This patient had a previous sleeve gastrectomy in April 2019 and cholecystectomy, and now the body mass index is 39, and we are proposing a second stage laparoscopic endoscopic magnetic side-to-side duodenal ileostomy. With four trocars around the umbilicus and on both sides, we are taking down adhesions from previous cholecystectomy. This is important because we want to clear the duodenum to have a free duodenum. And after cholecystectomy, the duodenum can be stuck to the undersurface of the liver, and therefore, with the ultrasonic dissector, we are taking down those adhesions, so the second duodenum can be more mobile. You can appreciate here the common duct and the cystic duct clip in the upper part, care is taken not to injure the duodenum. And in some cases, we may need to do a cochlear maneuver, but not in this case. We're going to finish clearing the adhesions. Of course, the goiteromentum will be split in the right side. And after identification of the ligament of trites, about 15-20 centimeter distal on the jejunum, we're applying a retrievable metal clamp. Now, from the ellistical valve, we will measure a distance of 250 centimeter. This is done with the umbilical tape of 50 centimeters long, therefore, five times this measurement will be made, going from distal to proximal. At 250, we will put two titanium clips on each side of the mesentery. You see the laparoscopic images in the upper part, the endoscopic images in the lower part, and the magnet, linear magnet, is introduced in the second, third, and fourth duodenum. Well, by laparoscopy, we can appreciate the scope in the stomach. And looking again near the ligament of trites, we will see the endoscopic light coming after the ligaments of trites. Therefore, now the magnet has reached the upper jejunum. We will apply the positioning device on the surface, anti-mesenteric surface of the jejunum and grasping the magnet. You can see when we grasp it, it sticks to the wall. And endoscopically, we will release this magnet by removing the catheter that has attached the magnet. We put some lubricant in the lumen of the jejunum. This will help to drag the magnet from the proximal jejunum to the marked clips at 250 centimeters from the ileocecal valve. Therefore, the retrievable bowel clamp is removed. You can see we will have some lubricant going into the bowel. The endoscope will be retrieved, going into the stomach, aspirating some of the air and CO2. We are now starting the dragging towards the ileum. There's a contraction with the atriomatic bowel forceps and the positioning device is pulling the magnet distally. Now during this time, the second magnet is introduced orally into the stomach and after the pallorus into the first portion of the duodenum. Once the dragging has reached the metal clip, we are moving the ileum anticolic towards the first portion of the duodenum. Here we can appreciate the pallorus, the first portion of the duodenum. The ileum is then attached with a click between the magnets in the first duodenum and in the ileum. The catheter will be released of this upper magnet. It is now free. In order to remove the positioning device, we have to rotate at about 90 degrees. You can also micro-position the magnet so that it is about 2 centimeters distal to the pallorus. Now, turning at 90 degrees will remove the positioning device but keep the two magnets into play very slowly. Here we can again view the micro-positioning of the two magnets, 2 centimeters from the pallorus. The scope is aspirating the content of the stomach before exiting. And then lastly, we have to close the mesenteric defect on the left side, the Peterson defect that is between the mesentery of the transverse colon and the mesentery of the ileum. You can see the marking clips. We use non-absorbable suture 2-0 and this is going to be run from top to bottom, closing completely the mesenteric defect. This is to avoid an internal hernia. Of course, it's not 100 percent, but one has the obligation to prevent an internal hernia that could be a lifelong risk. Now, the compression will make the anastomosis over the next two to four weeks, and the magnet will pass in the distal ilium into the stool. There is no risk of bleeding because there's no cutting a bowel here immediately. The anastomosis will happen over several weeks. There's no leak. And here we have a last look at the position of the two magnets.

laparoscopic endoscopic magnetic side-to-side duodenal ileostomy

adhesions

magnets

mesenteric defect

internal hernia

verdeyen