some terms and terminology that you need to know throughout this procedure, we did already get our first response and I d like to address this with Dr. Onopchenko. Viewers are curious, what happens to the rest of the stomach after it is divided? Rachel, that s probably the most common question that I m asked. In truth, nothing really happens to it. As you ll see later in the program, the stomach still empties into the

4 intestine and the intestine is reconnected down below. The only thing the stomach won t do is it will no longer accept food, so that is also part of the bypass. It is bypassed along with the first portion of the small intestine, so really it will do nothing much. It ll sit there. It s retired from its job as a capacitance organ, but all the things that it produces, acid, mucus, will still travel downstream and empty into the GI tract further down. Thank you, Dr. Onopchenko. So like I said, we re going to go through some terminology very quickly because I know you re more interested in seeing the procedure. These procedures are only performed on patients who have morbid obesity, so what is morbid obesity? The best way to say it is, it s defined as being greater than 200% of your ideal body weight, or in general 100 pounds overweight. It s also called clinically severe obesity, but it s the point at which serious medical conditions can occur as a direct result of the obesity. How do we measure these things? There s a body mass index scale, or BMI, that we use. It s calculated by using a ratio of your weight over your height in meters 2. A BMI of with comorbidities allows patients to be qualified for this surgery, as well as a body mass index of greater than 40. Because of that, as obesity certainly is associated with a higher or lower mortality rate, those with lower BMIs, such as 25, live longer, and those with higher mortalities have a higher BMI. Obesity is certainly a huge problem in our nation today. It is considered a disease and it is also an epidemic. It is affecting 25% of our industrialized world. 67% of Americans are overweight and the sad part is that 30% of our children are overweight. So that becomes a grand total of 5-11 million Americans who are morbidly obese. We discussed morbid obesity comorbidities, those diseases that are worsened or exacerbated by the obesity. Medically speaking, that could be anything from diabetes, sleep apnea, osteoarthritis, gastroesophageal reflux disease, stress urinary incontinence, and the list goes on. Physically, there s the challenges of being obese. In our population today, it is not fun to be large. Think about the last time you went to a movie. You can t go to the movie theater without the armchairs being present and if you can t fit into the chair, you re probably not going to attend a movie. It s embarrassing to have to go to special stores for specialized clothing. Psychologically, the impacts of being obese are far-reaching. Patients tend to come to us having some underlying depression. Economically, it affects patients. There have been studies that have been linked to people who have had similar SAT scores getting into colleges and the colleges have chosen, between a normally weighted and an obese student, they have chosen the normally weighted one, even though they had the same SAT scores. Socially, this is the last bastion of acceptable discrimination. We re not allowed to discriminate against anyone for their age, their race, their sexual orientation, but it s still funny to make those jokes behind someone s back. So before we go too far, I d like to take us back to the procedure and have Dr. Onopchenko give us an update on where he is.

