Rutledge MGB Technique

Rutledge Version of Mini-Gastric Bypass:
Tools, Tips, Techniques

Special needs for the surgery (instruments, etc.)

 

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First: Warning NO anticoagulants, NSAIDs

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PATIENT POSITIONING:

The patient is
supine (not lithotomy)

The table will be inclined to MAXIMUM Trendelenburg
position and Full tilt to the Left Side UP

The requires a simple but very important patient
immobilization on the table to ensure patient safety and make sure the
large patient does not move during the operation

Both arms are out at 90 degrees the knees
are
“broken’ to an angle of 45 degrees and two Large pillows are placed
beneath the knees

The Heels are padded

SCDs are applied

and then most importantly

3 Three LARGE Leather or Polyester Straps (Seat Belts)
are applied to the legs

At the upper thigh

the lower thigh
and mid tibia

Then to reassure all of the anesthesia,
nursing and other attendants
with all of the team watching

The table is slowly and carefully moved to MAXIMUM
Reverse
Trendelenburg and Full Tilt Left side up

Any adjustments are made

Often a pillow, doughnut or soft sand bag is placed by
the head

EndoTracheal tube placement and Vital signs assessed

Then and only then the patient is replaced to flat
supine and the patient is prepped and draped in the usual fashion

The surgeon
stands on the patient’s Right

Usually requiring a STEP Stool

The Camera is immobilized by a self retaining camera
holder and one assistant is on the patient’s Left side

Only two scrub for
the case

The Surgeon looks across the table from patient’s right
to left to a screen at the head of the patient located 45 degrees
between the patient’s head and the patient’s left arm

This means that this are must be kept free of IV poles
and anesthesia paraphernalia

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BOUGIE
We
use 24 – 32 French (NO Larger, No smaller)
In a pinch we can use Ewald Tube
Or Gastroenterologist Red Weighted Dilating Bougie
NO 36-38 Bougies

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INSTRUMENTS

The instruments need are simple but should be of high
quality.

The Mayo stand should contain

1 scalpel of any type
Veress needle
5 Ports in total
Of the 5 ports;
4 ports are 12mm ports (not 10 or 11mm) 12 mm ports that can accept the
stapler (12 mm) as well as the 5 mm operating instruments.
Of the 5 ports the remaining port is a single 5mm port

Three separate 5 mm
graspers of excellent quality, at least 2 should be Locking Graspers

One of the 3 three,
5 mm graspers should ideally have longer jaws to allow a firm safe
locked grip on the intestine

In case of emergency there should be two good quality
needle drivers (in most cases not needed, but should be on the back
table)

Stapler, Ideally Covidien 60 mm blue or Purple although
Johnson Can be used as backup

No other Open Surgery instruments on the back table

Skin closure is with 1 (one) single staple in each port
and for this we need a single pair of Adson’s forceps with teeth and
commercial staple gun

No suction is on the table

We use the Harmonic scalpel if possible

No sutures open.
but have 3-O
Vicryl on sh needle available if necessary,
Do Not Open

===========================

A brief summary of the procedure may be of interest

The surgeons approaches the patient in flat supine
position from the patient’s left side.

The abdomen is examined and the location of the left lateral extent of
the rectus
sheath
approximately 4-5 finger breadths below the left costal margin is
estimated.

With
the “go ahead”
from anesthesia a 5 mm incision is made and the Veress needle is
advanced into the abdominal cavity and insufflated.

The surgeon
moves
to the patient’s right side and after insufflation the scalpel is used
to make a 12mm incision 1 and 1/2 palm widths below the xiphi sternum

This may vary slightly with patient size but is
remarkably constant

The 12 mm “Camera port” is used to enter the abdomen

The surgeon
uses
the camera to briefly explore the abdomen and note the location of the
Veress needle and the Veress is removed under direct vision

The final 4 ports are now placed

The locations are as follows:

1, One 5 mm port several cm medial to the left axillary
line 2-3 finger breadths below the costal margin

1, One 12 mm port left mid-clavicular line 2-3 finger breadths below
the costal margin
1, One 12 mm port Midline 2-3 finger breadths below the xiphi sternum
1, One 12 mm port Right mid-clavicular line 2-3 finger breadths below
the costal margin

Total 5 Ports

In roughly a “Diamond” pattern

1 Midline 1 and 1/2 palms below xiphi sternum (the
Primary But not only,”
Camera Port”)

1 Left Anterior Axillary Line 5 mm grasper / retractor port
1 Right Mid-clavicular line port, used for stapler and camera at
several points during the case for only a few moments

2 Primary Surgeon’s Working Ports
(Right Hand and Left hand)

Left hand = Midline Port
Right hand = Patient’s
Left Mid clavicular Line port

Patient
is now, with approval of anesthesia,
tilted to Maximum Reverse Trendelenburg and left side up

Warning poor anesthesia can lead to hypotension

Anesthesia must be prepared and educated as tothe
planned revers Trendelenburg positioning and
drug use so to avoid hypotension when tilting the patient

Poor anesthesia
= No surgery

Now the steps in brief for the operation

The left hand grasper elevates the left lobe of the
liver and the harmonic is used to dissect the lesser curve of the
stomach at the junction of the body and the Antrum 5-10 minutes

Stapler is passed via the Left Hand Working port into
the abdomen and the stomach pouch creation is under way

Using the Left Hand working port or the Right side port
second stapler is fired

Surgeon
and anesthesia now discuss Bougie placement

The bougie is advanced and retracted under direct vision

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Surgeon
and anesthesia agree on bougie movement commands:
Advance
Retract
Tap Tap (A very tiny rapid in and out motion that aids in
bougie identification)

Now all staplers fired from the Right hand Working port
3-5 staples to EG Junction

WARNING FEAR THE EG JUNCTION

Stay lateral to EG Junction

Only fools and Sleeve surgeons dissect near the EG
Junction. It is not necessary for MGB and it is dangerous

With division of 80-95% of the stomach the area lateral
to EGJ is visualized

If necessary the short gastrics are divided under direct
vision with careful and meticulous dissection

Case Mantra “NO BLEEDING”

The division of the stomach and creation of the pouch is
completed

Op time 15-20 minutes

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Attention turned to the Left Gutter

Retract the omentum medially and Identify Ligament of
Treitz

Run the bowel 2 m

Count to 60

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Grasp and lock the loop of bowel with larger 5mm atraumatic locking
grasper

Gastrotomy with harmonic

Change camera to R Lateral port

Enterotomy

Pass 60 mm Covidien Stapler in via the “Camera” port

Fire to form GJ

Manipulate 24-30 mm bougie across the anastomosis

Change camera back to camera port and pass 60 mm stapler
in via the Right lateral port

Close the GJ

Case over
Op time 35 minutes

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