monthly focus

surgical intervention video

Gastrectomie longitudinale laparoscopique

In this video, the authors present the case of a 40-year-old female patient with a BMI of 37, suffering from arterial hypertension and obesity-related joint pain. She had no previous surgical history. Preoperative assessment was unremarkable, and the indication for surgery was discussed and approved during a multidisciplinary team meeting.

A laparoscopic sleeve gastrectomy (LSG) was performed. The procedure began with dissection of the angle of His using a LigaSure™ vessel-sealing device, followed by complete mobilization of the greater curvature of the stomach up to the pylorus, previously marked with bipolar cautery.

A calibration bougie was introduced by the anesthesiology team to guide gastric resection. Gastric transection was performed with five 60mm purple cartridges of the linear stapler. Staple line reinforcement was achieved with a running suture of PDS 3/0, with additional V-Loc™ suturing in the distal third of the stomach (please specify exact location). The resected specimen was retrieved using an Endobag®. The procedure was completed without intraoperative complications.

The patient was discharged on postoperative day 1. At 30 days of follow-up, she had no complications and she had lost 10 kg.

Bibliography:

1\. Shahed Tish, Ricard Corcelles. The Art of Sleeve Gastrectomy. J Clin Med 2024 Mar 28;13(7):1954. doi: 10.3390/jcm13071954. PMID: 38610719 PMCID: PMC11012326 DOI: 10.3390/jcm13071954

2\. Antonio Vitiello, Adam Abu-Abeid, Danit Dayan, Giovanna Berardi, Mario Musella. Vitiello A, Abu-Abeid A, Dayan D, Berardi G, Musella M. Long-Term Results of Laparoscopic Sleeve Gastrectomy: a Review of Studies Reporting 10+ Years Outcomes. Obes Surg 2023 Nov;33(11):3565-3570. doi: 10.1007/s11695-023-06824-8. Epub 2023 Sep 25. PMID: 37743393 PMCID: PMC10603075 DOI: 10.1007/s11695-023-06824-8

3\. Daniel Moritz Felsenreich, Christoph Bichler, Felix Benedikt Langer, Mahir Gachabayov, Gerhard Prager. Sleeve Gastrectomy: Surgical Technique, Outcomes, and Complications. Surg Technol Int 2020 May 28:36:63-69. PMID: 32359172

Laparoscopic sleeve gastrectomy (LSG)

video lecture

Principes de la chirurgie métabolique selon la pathogenèse du diabète de type 2 : un cadre axé sur la pathogenèse pour choisir les procédures

In this key lecture, Professor Luciana Janene El-Kadre, MD, MSc, PhD, FACS focuses on type 2 diabetes (T2D), namely a multifactorial metabolic disease driven by complex interactions between genetic predisposition, insulin resistance, and dysregulated glucose homeostasis. This lecture proposes a pathogenesis-first framework for metabolic surgery, emphasizing procedure selection based on the underlying biological mechanisms rather than solely on weight loss outcomes.

The presentation begins with an overview of T2D pathophysiology, highlighting the metabolic model that integrates insulin sensitivity, β-cell dysfunction, and hepatic glucose production. Genetic influences are discussed as key determinants of disease variability and surgical response. Particular attention is given to the metabolic effects observed after Roux-en-Y gastric bypass, where improved insulin sensitivity plays a central role in early glycemic control independent of weight loss.

The lecture further explores how malabsorptive and ileal-augmenting procedures modulate enteroendocrine signaling, bile acid metabolism, and nutrient sensing pathways. Changes in endogenous glucose production are examined as a critical mechanism contributing to rapid postoperative glycemic improvement. These physiological shifts collectively inform rates and durability of diabetes remission across different surgical strategies.

Finally, the concept of “ideal metabolic surgery” is introduced as a tailored intervention aligned with individual pathophysiology, integrating disease duration, insulin secretory capacity, and metabolic phenotype. By reframing surgical decision-making through the lens of T2D pathogenesis, this approach advances a more precise and mechanism-based model of metabolic surgery aimed at optimizing long-term remission and metabolic health.