5 Thank you, Rachel. That was a good synopsis of the problem that we re facing here in this country. Just to bring you up to date, we have completed the vision of the stomach. You can see how small, even in the magnified view, this pouch is. Again, we try and standardize this and make it between 15 and 20 ml. Just for a point of reference, meals for folks after gastric bypass can basically fit into the palm of your hand and they ll average about two meals a day. What we re going to do now is, we re going to place part of a circular stapler into the small stomach pouch in order to prepare it for ultimate communication with the rest of the GI tract. Dr. Aarons is placing an angiocatheter into the patient s left upper quadrant. Through that, he s going to be placing a wire guide. I m going to be disconnected and start moving to the top of the table to perform the first of two upper endoscopies that are done during this operation. WILLIAM AARONS, JR., M.D. I m going to put the little insert back into the angiocath. I wasn t quite happy with the direction. Now, through this catheter we re going to place a wire that you ll see us grasp and it will actually be pulled up through the stomach and into the mouth. It s easier to see than to try to explain it. Dr. Onopchenko is going to the head of the table. He s going to take an endoscope that s a fiberoptic scope and he s going to go down into the stomach. He s then going to deploy a little plastic catheter. I m going to make a small burn on the surface of the stomach that will allow the catheter to come through. Then he will deploy a loop and he will catch the wire that I m going to give him. You ll see this happen. He s getting ready to do the endoscopy. So we re going to use the wire that s pulled up through the stomach, into the mouth, to bring part of the stapler down into the stomach. You re going to hear me give some commands too, to another little device. Endosite, enable PIP. What Dr. Aarons is doing is enabling us to actually have a picture in picture while we re performing, synchronously, the laparoscopic and endoscopic portion of the operation. WILLIAM AARONS, JR., M.D. This is a little cautery device that I m going to use to make that little opening in the stomach. Now you re seeing a view, as Dr. Onopchenko advances the scope into the stomach, into the pouch, and then we ll see a light in the pouch and that s our hint that he s in the pouch. You can see the pouch up ahead. There s some blood. There s the light. We are now trying to line up the exact right position in that stomach pouch for the snare that I pass through the endoscope to come out. As you will see, it s a very coordinated effort we re going to need to perform in order to get the portion of the circular stapler

6 down into the stomach pouch in order to create the ultimate connection again with the rest of the intestine. We have deployed the snare. WILLIAM AARONS, JR., M.D. I m going to remove the cautery device. Now Dr. Aarons is going to feed the wire into the snare. WILLIAM AARONS, JR., M.D. You ll see the wire. I m putting the wire in through this catheter, which has come through the skin, then he s going to grab that. Now I m going to bring the wire in the snare back up. WILLIAM AARONS, JR., M.D. That blue wire has been pulled up, out of the patient s mouth, and he is now going to attach part of the stapling device to it, that we need to have in the stomach. There are a couple of ways to do it. This is the way we prefer to do it. Some people put it in through the abdomen, but this is a way that works very well for us. I think it s really important to realize we do communicate as we do this. I get a