Minimally Invasive Surgery (MIS) for Ileal Interposition

Authors: Dr. R. Padmakumar and Dr. Madhukar Pai
Consultant Metabolic Surgeons
Sunrise Hospital, Cochin, Kerala, India

Summary

Ileal Interposition is a surgery getting established as the procedure of choice in non-obese diabetics. The complexity of the procedure makes it difficult to be practiced by more number of surgeons.

We have successfully adopted a MIS technique to complete the procedure with the following modifications:

1. The modified sleeve will be completed by an above umbilical vertical incision of 2 cm for the endostaplers. This is instead of a high placed left sided horizontal incision (used for the specimen retrieval also).
2. Upon completion of the modified sleeve the vertical incision is extended to umbilicus making it 5 cm long. The specimen is removed and the small intestine is brought outside segment wise.
3. First the markings for small intestinal divisions are made at 30 cm from D.J and 30 cm proximal to the I/C and one between the two almost at equidistant from the proximal and distal.
4. Hand held Harmonic scalpel and cautery will be used for mesenteric and bowel division.
5. Hand sewn anastomosis, end-to-end is made at all 3 positions of interposition using 3-0 Vicryl and silk.
6. The mesenteric defects closed with silk after each anastomosis.
7. Each segment is placed back on closure of mesentery to avoid venous congestion.
8. Drain brought out through the 1 cm incision made for telescope.
9. Abdomen wound closed with Prolene and Vicryl subcuticular.

Advantages of this technique:

1. The number of cut ends reduced.
2. Weak spots reduced.
3. No use of staplers for small intestinal anastomosis.
4. Easy to perform
5. Time for procedure reduced at least by 1-½ to 2 hours.
6. Reduce cost considerably (avoids 9 to 12 catridges.)

Disadvantages

Having a small cut in the umbilical area.

This procedure is an innovative, mimicable alternative to completely laparoscopic metabolic surgery in the non-obese group.