Principles of metabolic surgery according to type 2 diabetes (T2D) pathogenesis: a pathogenesis-first framework to choose procedures

Obesity continues to represent a global health epidemic, driving the need for scalable, minimally invasive, and durable therapeutic strategies beyond lifestyle modification and pharmacotherapy. Within this evolving treatment landscape, bariatric endoscopy has emerged as a pivotal bridge between medical and surgical approaches, offering endoluminal interventions that modify gastrointestinal anatomy and physiology without external incisions, as Professor Andre F Teixeira, MD, FACS, FASMBS underlines in this key lecture.

This lecture defines bariatric endoscopy and explores the mechanisms of endoscopic bariatric therapies (EBTs), which include gastric restriction, delayed gastric emptying, hormonal modulation, and metabolic signaling changes. Central to clinical application is appropriate patient selection, with body mass index (BMI) thresholds, comorbidity burden, and prior surgical history guiding indication frameworks. Bariatric endoscopy also plays a growing role in both preoperative optimization and post-bariatric surgery management, including revision of weight regain or anatomical failure.

Key procedural innovations include Endoscopic sleeve gastroplasty, which achieves stomach volume reduction through full-thickness suturing, and comprehensive stomach remodeling techniques that expand the spectrum of endoluminal restriction strategies. Metabolic interventions such as Duodenal mucosal resurfacing further extend therapeutic impact by targeting insulin sensitivity and glucose regulation pathways.

The integration of bariatric endoscopy into clinical practice is increasingly structured, supported by multidisciplinary pathways and evidence-based protocols that improve accessibility and patient outcomes. As technology and technique advance, the future of bariatric endoscopy lies in refined patient stratification, combination therapies, and earlier intervention in the obesity disease continuum—positioning it as a cornerstone of next-generation metabolic care.

How does bariatric endoscopy fit in? Patient selection and indications for endoscopic bariatric therapies

Comment l’endoscopie bariatrique s’intègre-t-elle ? Sélection des patients et indications des thérapies bariatriques endoscopiques

This video demonstrates the resection of a gastrogastric fistula following a Roux-en-Y gastric bypass (RYGB) which was performed laparoscopically with a mechanical gastrojejunal anastomosis in a 43-year-old female patient who experienced a 10 kg weight regain along with epigastric abdominal pain.

An initial endoscopic treatment was decided upon. However, recurrence of the fistula, confirmed via endoscopic, radiologic, and CT-scan examinations, led to the decision of surgical management.

During the procedure, a complete release of the digestive structures was performed, followed by an endoscopic control of the fistula. The resection was then performed by stapling the gastrojejunostomy, including the fistula, with the creation of a new mechanical anastomosis. Postoperative outcomes were uneventful, and the patient was discharged on postoperative day 1 with resumption of a liquid, then soft diet, according to standard bariatric surgery protocols. Follow-up showed weight loss with stabilization at the target weight of 69 kg equaling a BMI of 25 and abdominal pain resolution.

Bibliography:

1\. Lester Carrodeguas, Samuel Szomstein, Flavia Soto, Oliver Whipple, Conrad Simpfendorfer, John Paul Gonzalvo, Alexander Villares, Natan Zundel, Raul Rosenthal. Management of gastrogastric fistulas after divided Roux-en-Y gastric bypass surgery for morbid obesity: analysis of 1,292 consecutive patients and review of literature. Surg Obes Relat Dis 2005 Sep-Oct;1(5):467-74. doi: 10.1016/j.soard.2005.07.003. Epub 2005 Aug 31. PMID: 16925272 DOI: 10.1016/j.soard.2005.07.003

2\. Khaled Alyaqout, Sulaiman Almazeedi, Mohanned Alhaddad, Evangelos Efthimiou, Marcelo de Paula Loureiro. Gastrogastric fistula after roux-en-y gastric bypass: a case report and review of literature. Arq Bras Cir Dig 2020;33(2):e1509. doi: 10.1590/0102-672020190001e1509. Epub 2020 Aug 24. PMID: 32844882 PMCID: PMC7448858 DOI: 10.1590/0102-672020190001e1509

