Ahmad Yousry0:06
Precise counting of total bowel length is a step of paramount importance. Easy bowel limb length in bypass procedures is a subject of controversy. In one anastomosis gastric bypass, most surgeons use a biliopancreatic limb of 200 cm length, but some cases may experience inadequate weight loss or weight regain. In SADIs, the alimentary limb is 300 cm; however, shorter alimentary limbs may result in serious malnutrition. We advocate counting of total bowel lengths in all cases of one anastomosis gastric bypass, Roux-en-Y gastric bypass, and SADIs. We use two soft bowel graspers marked at 5 cm and 10 cm. We count full stretched bowel hand to hand in all cases. This is the port sites here we see the camera port, two working ports, one assistant port, and liver retraction port. This is the surgical team positioning: the surgeon between the legs of the patient, the cameraman on the right side of the patient, the assistant on the left side of the patient. In this position we start the counting process. Now we start to count in this position, counting from the ligament of Treitz. This is one, this is two, you see full stretched bowel, this is three, hand to hand, four, five, six, seven, eight, nine, ten, eleven, twelve, thirteen, fourteen, fifteen. At 15 counts or 150 cm, I mark using 150. I do marking at 150 cm by one clip proximal and two clips distal. There are two clips distal at 150 cm. Then 16, we continue to count 16, 17, full stretched bowel hand to hand, 18, 19, 20. At 200 cm we use one clip proximal and a stitch distance. This is the marking done at 200 cm, 2 m. We do this marking: one clip proximal and a stitch distance. Here is the stitch, it's always not too tight. This is very important. At this stage we change the position of the operating team. After 200 cm count, the surgeon moves to the left side of the patient. These were the first cases where I didn't dock the left hand of the patient. Now I dock the left upper limb of the patient. I stand on the left side, the cameraman beside me. I use the previously left hand working port as a camera, and I use two working ports, liver retraction port, and the assistant port I use now as working ports. This is I record from the counting at this new position. I usually use this position for counting after reaching 200 cm, gives me ease of access to the small bowel up to the cecum. I use the liver retraction port and the previously assistant port as working ports. Now continue to count. This is 21, 22, 23, 24, 25, 26, 27, 28, 29. There is a Zell there, we will repair it. 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44. Whatever the length you can count. 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69. It's very easy. 70, 71, whatever the length. 72, 73. Here the stitch at 200 cm mark is apparent. Here reach 75, 77. It's very easy counting the total bowel length in all bypass procedures. It helps making the right decision that achieves best weight loss and avoids malnutrition. Thank you.