sense of the feel. I ask him where he is. He tells me how it feels. I m going to hit some resistance as we get into the pharynx, which is in the back of the mouth. It s coming. I have it. Basically, that has completed the first portion of our operation and that s the stomach division. I m going to toss it back to Rachel while I change my gloves and gown in preparation for the lower part of the operation. So, to recap about surgery, is surgery the solution? Studies have shown that it does help up to 90% with long-term control. Now, the word there that should be emphasized is control. This is only a surgical tool. We re not using it as a cure. Patients are not going to jump off of the OR table and magically be skinny. They have to work at this. We give them the tools so they can do it and be effective at it, but with surgery does come some

7 risk, some disability, and some discomfort, but overall we find that the benefits of surgery far outweigh the risks of the surgery, as well as the risks of remaining morbidly obese, with all the comorbidity problems. Surgery helps with the resolution of those comorbidities. Certainly as the weight starts to go away, they feel better about themselves. Their quality of life improves and all of the social and emotional benefits that come with that. We are starting to get several questions in, so Dr. Onopchenko, I m going to kind of send these over to you. The first one, I think, is a very good question. Are there any upper age or BMI limits for this procedure? That s a very good question. I think it also is a question that I like to answer with the word depends. It depends. It depends on what stage in your program you re at. Surgeons that are just beginning to do bariatric surgery should choose their patients very carefully. As you can see, this operation itself is an extremely technical one and that really will reflect on your outcome if you do not carefully choose your initial patients. Having said that, the age criteria, most bariatric surgeons are doing folks as old as 65. Aesop, move back. And as young as 18. The extremes of age, it becomes a little controversial as to whether bariatric surgery should be performed, so the age range is 18 to 65 on average. Body mass index, again, when you start operating on people that are super morbidly obese, and that s a body mass index of 50 or greater, again, the complication rate will tend to go up. What I m doing right now is we ve deflected the transverse colon upward. We ve identified an area of the anatomy called the ligament of Treitz and now we re going to be finding that Penrose drain that we placed initially from up above. Aesop, move down. What we re looking for is passage through that transverse mesocolon into the upper abdomen, through which we will pass the small intestine to reconnect the gastrointestinal tract. The area, if chosen properly, should be very avascular, meaning not a whole lot of blood vessels in the area. We do a retrocolic, retrogastric anastomosis, meaning we re going to pass the small intestine behind the colon and behind the stomach, which is actually the shortest route between the lower abdomen and the upper abdomen. The instrument that I m using here is a harmonic scalpel. It s a high frequency ultrasound dissector that also coagulates small vessels at the same time as dividing them. Again, we re trying to choose the absolute perfect spot in the transverse mesocolon to go through and get into the upper abdomen, where we want to place the small intestine. To depict this graphically and to reorient people, maybe we ll go to the videotape to kind of demonstrate what we ve done so far and the operation in general.