3\. Ricard Corcelles, Mohammad H Jamal, Christopher R Daigle, Tomasz Rogula, Stacy A Brethauer, Philip R Schauer. Surgical management of gastrogastric fistula. Surg Obes Relat Dis 2015 Nov-Dec;11(6):1227-32. doi: 10.1016/j.soard.2015.03.004. Epub 2015 Mar 12. PMID: 26003896 DOI: 10.1016/j.soard.2015.03.004

4\. Luis Pina, G Craig Wood, Sharma Richardson, Vladan Obradovic, Anthony Petrick, David M Parker. Bariatric revisional surgery for gastrogastric fistula following Roux-en-Y gastric bypass positively impacts weight loss. Surg Obes Relat Dis 2015 Nov-Dec;11(6):1227-32. doi: 10.1016/j.soard.2015.03.004. Epub 2015 Mar 12. PMID: 26003896 DOI: 10.1016/j.soard.2015.03.004

Laparoscopic treatment of gastrogastric fistula after laparoscopic Roux-en-Y gastric bypass (RYGB)

Traitement de fistule gastrogastrique après un pontage laparoscopique gastrique selon Rou

In this key lecture, Professor Andre F Teixeira, MD, FACS, FASMBS focuses on Roux-en-Y gastric bypass (RYGB), which remains one of the most effective and technically demanding procedures in metabolic surgery, requiring mastery of both anatomical precision and procedural sequencing. This lecture focuses on navigating the RYGB learning curve, emphasizing key intraoperative challenges encountered in laparoscopic approaches and how robotic platforms are reshaping operative efficiency and ergonomics.

Robotic assistance in RYGB introduces structured advantages in setup, port placement, and patient positioning, enabling improved dexterity and stability across complex reconstructive steps. Standardization of robotic setup across cases, along with thoughtful selection of sutures and stapling cartridges, enhances reproducibility and surgical flow. A central focus is the meticulous creation of the gastric pouch, where technical pearls—such as careful dissection of the angle of His and controlled pouch sizing—are critical for long-term outcomes and complication reduction.

Reconstruction techniques are explored in detail, particularly the gastrojejunostomy, comparing stapled versus handsewn approaches based on operative context and surgeon experience. Attention is also given to jejunojejunostomy construction and systematic mesenteric defect closure to reduce internal hernia risk. The lecture further addresses troubleshooting intraoperative challenges and structured strategies for complication prevention in the postoperative period.

Looking ahead, innovations in robotic platforms and technique refinement continue to expand the boundaries of RYGB safety and efficiency. The emphasis ultimately converges on key principles of success: disciplined technique, anticipation of pitfalls, and continuous adaptation—ensuring that RYGB remains a durable cornerstone in the surgical management of obesity and metabolic disease.

Roux-en-Y gastric bypass (RYGB): tips and tricks

Bypass gastrique en Y de Roux: conseils et astuces

The incidence of obesity in the general population continues to rise, leading to an increasing number of bariatric procedures, most commonly laparoscopic sleeve gastrectomy, followed by Roux-en-Y gastric bypass (RYGB). In parallel, the incidence of pancreatic neoplasms is also increasing in both sexes, with obesity recognized as a contributing risk factor.

This video presents the case of a 60-year-old woman with a surgical history of Roux-en-Y gastric bypass for obesity, which was performed one year prior to admission, resulting in a significant weight loss of 63 kg. She had no significant comorbidities and was referred to the Authors’ Hospital in June 2024 for new-onset jaundice. Laboratory tests on admission showed a total bilirubin of 8.6 mg/dL, with a direct bilirubin of 5.6 mg/dL, ALP of 896 U/L, GGT of 730 U/L, total proteins of 46 g/L, albumin of 25 g/L, prealbumin of 0.1 g/L, transferrin of 1.09 g/L, CEA of 8.4 ng/mL and CA 19-9 of 3,003 U/mL. CT scan revealed a 3 cm cephalopancreatic mass causing a marked dilatation of the common bile duct (2 cm) and Wirsung’s duct (1 cm). MRI further characterized the lesion, confirming its features as suspicious for a neoplastic process. The mass was technically resectable, with no vascular involvement, and was associated with severe atrophy of the pancreatic body and tail, as well as a suspected branch-duct intraductal papillary mucinous neoplasm (IPMN).

