Miller

OR case preferences

Always see patients before his surgeries, whether in preop or on the floor. 

Bariatrics pain meds: 5mg oxycodone moderate pain q4h PRN, oxycodone 10mg severe pain q4h PRN

Unless he tells you otherwise, most patients will be sent home with 28 pills of oxycodone 5mg

Miller Roux En Y

JJ first

Left omentum, fine LOT, measured at 50 cm.  Staple with white 60mm.  Harmonic mesentery a little.  Measure out ROUX limb 100 cm (tuck behind the BP limb)

Secure ends together with a long silk on hemostat outside of the top port.  Harmonic enterotomy both ends (cheat toward the inside of each 1) (check back sides to ensure no hole)

Staple enterotomy (big blade into the superior limb, skinny blade into the downside).  6 inch silk two thirds the distance to the opposite end of enterotomy.  Staple enterotomy closed (fat side behind)–cut both silks

(Check staple lines and oversew if needed)

Split omentum (do not cheat toward 1 side) and bring ROUX limb up a bit (situate omental legs around ROUX limb).

Bring in Nathanson and stand patient all the way up

Exposed left CRUS.  Open lesser sac and ensure posterior avenue for stapler.  Identify OG and to make sure it is suctioning.  Measure about 6 cm from GEJ with the end of the Babcock.  Gray 45 staple load with articulation to the right -divide lesser curve perigastric tissue.

Blue 60 (seam guard) staple load with articulation to the right.  Long blue grasper to make retrogastric window to the left CRUS. 

Blue 60 (seam guard) articulated to the left now with big blade retrogastric (this first 1 does not need to be directly toward the CR US–you can cheat outwards a little)

More blue 60s (seam guard) until completely divided.

Check staple lines and clip any bleeders

Blunt graspers on staple line edges–situate NG towards anterolateral aspect of pouch and make enterotomy with harmonic–whole NG through, spread on lateral side

GO down and fine ROUX lymph–make it taut–harmonic enterotomy on the antimesenteric edge

Blue 45 with big blade in ROU X limb–drag up to pouch–pushed through with NG exposed, have anesthesia pull NG back in–stable–make sure the ends lined up perfectly

6 inch silk at the distal end, then proximal end.

Push NG down into ROUX limb

Staple close to the enterotomy.  Check staple line ends

8 inch silk, lateral to medial to imbricate the GJ.  6 inch medial to lateral tied in the middle.  Occlude the ROU X limb.  Leak test.  Clipped any bleeders on the staple line.  Vistaseal.  JP

Miller Roux en Y