8 The first portion you see operating here is what you ve already seen in the operating room. We used the staples to divide a smaller portion of the stomach from the larger portion of the stomach. What you re going to see next is the surgeons go down and they bypass the first portion of the intestine, the duodenum, and re-link the next portion of the intestine up to that new small stomach pouch. Thank you, Rachel. Basically, we re continuing to do a very careful dissection in the area where we re going to go into the retrogastric space. Again, what we re trying to identify from below is the posterior wall of the stomach. It s highly variable amongst individuals. Some folks have a little more fat in this area, that makes it a little more difficult. Others, there s a clear plane that you can see almost immediately that is behind the stomach. We re just going to very carefully probe the area to try to identify the posterior wall of the stomach. Sometimes it helps to completely reorient yourself at this point because there may be some adhesions to the area. Aesop, move back. Move back. Stop. Move in. Again, sometimes you get a wider scope of the picture to get an idea of the anatomy. Dr. Aarons suggested that this might be pancreas and, in actuality, that s what it appears to be. The stomach is superior to that. Again, we re looking for a nice clean plane. Aesop, move in. While we re doing this, I am going to toss it back to Rachel to give you some more background information. There are several different types of bariatric surgeries. There s a restrictive surgery, which restricts the amount of food that you can eat, as well as a malabsorptive type of procedure, which changes part of your intestines so you don t absorb as much of the food that you eat, and then there s a combined procedure, which is what you re seeing today, the proximal Roux-en-Y gastric bypass. It s combined because we both restrict the size of the stomach and we also mildly bypass the first portion of the intestine, the duodenum, so patients get that combined effort, which enhances their weight loss. From the slide on your screen, you can see another picture of what this new anatomy will look like, with the small pouch at the top, the larger portion of the stomach off to the side and, as Dr. Onopchenko said, there are still some digestive juices and enzymes that are being produced and needing to be excreted further downstream. Where those are hooked up, there s a junction that s created and it looks like a Y, and that s where we get the name Roux-en-Y. There are several really great questions that you viewers are writing in. One of them, I m going to combine into kind of two questions. Dr. Onopchenko, patients are interested in how you determine the size of the gastric pouch, 15 ml, 30 ml, and why different doctors are doing different sizes, as well as we re doing the proximal gastric bypass, but there is

9 also the distal gastric bypass. How do you decide how much intestine that you leave or how much you bypass? We try to make a small gastric pouch, ml, and we do that by gauging it with the balloon, with the measuring balloon. That, we find, produces the best restrictive portion of the operation, as Rachel said. The amount of small intestine that is bypassed is between 75 to 100 cm or 150 cm for proximal bypass and 200 cm for distal bypass. Sometimes that can be done by doing a measurement of the patient s BMI. Super morbidly obese patients may require more of the small intestine to be bypassed, as opposed to someone with a body mass index below. We are going into the lesser sac in a different way at this point, to try to identify, again, a clean pathway behind the mesocolon and behind the stomach. What we re doing is, there s several ways to get into the lesser sac and this is one of the ways, to reflect the omentum away from the transverse mesocolon and take a look at the transverse mesocolon from above. Sometimes folks will have a varying degree of scarring in the lesser sac, sometimes due to pancreatitis, sometimes just from congenital adhesions, and this is another way for us to get kind of a clearer view of where we want to go. What we ll see here is, from above, a different angle of both the transverse mesocolon and the retrogastric space, to kind of identify, again, the safest pathway from the lower abdomen to the upper abdomen. Dr. Onopchenko, we re getting several questions in about, is it more difficult to do this laparoscopically than open. I was wondering if you may be able to address this. Certainly you are a very skilled minimally invasive surgeon, so for you it may not be as technically challenging, but I was wondering if you could address the laparoscopic versus open question. That s another great question. No doubt, of the advanced laparoscopic procedures that we perform, this is probably the most technically challenging. Is it harder to do than open gastric bypass? Again, it depends on the surgeon s experience. I ve come to do the procedure more as an advanced laparoscopic surgeon than an open bariatric surgeon. I think that anyone considering doing laparoscopic bariatric surgery does need to have both the ability to do the operation open and the ability to treat folks of this size open and then advanced laparoscopic skills that would allow them to translate that to a minimally invasive procedure. Most importantly, again, it has to be an institutional commitment to taking care of morbidly obese patients.

