Chapter 29

• The biliopancreatic diversion (BPD) with duodenal switch (DS) is a mixed, hybrid surgery to treat morbid obesity.
• The vertical sleeve gastrectomy with a >50 cc pouch is the restrictive part.
• The biliopancreatic diversion of the DS is the malabsorptive part.
• Technically difficult but with excellent weight loss and quality of life.

Laparoscopic Biliopancreatic Diversion: Duodenal Switch

The duodenal switch (DS) is one alternative to the Scopinaro biliopancreatic diversion (BPD). Hess1 did the first case in March 1988 (in a woman with BMI = 60 and she has BMI = 29 17 years later), and Marceau2 made the first publication. Baltasar3,4 showed more cases. Gagner5 performed the first LDS in July 1999, and Baltasar6,7 published the second world experience.

LDS is (1) vertical sleeve gastrectomy (VSG) with pyloric preservation of less than 60 cc and (2) BPD of common channel (CC) of 65 cm, a alimentary loop (AL) of 235 cm, and the remaining biliopancreatic loop (BPL) as the proximal small bowel.

General endothracheal anesthesia is given. The patient is supine with the separated legs. Three surgeons perform the operation, one in between the legs and the other two on the sides. Direct vision approach is always used for the first trocar with an Ethicon Endopath#12 on the lateral border of the right rectus muscle, 3–4 fingerbreadths below the right costal margin. This is the only large trocar, the working trocar (WT). Trocars are positioned. The camera is 30° and placed in the midline, and the other four trocars are 5 mm. A silk suture passed from the right costal margin around the round ligament brings the liver and round ligament to the right and leaves the antro and duodenum well exposed. Cholecystectomy is done at this time.

The harmonic ultrasound (HUS) is used to cut the vessels at the greater curvature of the stomach, starting opposed from the incisure angularis, and progressing to the top and freeing the stomach from the left crura. Sometimes adhesions from the posterior stomach wall and pancreas have to be separated.

The left-side-placed surgeon cuts the vessels the distal stomach down and passes the pylorus, for at least 3 cm, and he creates a tunnel posterior to the pylorus and in between duodenum and the pyloric artery.

The right-side-placed surgeon passes the stapler by the WT, divides the duodenum with a linear white stapler with a single 6-cm cartridge firing.

The surgeon in between the legs places a seroserosa continuous running suture of 3-0 PDS to prevent duodenal leaks.

The anesthetist inserts a #12-mm nasogastric tube (RUSCH) in the antrum with a guide wire inserted within and to the tip. The right-placed surgeon divides the antrum by the WT, starting 1 cm proximal to the ...

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