Preoperative histologic assessment was not feasible. Endoscopic biopsy was precluded by the patient’s altered anatomy, and percutaneous biopsy was contraindicated due to its proximity to major vessels.

Although a standard pancreaticoduodenectomy would have been sufficient from an oncological standpoint, a laparoscopic spleen-preserving total pancreatectomy was decided upon since the patient’s preoperative malnutrition and marked parenchymal atrophy placed her at high risk for postoperative pancreatic fistula (POPF). In addition, preservation of the pancreatic body and tail was not advisable due to the presence of a suspected branch-duct IPMN, which carried a potential risk of neoplastic progression. From an oncological standpoint, pancreatic head tumors do not require splenectomy. Consequently, the spleen was preserved to maintain its hematologic and immunologic functions.

Regarding the reconstruction, the authors performed a gastrectomy of the gastric remnant and used the biliopancreatic limb of the previous Roux-en-Y gastric bypass—transposed through a transmesocolic route—to construct the hepaticojejunostomy. This strategy was chosen to decrease the number of anastomoses and thereby reduce postoperative morbidity. Although preserving the gastric remnant may offer theoretical endocrine and motility benefits, it requires an additional anastomosis and is associated with higher risks of leakage, ulceration, bleeding, and delayed diagnosis of potential future gastric malignancy.

Among spleen-preserving distal pancreatectomy techniques, the Kimura procedure which preserves the splenic vessels was selected. The Warshaw technique (WT) was not feasible because the short gastric and gastroepiploic vessels had been divided during the gastrectomy of the gastric remnant.

An end-to-side handsewn Roux-en-Y hepaticojejunostomy was then constructed using continuous 3/0 barbed slowly absorbable sutures for both the posterior and anterior walls. The literature suggests choosing continuous versus interrupted sutures based on hepatic duct diameter, with a cutoff of 8 mm. Interrupted sutures are preferred for duct diameter inferior to 8 mm, whereas continuous sutures are suitable for duct diameter superior or equal to 8 mm due to their reliability, speed, and reproducibility in laparoscopy. In this case, the markedly dilated duct (superior to 1 cm) allowed for the safe use of continuous sutures without a biliary stent. The posterior wall was created using a continuous monolayer “small-bite” technique, followed by a transverse jejunotomy tailored to the duct. The anterior wall was completed in the same fashion.

The postoperative course was uneventful. After a brief stay in the intensive care unit (ICU), the patient was transferred to the surgical ward on postoperative day 3 and discharged on postoperative day 14. Final histology confirmed a pT2 G2 N2 cephalopancreatic ductal adenocarcinoma, associated with IPMN of the pancreatic body and tail with dysplasia ranging from mild to severe. Regarding lymph node distribution, four of seven pancreatic head lymph nodes were positive for metastatic involvement. One of fifteen lymph nodes along the celiac trunk was positive. None of the two lymph nodes at the hepatic hilum showed metastatic involvement. Additionally, none of the fourteen lymph nodes from the pancreatic body and tail were positive.

One and a half months after surgery, the patient began adjuvant therapy and completed 12 cycles of FOLFIRINOX. At the most recent oncology follow-up in September 2025, she remained in good general condition, with no evidence of disease recurrence.