10 Again, we have created a hole in the omentum. At the top of the screen, you can see the stomach. Again, we re looking for the retrogastric space from above. Here you can start to see that we re moving toward that. Usually, again, it depends on the patient s anatomy. This is not often necessary, but it can be and you have to have in your approach different ways to conform to the patient s anatomical condition. Dr. Onopchenko, if I may, I d like to return back to some of the complications that are associated with this surgery. First of all, you ll see on your PowerPoint screen that generally 92% of gastric bypass Roux-en-Y patients experience no complications whatsoever. However, nationally speaking, there are several things that you should be concerned about. Whenever the inside of your anatomy is rearranged and reconnected, any area that there s a reconnection, there s a chance for an anastomotic leak. Leaks are very important. They need to be treated immediately. There s also other things that can happen. They usually can occur with any major abdominal surgery, like a deep vein thrombosis or blood clot in the legs, respiratory complications like pneumonia or atelectasis, wound infection. Any time the skin is cut, there s a possibility of wound infection. The other thing that people are always very concerned about is mortality rate. Can I die from having surgery? Nationally speaking, there is a 1 in 200 or 0.5% chance that patients could die as a complication of their gastric bypass. If you take a look at your screen, there is a statistic graph of how we ve been tracking, compared to the national benchmark. As you can see, we re very fortunate. We ve had 0 mortalities. Our leak rate is well within national average at 4%. Also major infection is really low. Incisional hernia is very low at 0%. We also have a bleeding complication that is at national benchmark. Overall, the results of gastric bypass, we can look at it, it s the longest and most thorough follow-up within the United States for any bariatric surgery. It is significant and durable weight loss. Patients generally lose between 60-90% of their excess body weight within the first golden year, as we call it, which is roughly 9-15 months after their surgery. This is a very powerful tool to control those comorbidities. Our patients here have actually had 100% resolution of their diabetes and most of those happen within the first few days after surgery. 100% resolution of their sleep apnea. 88% resolution of hypertension. 86% resolution of their gastroesophageal reflux or heartburn. Those numbers are staggering. When you look at a patient who is faced with these comorbidities that are wreaking havoc in their life and making them realize they may not be able to see their children grow up or see their grandchildren, this surgeon gives them an opportunity to have an improvement in those comorbidities and perhaps a complete resolution. Let s check back with Dr. Onopchenko and see where they are in the procedure. Thank you, Rachel. We have successfully identified our Penrose drain in a two-step fashion. Aesop, move in. Now we re ready to do the second part of the operation. This basically is just a guide and you ll see that this will serve as a guide to get the small intestine back up into the upper abdomen in order to reconnect the GI tract, so again we

11 have reindentified the ligament of Treitz. Aesop, move back. Now we re going to start to divide the small intestine. We divide the small intestine approximately 20 cm distal to the ligament of Treitz, basically at a comfortable place. It usually ends up being somewhat near the hepatic flexure of the colon. We re using the stapler again to divide. We re using a different load, meaning the staples are smaller and more compact. The closure is more compact in order to create hemostasis. Again, we waited, in this case, 12 seconds prior to dividing. There also can be a little bit of bleeding that we manage with a little Bovey cautery. Aesop, move in. Stop. Move down. We ll divide a little bit of the mesentery. Some surgeons divide a little bit more than others, depending on how the small intestine is brought up into the upper abdomen. Again, the mesentery is where the blood supply is. Again, we experience a little bleeding. This kind of bleeding can usually easily be handled with the Bovey cautery. At this point, as we were talking, this is going to be the bypass portion of the operation, the small intestinal bypass. Now, since this patient s BMI is 42, I m going to be performing about a 75 cm bypass of the first portion of her small intestine. We re going to estimate that by passing a 5 mm grasper 15 times. While we do this, Rachel, perhaps you can show a few more slides. Sure. We had talked about the results of gastric bypass being the longest and most thorough follow-up, but we also talked about the reduction and improvement in comorbidities. One other thing and probably most importantly is, of course, the weight loss. I d just like to show you our statistics here. At three months, patients are losing 44% of their excess body weight. Six months, 60%. Nine months, 71%. At 12 months, and this was based off of our first 100 cases, 77% of their excess body weight was lost. That s why those comorbidities are improving. We here at Atlantic City Medical Center have build a comprehensive program around our patients care. There are several hoops that we make patients jump through prior to surgery and I d like to show you a list. The first, of course, if patients want to get started in our program, they need to come to an educational seminar, where we talk a lot about the risks and benefits of surgery, the different types of surgeries, what types of patients really come for surgery, and go through what is going to be expected in our program. If patients wish to continue, they ll be evaluated by the surgeon and then go for several different medical evaluations and tests, generalized diagnostic tests, one of which is an upper endoscopy, ultrasound, and a pulmonary screen for sleep apnea. Every one of our patients go through a psychological evaluation. Some of our s have come in with patients asking questions about their particular mental diagnosis. Through this psychological evaluation, it s not saying that morbidly obese patients are crazy or at a higher rate than the rest of the normal weighted population, but this is such a drastic life change, we need to make sure the patient is committed, that they don t have any underlying eating disorders, that they do understand the expectations and responsibilities that they will have after surgery. We do have dietary counseling and evaluation preop and postop. Let s quickly cut back to the surgery and see what Dr. Onopchenko is doing.

