Laparoscopic sleeve gastrectomy

Laparoscopic sleeve gastrectomy (LSG) is an emerging bariatric procedure. Its acceptance as an alternative surgical treatment for morbid obesity in the last years is due to the fact that is a rapid and less traumatic operation and thus far is showing good resolution of co-morbidities and good weight loss. We present the stepwise approach for the construction of sleeve gastrectomy in an obese patient with the aid of five abdominal trocars.

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Laparoscopic sleeve gastrectomy

Authors

M Vix, J Marescaux

Abstract

Laparoscopic sleeve gastrectomy (LSG) is an emerging bariatric procedure. Its acceptance as an alternative surgical treatment for morbid obesity in the last years is due to the fact that is a rapid and less traumatic operation and thus far is showing good resolution of co-morbidities and good weight loss. We present the stepwise approach for the construction of sleeve gastrectomy in an obese patient with the aid of five abdominal trocars.

Classification

basic techniques

Keywords

Laparoscopic sleeve gastrectomy

Media type

Surgical video

Duration

11'44''

Publication

2009-07

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E-publication

WeBSurg.com, Jul 2009;9(07).
URL: http://www.websurg.com/doi-vd01en2474.htm

Laparoscopic sleeve gastrectomy

1. Pylorus identification 00'13''

The first step of the procedure is the identification of the pylorus. Retraction of the left lobe is helpful in doing so. Once the pylorus has been identified, 6cm are measured superiorly before beginning the opening of the lesser sac and the gastrolysis.

2. Lesser sac opening 00'45''

The opening of the lesser sac can be achieved atraumatically using the hook. By all means, injury of the vascular network should be avoided to prevent a hemorrhage and to keep the operative field clean. Once the lesser sac has been opened, gastrolysis can begin with the Ligasure device. Careful hemostasis is achieved.

3. Exploration of gastric posterior surface 01'33''

Exploration does not show any adhesions from the posterior surface of the stomach to the anterior aspect of the pancreas. Once the gastrolysis has begun, we move to the upper part of the stomach in order to free the region of the cardia.

4. Phrenogastric fat dissection 02'07''

The phrenogastric fat is freed in order to ensure perfect visualization of the angle of His.

5. Left crus dissection 02'13''

The aim of this maneuver is to dissect the left crus in order to free it and improve the retrogastric passage when the gastric pouch is dissected and divided.

6. Angle of His dissection 02'32''

The adipose tissue covering the angle of His is dissected in order to be resected and so that it is not caught in the staple line. Dissection is carried out carefully in order to avoid any bleeding. The phrenogastric flexure is freed with the hook. The spleen then becomes very close. Once the angle of His is completely dissected, the gastrolysis is continued. Hemostasis is performed carefully to avoid any bleeding of the omentum postoperatively.

7. Gastrolysis 03'24''

The inferior portion of the gastrolysis is the easiest part of the procedure thanks to the use of the Ligasure device. On the superior portion of the gastrolysis, the spleen will become very proximal once the short gastrics are divided. The use of a 30 degree scope improves the view on the very superior part of the dissection. The last few centimetres are particularly uneasy to handle because of the proximity between the stomach and the spleen. Dissection is continued meticulously in order to avoid any injury to a short gastric vessel as its hemostasis is difficult. When the gastrolysis has been completed, the landmarks are checked before the division begins. The 6 centimetres measured from the pylorus will be in front of the division of Latarget’s nerve.

8. First staple line: division of antrum from fundus 06'03''

A linear stapler is introduced through the right hypochondrium port. It will help with the division between the antrum and the fundus. The nasogastric tube is of course removed from the stomach before the first division.

9. Bougie introduction 06'31''

A bougie is introduced into the stomach in order to calibrate the gastric tube. This bougie is introduced in an orogastric fashion.

10. Completion of greater curvature division 06'45''

Thanks to this calibration, the division of the greater curvature can be completed. The use of roticulating cartridges will help in adjusting the orientation of the stapler. The retrogastric tunnel is controlled before each application of the stapler in order to keep as proximal as possible to the bougie. Once at the superior part of the stomach, the retrogastric tunnel is carefully dissected, and then divided. The last firing of the stapler must avoid any injury to the spleen, which may be concealed in the adipose tissue. Following division of the stomach, there may be a few vascular adhesions left that will be divided by the Ligasure device before freeing the gastric pouch completely.

11. Introduction of gastric pouch in the endobag 09'12''

The gastric pouch is immediately introduced in an extraction bag, which will facilitate its removal from the abdomen.

12. Running suture of the staple line 10'05''

A running suture is done in order to bury the staple line to prevent any bleeding originating from it and exclude any fistula. The fashioning of the running suture to bury the staples will help to control the perfect continuity of the staple line and check for the absence of devascularization. During the burying of the staples, the bougie is left in place to prevent the risk of stenosis.

13. Bougie removal and control of hemostasis 11'17''

The bougie can then be removed. Hemostasis is further controlled.