Bibliography:

1\. William F Morano, Mohammad F Shaikh, Elizabeth M Gleeson, Alvaro Galvez, Marian Khalili, John Lieb 2nd, Elizabeth P Renza-Stingone, Wilbur B Bowne. Reconstruction options following pancreaticoduodenectomy after Roux-en-Y gastric bypass: a systematic review. World J Surg Oncol 2018 Aug 13;16(1):168. doi: 10.1186/s12957-018-1467-6. PMID: 30103758 PMCID: PMC6090772 DOI: 10.1186/s12957-018-1467-6

2\. Ernesto Barzola, Jordi Navinés-López, Alessandro M Bonomi, Miguel Ángel Gómez-Bravo, Esteban Cugat, Marc G Besselink. The Trunk of Henle and Belcher's Vein: Important Venous Landmarks in Robot-Assisted Pancreatoduodenectomy. J Clin Med 2025 Aug 30;14(17):6144. doi: 10.3390/jcm14176144.PMID: 40943904 PMCID: PMC12429759 DOI: 10.3390/jcm14176144

3\. Stefano Granieri, Alessandro Bonomi, Simone Frassini, Elson Gjoni, Alessandro Germini, Alessia Kersik, Greta Bracchetti, Federica Bruno, Sissi Paleino, Laura Lomaglio, Alice Frontali, Christian Cotsoglou. Kimura's vs Warshaw's technique for spleen preserving distal pancreatectomy: a systematic review and meta-analysis of high-quality studies. HPB (Oxford) 2023 Jun;25(6):614-624. doi: 10.1016/j.hpb.2023.02.009. Epub 2023 Mar 1. PMID: 36941150 DOI: 10.1016/j.hpb.2023.02.009

4\. Rajan Saxena, Nalini Kanta Ghosh, Saurabh Galodha. Economics and safety of continuous and interrupted suture hepaticojejunostomy: An audit of 556 surgeries. Ann Hepatobiliary Pancreat Surg 2021 Nov 30;25(4):472-476. doi: 10.14701/ahbps.2021.25.4.472. PMID: 34845118 PMCID: PMC8639300 DOI: 10.14701/ahbps.2021.25.4.472

5\. Shahin Hajibandeh, Shahab Hajibandeh, Alessandro Parente, David Bartlett, Nikolaos Chatzizacharias, Bobby V M Dasari, Hermien Hartog, M Thamara P R Perera, Ravi Marudanayagam, Robert P Sutcliffe, Keith J Roberts, John R Isaac, Darius F Mirza. Meta-analysis of interrupted versus continuous suturing for Roux-en-Y hepaticojejunostomy and duct-to-duct choledochocholedochostomy. Langenbecks Arch Surg 2022 Aug;407(5):1817-1829. doi: 10.1007/s00423-022-02548-y. Epub 2022 May 13. PMID: 35552518 DOI: 10.1007/s00423-022-02548-y

Laparoscopic spleen-preserving total pancreatectomy for pancreatic head cancer after Roux-en-Y gastric bypass (RYGB)

Pancréatectomie totale laparoscopique avec conservation de la rate pour cancer de la tête du pancréas après bypass gastrique

This educational live video presents the case of a 37-year-old female patient who underwent laparoscopic sleeve gastrectomy (LSG) for morbid obesity. Her initial body mass index (BMI) was 41 kg/m². During the preoperative period, she lost 3 kg, reaching a BMI of 39 kg/m². The preoperative assessment was unremarkable. Her medical history included obstructive sleep apnea (OSA), which was managed with continuous positive airway pressure (CPAP). Upper gastrointestinal endoscopy and barium swallow studies revealed no hiatal hernia or gastroesophageal reflux. High-resolution manometry demonstrated adequate lower esophageal sphincter (LES) pressure; therefore, the patient was considered a suitable candidate for laparoscopic sleeve gastrectomy (LSG).