12 Thanks, Rachel. What we re doing is we re now performing the small bowel anastomosis, reconnecting the small bowel so all the things that are in the stomach and in the first portion of the small intestine will mix with the other GI tract contents further downstream. Again, we re doing this with staplers. We ve marked out 75 cm. That s how much of the intestine is being bypassed. Now we re doing a side to side stapled anastomosis. This is really a critical portion where your first assistant is tremendously valuable. That s another thing: this operation really requires a co-surgeon, almost, where Dr. Aarons role is invaluable in order to ensure a positive outcome in the operation. Now, we ve completed reconnecting the small intestine, but obviously we have to close this hole, through which we ve passed the stapler, to reconnect the small intestine. We will close it again by using the same linear cutting stapler. We want to do this, obviously, in a way that we will not narrow the new communication at all, so we want to take as little of the tissue as possible. Again, this is a very common area to have a little bit of oozing that we should be able to take care of with a little Bovey cautery. The small intestine does obviously contain some bacteria. In order to take this little piece out of the abdomen, Dr. Aarons is inserting a pouch in order to preserve the sterility of the operative field. He ll be removing that piece of intestine with the pouch. We ve now completed the small intestinal anastomosis. Now I m going to complete a little bit of hemostasis again by very gently applying the Bovey, just to the bleeding points along the staple line. I m going to use this as gingerly as possible. We re going to check that anastomosis. Now we re going to place a strain release suture in order to straighten the bowel out as much as possible so that that connection is not narrowed at all, also to prevent any internal hernias. Hernias are spaces which were created during surgery, through which the intestine can pass and create a bowel obstruction, so by suturing this together, and we re doing this, again, laparoscopically with special instruments, we are trying to prevent the occurrence of a postoperative hernia by closing any potential spaces that we ve created during the procedure. This is a very clever device that, as you can see, is passing the needle from one jaw to the other. It s one of the time-saving devices that can be used for laparoscopic surgery. The sutures are the same as we use for open surgery. We use laparo-ties. It saves time, again, rather than tying knots. Those are the little purplish things that you see on the end of the sutures. They re absorbable and they stick around just long enough for scarring to occur between the two sutured ends of the intestine, in order to keep it in the place you want it to stay in. We ll continue to suture up into the mesentery and part of the mesentery. This is one of the three areas where an internal hernia can occur. We re just going to take a couple more stitches and basically this will eliminate a hernia through this space. We ve completely now 2/3 of the operation. We re about to pass the small intestine up into the upper abdomen to make the final connection between the small intestine and the small stomach pouch, and that will complete the reconnection of the GI tract. Again, the way we do this is by using that Penrose drain as a guide. I m going to suture the divided

13 end of the so-called Roux limb to that Penrose drain and by upward traction on the Penrose drain, deliver the Roux limb into the upper abdomen. Again, as you can see, it s a very choreographed procedure. I m not talking much to the scrub nurse, Mark. He knows the steps of the procedure and is able to give us the right instrument at the right time, making it a much more efficient operation. Beth is in charge of everything. She has kept the technical aspects of the operation going. I started to say our administration has made a significant investment in order for us to perform this operation in a minimally invasive fashion. We re the only hospital in the tri-state area that uses the heads-up display system together with the robotic arm. Other institutions may have the robotic arm, but no one else is using the heads-up display system and I think it truly does make a difference. We ll cut back to Rachel while we re passing the Roux limb up into the upper abdomen. Patients write, we re looking into different programs that offer bariatric surgery. Which members of the team and what kind of programs should they be looking for? I can certainly answer that question very easily. Certainly you need to look to see if your surgeon is dedicated to preoperative education, has the technical expertise to be able to do your procedure, and is willing to follow you very closely postoperatively. You become a patient for life. There should be a nurse clinician involved, a hospital program coordinator. The staff involved in the hospital should know how to care for the patient. You would definitely need a registered dietitian. Exercise physiologists or exercise staff in order to get you through preop and postop, all the transitions, and dedicated clinical psychologist that you should be looking for within a program team. We do offer all those things here at Atlantic City Medical Center. I have another questions that asks, if you have a laparoscopic procedure, how long do you stay in the hospital and what medications for pain are given? The laparoscopic procedure does offer less pain after the procedure. You still have some. We do give you a patientcontrolled analgesic pump to get you through the first 24 hours before we can start weaning you onto oral medications. There is also a lesser hospital stay. Our patients are typically 2½ days in the hospital, which is a wonderful thing. You get home to your family sooner. If you have children to care for, you can t go right back to work and right back to your home life, but certainly it does give you a head start compared to having a long, open incision. Our patients are given 5 simple rules to follow to be successful after surgery. There s certainly more education that goes along with this, but we have tried to drill them down into 5 simple rules. Patients can only eat 2-3 small meals a day. The meals that they eat need to be protein- and nutrient-rich, so they eat their protein first. They have to drink a lot of water, 6-8 glasses of water a day. They need to exercise every day, at least 20 minutes of aerobic activity a day. Don t snack between meals. Take your vitamins as

