Dabbs Bari Notes
Big OG with balloon
Veress palmers
0 degree 5mm scope optivew small hand breadth below left costal margin
Switch to 30 degree
Additional ports
Nathanson head up and attach
Take peritoneum off left crus
Blow up 30cc balloon
Decide landing point - between 2nd 3rd NV bundle
Enter lesser sac via lesser curve (pars flaccida)
Angle perpendicular to pouch
Blue 60 (not entire staple load 40cm in length truly) rotate stapler cephalad so it turns the staple line upward
Put next stapler in, deflate balloon, push to pouch tip, and hug the NG up toward L crus
Intermittently clear off retrogastric tissue
Clear off some retrogastric tissue at pouch tip staple line with monopolar scissors
Make retrogastric gastrotomy and situate balloon at the tip
Table down to 15 degrees vessel sealer back into 3
Split omentum
Find LOT and measure out 50cm
Proximal is on the right
Hold it in front of yourself and throw a silk through it there using the vessel sealer
Grab silk with arm 4 and take up toward head to ensure it will reach
Monopolar scissor in 3 and make enterotomy (just a touch anterior - this is contrasted to Miller)
Caudiere into 3 and blue 60 into 1
Big blade into jejunum
Use stapler to take it up to stomach
Make GJ about 30cm on posterior side without overlapping
3-0 stratifix PDS just throw once to get it ready
Take balloon out and put in regular NG and pass into jejunum
Close GJ
First layer like normal, second layer fold the anterior staple line over the closure to imbricate
Give ICG green
Make mesenteric window at blind end
White 60 to transect SB check IGC green
Measure out 100cm Roux limb
Hold it out transversely in front of yourself with left hand holding stomach side of roux limb
Monopolar scissor in 3 and make enterotomy
Make another enterotomy on BP limb just next yo staple line
60cm white load
3-0 stratifix PDS to close common
Close mesenteric defect with silk from before
Leak test - occlude Roux limb with Caudiere
(Have suction irrigator ready at beginning of case)
20 degrees head up
Assist, cadiere, camera, vessel sealer, cadiere
- [ ] Expose left crus
- [ ] 30 cc balloon, suction, pull back to resistance
- [ ] Enter lesser sac via pars flaccida just next to stomach (Dabbs does a long skinny pouch instead of coming right onto the balloon
- [ ] Dissect posterior to stomach toward left crus
- [ ] Fire blue load transverse small blade behind
- [ ] take air out of balloon and push to staple line
- [ ] Blue loads up toward angle of His
Clear off posterior pouch of stomach and clear path for blue loads
- [ ] Scissors in 3 - open stomach on backside under staple line
Pull bougie back so it doesn’t get stapled in
- [ ] Table down to 15 degrees
- [ ] Split omentum
- [ ] Use epiploica on transverse colon to lift it up (with vessel sealer) and find LOT
- [ ] Measure out 50cm (?or enough to reach to pouch) let go with vessel sealer
- [ ] Tie silk to jejunum to take up to pouch (be careful not to pull just on silk cuz it’ll rip
- [ ] Make hole in jejunum
- [ ] Blue load for GJ 35ish mm anastomosis posterior to staple line (fat paddle in jejunum)
- [ ] PDS Stratifix 2-0 or 3-0 to close GJ, run it back to pull staple line over suture line. Put regular OG thru nasty before sewing anything at all
This is were i would differ and just staple this closed
Then oversew with PDS stratifix (or Vlock?)
- [ ] ICG green (2cc 5mg), White load divide jejunum
- [ ] Measure out roux limb 100cm
- [ ] Divide with white load
- [ ] Open jejunum and anastomose with white load
- [ ] Close defect with stratifix
Again if possible would just staple this closed
- [ ] Close JJ defect with silk
- [ ] Cut all needles off at the end