Laparoscopic single incision sleeve gastrectomy

Laparoscopic sleeve gastrectomy has gained increasing popularity due to its simplicity and good results. Nowadays, many attempts are made to minimize port access, and sleeve gastrectomy is no exception for that. This video shows a laparoscopic single incision sleeve gastrectomy in a 40-year-old female patient with a BMI of 40.

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Laparoscopic single incision sleeve gastrectomy

Authors

M Vix, J Marescaux

Abstract

Laparoscopic sleeve gastrectomy has gained increasing popularity due to its simplicity and good results. Nowadays, many attempts are made to minimize port access, and sleeve gastrectomy is no exception for that. This video shows a laparoscopic single incision sleeve gastrectomy in a 40-year-old female patient with a BMI of 40.

Classification

single port

Keywords

Laparoscopic single incision sleeve gastrectomy

Media type

Surgical video

Duration

17'00''

Publication

2010-07

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E-publication

WeBSurg.com, Jul 2010;10(07).
URL: http://www.websurg.com/doi-vd01en3006.htm

Laparoscopic single incision sleeve gastrectomy

1. Clinical case presentation 00'24''

This is the case of a 40-year-old female patient with a BMI of 40. The preoperative workup has shown no abnormality and the patient’s abdomen allows for a single incision access. To do so, three trocars will be used.

2. Operative settings 00'49''

The patient is placed in a supine position, both legs spread apart. The surgeon stands between the patient’s legs. The incision is performed subumbilically, almost intra-umbilically, leaving a 5cm scar. Two 5mm trocars are placed on each side of a 15mm trocar. Each trocar will go through the aponeurosis via its respective introduction site. As a result, a minimal triangulation is sufficient to perform the procedure. The crossing of instruments is therefore ruled out. The trocar heads are slightly pushed aside to allow for a better triangulation and for fewer constraints on both the camera and the instruments.

3. Liver retraction 02'03''

In order to help retract the liver, a gauze swab is introduced through the 15mm trocar. The liver is then lifted up using a Berci grasper.

4. Lesser sac opening 02'15''

The procedure starts with the opening of the lesser sac at the lower part of the fundus. There, the lesser sac can be easily accessed since the omentum is extremely thin. A 5mm Ligasure® vessel-sealing device is used to entirely achieve the gastrolysis.

5. Gastrolysis 02'36''

The gastrolysis is carried on first towards the cardia. When the dissection becomes uneasy, it is continued caudally towards the pylorus in order to obtain an axial rotation of the stomach that will facilitate the dissection of the cardia at this time in the procedure. The inferior limit of the division of the vessels at the greater curvature is situated either 6cm proximal to the pylorus or opposite the end of Latarget’s nerve. Here the lower part of the gastrolysis is approached. Not having a third instrument that would allow to retract the omentum is disturbing. Nevertheless, the dissection can be easily achieved by placing traction to lift up the stomach. The final landmark of this dissection is controlled. The triangulation is satisfactory despite the minimal distance between the two operating trocars. The adhesions at the posterior aspect of the stomach, between the pancreas and the posterior surface of the stomach and of the lesser curvature, are then taken down. The liver is retracted with a gauze swab maintained by a Berci grasper.

6. Cardia dissection 04'23''

The cardia is dissected anteriorly in order to remove the gastrophrenic adipose tissue situated on the beginning of the stomach. The hook is used in order to ensure a precise and blunt dissection. Once the stomach has been lowered, the rest of this adipose tissue can be divided with the Ligasure® device. The dissection is continued until the left crus. This maneuver will facilitate the opening of the angle of His. It will also allow for an easier application of the automatic suture forceps. Once the vascular dissection is complete, the Ligasure® device is used to resect the adipose part that has been detached from the anterior surface of the stomach. Here the beginning of the left crus can be seen. The maneuvers are slightly limited by the absence of distance between the 2 instruments. However, this procedure can be performed in excellent conditions with these 2 trocars placed 6cm away from one another. The superior part of the cardia is then accessed and the isoaxial rotation of the gastric pouch facilitates the cranial dissection, allowing for a good visualization of the cardia. A few posterior adhesions prevent the stomach from rotating completely. These adhesions will be taken down using the Ligasure® device. This maneuver will lead to ideally identify the posterior and upper part of the stomach. The finding of the posterior part of the cardia is essential. The short gastric vessels are found here. The relationships with the spleen are quite tight and it is frequent to find an extremely short gastrosplenic ligament. Some small bleeders originate from an injury of a short vessel.

7. Application of the first stapler 07'20''

The first linear Endo-GIA stapler —green cartridge— used to divide the stomach will allow to separate the antrum from the fundus. At this time in the procedure, there is no calibration of the access route. The calibration will be achieved when the Endo-GIA stapler is fired for the second time. A bleeding occurred when the first row of staples was placed. A hemostasis is easily performed using the bipolar forceps.

8. Calibration tube insertion 07'59''

A 36 French calibration tube is then brought down into the stomach. It is placed in the remaining gastric channel in order to avoid a complete division of the stomach or a stenosis postoperatively. The tube reaches the part that has already been divided. It is pushed slightly towards the pylorus. It is then slightly withdrawn so that it is placed along the lesser curvature.

9. Completion of the gastrectomy 08'45''

Successive firings of the 60mm Endo-GIA linear stapler —blue cartridge— are then applied. Each time firings are applied, the posterior gastric part is visualized to prevent the posterior gastric pouch from remaining in contact to the gastric channel. When the superior part is reached, the benefit of freeing the entire posterior part of the cardia is clear. A few adhesions may still be present between the omentum, the short gastrics, and the gastric pouch, which will be resected. The gastric pouch is slowly separated away when the last staple line is applied. The gastric pouch is placed in a bag. The Berci grasper allows to have a second hold to facilitate the introduction of the specimen into the bag.

10. Running suture on stapling line 10'12''

We regularly use an absorbable suture along the entire staple line, which is buried in order to limit the risk of postoperative bleeding and of adhesions in the omentum or in the colon along the staple line. The thread is prepared. It has a loop at its extremity. The first knot is not necessary to fix the suture. The rest of the stapling line is then sutured. The instruments have a minimal triangulation at the upper portion of the stomach. The triangulation is easier at the lower portion of the stomach. The liver is retracted using a Berci grasper leaning on a swab. In this patient, the liver retraction is minimal. The end of the first suture is reached. The needle is removed. A second thread is introduced. It will be fixed using the aforementioned loop. In order to eliminate the bleeding part, only the loop is introduced. A stitch is placed in the loop after introducing the thread. A knot is tied between the new thread carrying the needle and the end of the first thread in order to pull the suture away. This single incision position does allow to perform technical procedures such as suturing or knotting, since there is sufficient triangulation. When the low portion of the suture line is approached, the Berci grasper can be used to tighten the suture. This can make the suture of the staple area more comfortable. The entire stapling line is buried. It is protected by the calibration tube, which will only be withdrawn at the end of the suture in order to make it shorter. At that moment, the Berci grasper is used to hold the thread. It allows to pull the stomach upwards in order to facilitate the suture of the major portion. Indeed, when a sleeve gastrectomy is performed, the position of the trocars cannot be ideal for both the lower and the upper portion of the stomach, as it is too long. When a good placement for the dissection of the cardia is achieved, the position is not that good for the end of the suture line, reaching the lower portion of the stomach. A good solution to that consists in pulling the stomach upwards and separating the specimen from the trocar introduction sites.

11. Final view 16'11''

Here can be seen the resulting scar at the end of the procedure. It is a 6cm scar. A simple dressing will be more than enough. The orifice through which the Berci grasper was introduced cannot be seen.