14 prescribed. After you have gastric bypass surgery, you do have that malabsorptive component. You will be required to take some vitamins to keep yourself well nourished. There s another component to gastric bypass, that a lot of patients choose this procedure over others for, and that would be dumping syndrome. It s a phenomenon that, when patients eat foods that are higher in either sugars or fats, the sugars and fats are quickly digested in that small stomach pouch and quickly move into the intestinal portion. Now, since that s really the second portion of the intestine, that s hooked up in the new tract, it quickly goes through. It s very sensitive, so water shifts out of our bloodstream and goes into the intestine to try to dilute that down. Because of that, that large shift of fluid, patients will experience dizziness, sweatiness. Their heart starts to race. Quickly all that fluid moves through their intestinal components and they get diarrhea, abdominal cramping, and certainly it encourages patients not to eat those types of foods that are high in sugars and fats. As we re starting to wrap up, I d like to move back to Dr. Onopchenko in the operating room for any last thoughts. We re about to introduce the circular stapler that will finish the communication and reestablish continuity of the GI tract. In order to do that, we have to enlarge one of the port sites, which is what Dr. Aarons is currently doing, in order to place the instrument into the abdomen and still maintain the pneumoperitoneum. We do this by enlarging the incision just a little bit. This is the biggest incision the patient gets. It s about 1 at most. Then, once the dilatation is complete, we ll be able to introduce the rest of the circular stapler into the abdomen to complete the connection between the intestine and the stomach pouch. All in all, as Rachel said, the hospital stay is about two days. The course for the patient, the first postoperative day they will get a gastrographin swallow and that is some dye that is given to the patient to swallow to make sure the connections have integrity, meaning there s no leak, and we will test for leaks as well as the end of the operation, so we re testing twice. Once the patient is tolerating clear liquids, the patient is discharged. On average, it s the second postoperative day that the patient will go home. As Rachel said, the average recovery at home is about two weeks laparoscopically. Should the patient require an incision, that s doubled to at least four weeks and sometimes six weeks. What we re doing right now is placing sutures. Because we ve dilated this hole, we re placing sutures that will be tied at the end. This is the only port site that gets closed, because it s been dilated to a larger size, in order to prevent hernia through the abdominal wall. In fact, that s why laparoscopic gastric bypass was developed in 1993 by two surgeons by the names of Drs. Whitgrove* and Clark. They found that with open surgery, surgery through an incision, their patients were developing an incisional hernia, hernia through the incision, about 20-25% of the time, so ¼ of the patients had occasionally developed a hernia that would require another operation to repair. This basically has eliminated that complication.

15 So now we ve dilated that one hold, one port site. We ve pre-placed sutures to close at the end of the operation and now we re going to be getting ready to make that final connection between the intestine and the small stomach pouch. In the time that we have left, we may not be able to, at least live, show you the completion of the operation. This will be available in archived form and certainly we will also continue to take your questions at the end of our live webcast and we ll answer them as thoroughly as we possibly can. We want to thank you very much for joining us today for our live OR procedure. Just to reiterate what Dr. Onopchenko has said, we did receive several questions during the course of today s broadcast and we do want to encourage you to keep sending them in. Over the next several days to a week, we re going to try to get back to every single one of you. If you have any questions or want us to send you any information about the program or the procedure, please send in your . We ll be happy to get back to you. This has been our pleasure today to provide this service to you. Again, thank you very much for joining us, on behalf of Atlantic City Medical Center. NARRATOR This has been a live internet demonstration of minimally invasive Roux-en-Y gastric bypass surgery, presented by surgeons at the Center for Surgical Weight Loss and Wellness at Atlantic City Medical Center in Atlantic City, New Jersey. If you would like more information about Roux-en-Y gastric bypass surgery or you would like to make a referral or an appointment, please click the buttons on the program player window.