Laparoscopic sleeve gastrectomy for morbid obesity: a stepwise approach

Laparoscopic sleeve gastrectomy (SG) was first described in 1999 as part of the biliopancreatic diversion-duodenal switch (BPD-DS) procedure. Subsequently, laparoscopic SG has been performed as a stand-alone procedure or as part of a staged surgical approach, with the intention of completing the BPD-DS at a later date. This procedure is relatively easier to learn, easier to teach and its initial results are comparable to the gastric bypass in terms of excess body weight loss. We show here a standard 5 port technique for an obese woman with a BMI of 41.

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Laparoscopic sleeve gastrectomy for morbid obesity: a stepwise approach

Authors

M Vix, J Marescaux

Abstract

Laparoscopic sleeve gastrectomy (SG) was first described in 1999 as part of the biliopancreatic diversion-duodenal switch (BPD-DS) procedure. Subsequently, laparoscopic SG has been performed as a stand-alone procedure or as part of a staged surgical approach, with the intention of completing the BPD-DS at a later date.
This procedure is relatively easier to learn, easier to teach and its initial results are comparable to the gastric bypass in terms of excess body weight loss.
We show here a standard 5 port technique for an obese woman with a BMI of 41.

Classification

basic techniques

Keywords

Laparoscopic sleeve gastrectomy, morbid obesity, stepwise approach

Media type

Surgical video

Duration

19'30''

Publication

2009-02

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E-publication

WeBSurg.com, Feb 2009;9(02).
URL: http://www.websurg.com/doi-vd01en2511.htm

Laparoscopic sleeve gastrectomy for morbid obesity: a stepwise approach

1. Clinical case presentation 00'20''

This is the case of a female patient with a BMI of 41. Her operative workup is normal and she would like weight loss surgery. After reviewing the different techniques available, it was decided with the patient to proceed with a sleeve gastrectomy.

2. Trocar placement 00'36''

Here is an external view showing the trocar positioning. The first trocar installed is a 12mm optical trocar. The patient’s head is here and her feet are here; this trocar is at one and a half handbreadth’s under the xiphoid process. A 5mm epigastric trocar will be used to perform the liver’s retraction. Here, a 15mm trocar that will allow placement of the first stapling line on the stomach: it is a green stapler manufactured by Covidien; we therefore need a 15mm trocar. A 12mm trocar is used for the Ligasure device in order to dissect the greater curvature, and a 5mm trocar is placed in the left hypochondrium to help with the stomach’s retraction. Here is the internal view, obtained with a Karl Storz HD camera. The pylorus is the first landmark to find. The pylorus can be seen very clearly and so we are going to measure 6cm; the 6cm arrive around this vessel here. You see that when looked at from above, the Latarjet’s nerve runs here, on the vessels of the lesser curvature. The division of the Latarjet’s nerve will be done opposite to this vessel.

3. Lesser sac division 02'04''

We begin to open the lesser sac here using blunt dissection.

4. Gastrolysis 02'16''

Now I opened the lesser sac and I can begin to perform the gastrolysis. We now suspend the stomach using the trocar introduced through the left hypochondrium, and I will use the Ligasure device in my left hand trocar to change the orientation and begin the gastrolysis. Using the Ligasure, the division of the gastric vessels is not difficult, it needs to be done carefully though in order to avoid any bleeds and try to keep a clean operative field. I always try to keep a small safety margin when beginning the dissection to not burn the stomach with the Ligasure system, just in case we are unable to complete our dissection; this has not occurred for the moment but it is safer. When starting on a more vertical aspect of the stomach, I place the Ligasure device in the other trocar. You can use the 5mm Ligasure, it works perfectly well; however, I have always preferred to use the 10mm because you have the impression that you have a large finger that allows you to dissect and lift elements in a blunt fashion. We now alter the instruments in each trocar and we continue. We are now deeper in the lesser sac. We can see the pancreas, with the splenic vessels that we will discover superiorly. The vascular line that we wish to divide can be seen quite clearly. We can guess the spleen’s outlines in the back.

5. Short gastric vessels dissection 04'03''

The hardest task in this procedure will be the short gastrics because sometimes the patients have very short gastrics, and we have to get very close to the spleen in order to manage the dissections near it. This dissection will run up to the cardia. It is occasionally difficult to continue this dissection up to the cardia by going through this way because the angles are not right; we can then start again on the other side, begin the cardia’s dissection near the lesser curvature. This is what we are going to do here. You can see here that the patient’s position has changed.

