Conclusions and Techniques of Laparoscopic Cholecystopancreatic Diversion with Duodenal Transposition

in conclusion

These preliminary case results suggest that the BPD-DS technique is feasible, especially for high-risk, morbidly obese patients.

Further studies with more cases are needed to demonstrate the effectiveness of this surgical method and its therapeutic effect on coexisting diseases, such as hyperlipidemia, sleep apnea syndrome, hypertension, and diabetes.

We recommend performing this surgical procedure laparoscopically to minimize local and systemic complications in these high-risk patients.

In the series of studies by Dolan and Fielding, and Slater and Fielding, we see a future trend where BPD or BPD-DS may become the "final weight loss surgery option" after other weight loss surgeries have failed.

Techniques of laparoscopic cholecystopancreatic diversion

Scopinaro's long-standing dedication to bile-pancreatic diversion (BPD) has demonstrated the effectiveness of the procedure in long-term weight loss.

Scopinaro has not changed much since the surgical method was first used in the 1970s.

This surgical method has a dual effect: first, it restricts food intake, and then it restricts the absorption of nutrients in the intestines.

The application of laparoscopic techniques in abdominal surgery has eliminated surgical incision-related complications, such as pain and discomfort, as well as delayed complications caused by the incision itself.

For some surgical procedures where incision-related complications are the main postoperative complications, especially cholecystectomy, fundoplication, upper abdominal splenectomy, and lower abdominal inguinal hernia repair and colectomy, the advantages of laparoscopic technology have been more fully utilized.

Complications related to incisions during bariatric surgery can vary, and the size of the abdominal wall incision is related to the incidence of incision infection, respiratory complications, and incisional hernia.

However, the most serious complication is intestinal fistula.

The application of laparoscopic techniques has not eliminated the occurrence of intestinal fistulas; in fact, the incidence of intestinal fistulas actually increases before laparoscopic procedures in obese patients are mastered.

Because establishing the Roux loop during the surgical procedure is quite difficult, and it needs to be pulled to the esophagogastric junction in the abdomen to establish an anastomosis, there are various methods for establishing the anastomosis, including using a circular stapler, using a straight stapler for side-to-side anastomosis, and manual anastomosis.

The number of open and laparoscopic BPD surgeries is less than that of laparoscopic Y-type gastric bypass (RYGB).

However, there is no difference between the two in terms of operational principles.

In the 1990s, it was proven that the safest and most effective way to perform advanced laparoscopic surgery was to strictly simulate the process of open surgery, as many open surgeries had been tested by a large number of cases and time.

The described laparoscopic BPD procedure is based on the process of simulating the open BPD procedure of Scopinaro et al.

Surgical procedure

During surgery, the surgeon stands to one side of the patient.

However, in Europe, the surgeon usually stands between the patient's legs, with the camera in the middle, and operates on either side of the camera.

The patient lies supine with legs together, achieving the same effect of abdominal cavity exposure. This position is simpler, more comfortable for the patient, reduces the incidence of deep vein thrombosis, and makes it easier for nurses and other staff to stand during the operation.

Since the surgery was performed on the upper abdomen, there was no need to insert a Foley catheter. Moreover, inserting various catheters into obese patients is very difficult and does not bring much benefit.

The Nathanson liver retractor is inserted below the xiphoid process, and the other side is fixed to the operating table. This is the most effective way to retract the liver.

The advantage of this traction device is that it does not require a special assistant for support, is well fixed and does not move, does not damage the liver, and can effectively expose the surgical field of the upper abdomen.

Through an abdominal wall incision, a trocar is inserted toward the right iliac fossa to establish the Roux loop. The trocar is then removed, and through the same incision, another trocar is inserted toward the upper abdomen to perform gastric manipulation.

Whenever possible, use a cannula that can be inserted through the muscle, such as Optiview, so that the incision left by the cannula will not need to be sutured after the procedure.

Cholecystectomy is usually not performed at the same time. If the patient develops biliary colic after surgery, cholecystectomy is performed at that time. By then, the patient's weight has been reduced and the liver volume has been significantly reduced.

Using the Optiview puncture needle cannula, insert it into the abdominal cavity below the left costal margin to establish pneumoperitoneum, which is the thinnest part of the abdominal wall in patients with morbid obesity.

Establishing pneumoperitoneum here avoids complex dissection procedures around the navel and some secondary damage caused by the Veress needle.

Moreover, the biggest advantage of doing this is that it leaves only a 4-5mm incision on the abdominal wall after surgery, without the need for sutures.

By establishing pneumoperitoneum below the left costal margin, the greater curvature of the stomach can be visualized more clearly, and the right iliac fossa can be clearly exposed, facilitating the establishment of the Roux loop.

puncture cannula position

The location of the abdominal wall puncture hole is shown in Figure 22.2-2.

The first trocar is placed below the left costal margin to establish pneumoperitoneum using an Optiview trocar. The second trocar is placed in the left iliac fossa, at the midpoint between the umbilicus and the anterior superior iliac spine, through which the Roux loop is established. The third trocar, 5 mm in size, is placed below the xiphoid process, through which a Nathanson liver retractor is inserted. The fourth trocar is placed along the midline of the abdomen, at the midpoint between the xiphoid process and the umbilicus, through which the Roux loop is established, and gastrojejunostomy can also be performed. The fifth trocar is placed below the right costal margin, towards the midaxillary line. A 12 mm Optiview trocar is first used to anastomose the Roux loop, then the trocar is turned cephalad to dissect the duodenum.

Sometimes, it may be considered to place a sixth cannula between the fourth and fifth cannulas, especially when performing duodenal dissection, as the pancreas is difficult to push aside.

The laparoscopic bile-pancreatic diversion procedure uses the standard Scopinaro open approach, which involves gastrectomy to create a 250ml gastric pouch, which is then anastomosed to a 200cm long functional intestinal loop, resulting in a common intestinal length of 50cm.