Bibliography:

1\. Marko Kraljevic, Julian Süsstrunk, Bettina Karin Wölnerhanssen, Thomas Peters, Marco Bueter, Daniel Gero, Bernd Schultes, Adisa Poljo, Romano Schneider, Ralph Peterli. Long-Term Outcomes of Laparoscopic Roux-en-Y Gastric Bypass vs Laparoscopic Sleeve Gastrectomy for Obesity: The SM-BOSS Randomized Clinical Trial. JAMA Surg 2025 Apr 1;160(4):369-377. doi: 10.1001/jamasurg.2024.7052. PMID: 39969869 PMCID: PMC11840683 DOI: 10.1001/jamasurg.2024.7052

2\. Arnaud Liagre, Francesco Martini, Olivier Van Haverbeke, Hubert Boudry, Niccolo Petrucciani. Ten-year outcomes of sleeve gastrectomy in a single-center series of 156 patients: weight loss and need of revisional surgery. Am J Surg 2025 Oct:248:116525. doi: 10.1016/j.amjsurg.2025.116525. Epub 2025 Jul 16. PMID: 40706117 DOI: 10.1016/j.amjsurg.2025.116525

3\. Salman Al Sabah, Eliana Al Haddad, Iman Qadhi, Muneerah AlMuhaini, Abrar AlAwtan, Omar A AlQabandi, Ali AlKhayat, Ammar F Saleem, Mousa Behbehani. Beyond the decade: unveiling long-term weight and co-morbidity outcomes up to 10 years post laparoscopic sleeve gastrectomy. Langenbecks Arch Surg 2025 Mar 31;410(1):112. doi: 10.1007/s00423-025-03680-1. PMID: 40163236 PMCID: PMC11958372 DOI: 10.1007/s00423-025-03680-1

4\. Raul J Rosenthal; International Sleeve Gastrectomy Expert Panel; Alberto Aceves Diaz, Dag Arvidsson, Randal S Baker, Nicola Basso, Drake Bellanger, Camilo Boza, Haicam El Mourad, Michael France, Michel Gagner, Manoel Galvao-Neto, Kelvin D Higa, Jacques Himpens, Colleen M Hutchinson, Moises Jacobs, John O Jorgensen, Gregg Jossart, Muffazal Lakdawala, Ninh T Nguyen, David Nocca, Gerhard Prager, Alfons Pomp, Almino Cardoso Ramos, Raul J Rosenthal, Shashank Shah, Michel Vix, Alan Wittgrove, Natan Zundel. Surg Obes Relat Dis 2012 Jan-Feb;8(1):8-19. doi: 10.1016/j.soard.2011.10.019. Epub 2011 Nov 10. PMID: 22248433 DOI: 10.1016/j.soard.2011.10.019

Laparoscopic sleeve gastrectomy (LSG) for morbid obesity: educational live procedure 

In this key lecture, Professor Andre F Teixeira, MD, FACS, FASMBS focuses on tobotic surgery, which has entered a transformative era, evolving from a technical innovation into a comprehensive paradigm shift in operative care. Drawing from firsthand clinical experience, this abstract outlines the rapid growth of surgical robotics and its tangible benefits, including reduced recovery times, elimination of physiological tremor, and mitigation of surgeon fatigue. Established platforms such as the da Vinci Xi and emerging systems like the DV5 platform exemplify the technological trajectory, while new Asian-developed robotic platforms highlight a global expansion and diversification of innovation.

Advances in 3D visualization, fluorescence-guided surgery, and smart energy devices are enhancing intraoperative precision and safety, contributing to improved surgical outcomes and reduced complications. The integration of artificial intelligence—through AI-assisted navigation, predictive analytics, and augmented reality—signals a shift toward data-driven, image-guided surgery, enabling more informed intraoperative decision-making. These capabilities are particularly impactful in bariatric workflows, where increasing autonomy and robotic assistance promise greater efficiency and consistency.

Emerging trends such as single-port robotics further optimize patient outcomes by minimizing invasiveness, while innovations in surgical training are reshaping how future surgeons acquire technical proficiency. Institutional programs, including those at Orlando Health, demonstrate how robotics can be embedded into clinical ecosystems to drive excellence at scale. Looking ahead, the convergence of robotics, AI, and advanced imaging underscores a future where surgeons are empowered to think beyond conventional boundaries—redefining what is possible in patient-centered surgical care.

Focus on bariatric surgery

Robotic surgery revolution: what's in the horizon