6. Cardia dissection 04'50''

The dissection we are going to carry out now will free the superior part of the cardia. It is a dissection I like to complete with the hook. It may be archaic but, in my opinion, it remains very useful here. You can see the type of exposure that is obtained of the cardia’s superior section. We come across the dissection plane we had started previously, and here again we are very close to the spleen. The peritoneum is opened in order to reach the left crus. The left crus is here, we sometimes encounter a small sliding hiatal hernia, which is quite typical in obese patients. We would like to stay close to the spleen to dissect it, but the dissection plane is no longer here; it is closer to the stomach and so we go back to a far less dangerous area when it comes to vascularization. There is still a short gastric here that we will divide with the Ligasure device, and we will have almost completely freed the left part of the stomach. We can continue a little over there, but here the problem is not the spleen but a sort of gastrosplenic ligament in the cardia’s superior part. We can dissect it easily and here you can see that we have completely freed the crus. We carry on on the posterior part because we will need this later when applying the stapler. What we can also occasionally do is free that small bit of fat located on the gastrophrenic junction: this allows to be more accurate when applying the last stapling lines. This small piece of fat is easy to dissect although we should always be careful of vessels that may be running through it and that can cause the operative field to become less clear through bleeding. We have now freed this fat. I think it is enough here as we have freed all the gastric adhesions. The stomach is entirely freed here up to its internal part. You can see clearly the landmark of the lesser curvature’s vessels. Here we have a very nice view of the pancreas. It can be a problem when we have posterior adhesions and that we are situated a bit too deep.

7. First stapling line 07'39''

We are now going to use the first Endo-GIA. We then ask the anesthesiologists to remove the gastric probe. The first staple line is placed here; this first line should not completely cut the stomach. The stapler is placed almost vertical to the stomach. Here you have a part of stomach that remains, as well as having some posteriorly. The calibration of this part here is not very important. It is a green cartridge Endo-GIA linear stapler that I fire at this moment. We are now going to use blue cartridge Endo-GIA to complete this, but first of all, we are going to set the calibration probe. I check the hemostasis.

8. Intragastric calibration tube insertion 08'23''

The probe’s passage through the back of the throat is not easy due to its size; this is where it is tight. It must be brought to the duodenum to be sure that if the probe moves back a little, we will not be impeded. I have the probe pulled back a little to make sure that it stays at the level of the lesser curvature and does not loop around the stomach. We should not forget that the anterior surface of the stomach is quite plane, and the posterior surface is arched and that the probe has to go through this.

9. Gastric sleeve completion 09'00''

This is a roticulated Endo-GIA that I use to do this and you can see that I trap the calibration probe that allows me to calibrate. We need to maneuver here by passing posterior in order to see if the calibration is also perfect there, and we do not leave too much posterior gastric pouch. I ask my assistant to grasp the staple line here in order to stabilize the Endo-GIA and I fire it. We are protected by the calibration tube. What is important here is to obtain a staple line that is as straight as possible. Here you see the joint between the two stapling lines: there are no major angles on this spot. An angle between 2 stapling lines can be the cause of an early fistula. Here, we recover the probe; you can see that we can really calibrate the gastric pouch; we can see the internal part of the pouch here. It is very important to grasp the staple line and not the stomach with the Endo-GIA. We then check the superior part with the camera to see if the forceps has completely made the posterior channel and that we have entirely dissected the retrogastric tissue here. The last stapling line can be done with a straight stapler although I prefer to keep it angled as it allows me to better adapt to the gastric pouch that I wish to do. You’ll see that the stapling line on the internal part is completely straight. I will have a few mishaps on the falling stapling line, but as it does fall, it is relatively unimportant. The stomach is entirely divided, but we should always be cautious of posterior adhesions that have not been divided. There is a very small adhesion here that will be removed with the Ligasure. The stomach is placed in an extraction bag and placed in the bottom part of the abdomen for the moment. We must then check the hemostasis, in particular on the omentum’s division line that you can see here, we can see the short gastric vessels’ division line, as well as the division line of the greater curvature’s vessels that we also see here. There is a small bleed on the superior part as we often staple the fat and the diaphragm’s peritoneum on the left crus.

10. Gastric running suture 11'47''

We now start performing a running suture. You see that the thread is blocked. It saves us from tying a knot on the superior part in difficult conditions. The suturing material I am using is absorbable. When using non-absorbable material, ulcers may form on the anastomosis line. This may lead to pains or dysphagia. For the moment, we have not had any fistulas on the stapling line; you see that the stapling line has been performed very carefully. I keep the calibration probe in place when performing the running suture to be sure that I am not inducing any stenosis. When finding a hemorrhagic area, we use the bipolar forceps to perform the hemostasis, but one of the running suture’s advantages is in obtaining a perfect hemostasis on these stapling lines. We still have the equivalent of one and a half cartridge of stapling line to bury; it is a time-consuming and fastidious job. The running suture is now finished; we gather the needle and recheck the superior part’s hemostasis. During the last part of the running suture, we could have placed the patient horizontally to make things easier; you can see here that there is a bit of hemorrhage superiorly but nothing has worsened since we have finished the running suture. The orogastric probe has been removed and you see the very thin gastric tube that is still in place.