Laparoscopic sleeve gastrectomy in a female patient with a BMI of 42

Laparoscopic sleeve gastrectomy (LSG) was initially introduced for super-obese patients in a two-step concept in order to reduce the perioperative risk. Presently, it is proposed as one of the effective standard procedures for surgical treatment of morbid obesity. This video shows a laparoscopic sleeve gastrectomy in a female patient with a BMI of 42.

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Laparoscopic sleeve gastrectomy in a female patient with a BMI of 42

Authors

M Vix, J Marescaux

Abstract

Laparoscopic sleeve gastrectomy (LSG) was initially introduced for super-obese patients in a two-step concept in order to reduce the perioperative risk. Presently, it is proposed as one of the effective standard procedures for surgical treatment of morbid obesity.
This video shows a laparoscopic sleeve gastrectomy in a female patient with a BMI of 42.

Classification

routine cases

Keywords

Laparoscopic sleeve gastrectomy, female patient, BMI of 42

Media type

Surgical video

Duration

16'00''

Publication

2009-06

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E-publication

WeBSurg.com, Jun 2009;9(06).
URL: http://www.websurg.com/doi-vd01en2609.htm

Laparoscopic sleeve gastrectomy in a female patient with a BMI of 42

1. Trocar positioning 00'17''

This is the case of a 35-year-old female patient with a BMI of 42 who will be operated on for a sleeve gastrectomy. Here is the outside view to show you where I put the trocars: the optical trocar is placed one handbreadth underneath the xiphoid process, and on each side we place a 12mm trocar. Two 5mm trocars are placed, one in the left hypochondrium and one just underneath the xiphoid process. This trocar will be for the liver retractor; this trocar will be to help with the dissection of the stomach. Here are the two operating trocars; sometimes we change the place of the camera and put it in another trocar to have a better view and to be able to place the Endo-GIA linear stapler in with a better angle.

2. Pylorus identification 01'17''

The first step is to view the pylorus: you see it here very easily. We will measure 6cm backwards and begin there. The opening between my grasper’s jaws is 2cm, so you see that I can measure 6cm here.

3. Laterjet nerve identification 01'46''

Another landmark to find is the Latarjet nerve here, you can see it easily here. The Latarjet nerve will finish here on the lower part of the vertical portion of the stomach, just in front of the 6cm that I described before.

4. Opening the lesser sac 02'17''

When this is done, we will have to open the lesser sac to begin the dissection of the greater curvature, and with the Ligasure we will remove all the vessels from the greater curvature. I begin to open the peritoneal sheath very gently with the hook, there are some vessels here that we avoid in order to not have bleeding. When the peritoneal sheath is opened, we can dig inside the fat, just with some graspers, you see you open the graspers and see exactly where you are and it’s quite easy to continue to go inside the lesser sac. If you come closer to the pylorus, as it is described by some teams, I think you can have some problems with pouch dilatation because you can have insufficient gastric pouch to push your food through the pylorus. You can change the entrance of your Ligasure coming from the left hand trocar, here I think it will be correct to put it here but you can change it. I try to avoid some movements that are not necessary. We will go very slowly upwards, you can see very well the posterior aspect of the stomach here and very quickly you will see that the liver can be a problem for exposure so we put the trocar for liver exposure here and I will give the left lobe to my assistant here. So you see the cardia at this moment, the cardia will be here, we will have to prepare it afterwards in order to create a nice gastric tube. I will ask the anesthesiologist to remove the nasogastric tube that is inside to empty the stomach. This nasogastric tube will be replaced by the calibrating tube when we begin to cut the stomach. So you have the posterior aspect and sometimes you see the two sheaths of the omentum when you come close to the short gastrics, the anterior and the posterior part and you can have to cut it separately sometimes. You see the splenic vessels here very clearly and you have to cut all the short gastrics here. I need to change my exposing grasper here.

5. Left crus dissection 05'37''

I removed all the short gastrics, I am coming to the left crus and you see I just have to pull, we have little vessels here: don’t disrupt this because it is bleeding, it’s not very dangerous but it bleeds a lot immediately and you can’t see very well what you are doing. You see here the left crus dissected, I have a little sheath here. I will have to open all the tissue that will be here, but I will open it afterwards with the hook because it is more precise and I will continue to dissect here the tissue between the stomach and the left crus. I will ask my right hand assistant to take the stomach here and to pull it down gently. So you see it’s quite the same aspect that we have coming from the left side of the stomach. Here it is very important to dissect the posterior aspect of the cardia here to remove all the little tissues you have here, sometimes it’s fat, some vessels can be inside, because here will be the outcome of the stapler when I finish stapling my gastric pouch. Here I will use the Ligasure to remove it. I try to remove it immediately outside. If it is too big, I can put the bag I will use to extract the specimen inside, but here the tissue is not large enough for this. We dissect all the greater curvature of the stomach, you see where we have to arrive very well, and so we will begin to cut the stomach. To do that, I go back down and measure again to be sure that I am in a good position here. Another little trick is to remove this little tissue that you have just here behind the stomach, some adhesions between the anterior aspect of the pancreas and the posterior aspect of the stomach here, and that is quite easy to remove with the hook or with the scissors. If you don’t do that, you can’t see very well where you are and at what distance you are from the lesser curvature. There are very loose adhesions here but you have to remember that you have all the vessels of the lesser curvature behind so you have to avoid bleeding and an injury here. The head of the pancreas is here, it is interesting to do that with the hook because you see by transparency what you have inside your tissue here to avoid having to remove some vessels. The pancreas is very close to our dissection here. I have finished here, you can see easily all the inner part of the stomach.

6. First staple line 07'37''

The first staple line would be here inside, you open it widely. I don’t put a calibration tube at this time because it is very difficult to put it inside in a good position. It is easy to see the stomach wall that you can have here, but you don’t have to reduce, it’s just to have a vertical stapling of the stomach here. We can begin the stapling, I have enough gastric tissue here to be sure that I am not cutting the stomach in two.

7. Calibrating tube insertion 08'23''

After that, the next step will be of course to place the calibrating tube inside. I have just put a regular nasogastric tube inside my calibrating tube because the calibrating tube is too soft and I need to have a stronger one; sometimes the tube is going in the right direction, it goes inside the stomach, you see it here arriving. Push it in the pouch and you see that I haven’t interrupted the stomach here. I always try to put it very far up to the pylorus to be sure that the tube will not go away when I am beginning the cutting with my staple line.

8. Gastric pouch stapling 09'28''

It is a blue cartridge 60mm roticulated stapler that I will use here and so you see that it is quite easy to move up. We will check just at the posterior aspect that we have no trouble. We move the stapler and you need to have a very good calibration of the pouch to avoid a dilatation. Remember that you have a very long staple line so that if you have a crossing or devascularization on a part of it, then it can be a very difficult situation, especially in the upper part of the stomach. I am just in front of the channel I have performed here, I will use my grasper to be sure that I can use this channel to go in. You must be careful because if you push too much, you can have an injury to the spleen. We change the entrance of the camera because I think that the angle will be better here. You need to be very careful when you remove the specimen because of these two or three vessels. You see the region very nicely with the short gastrics that were cut, the splenic vessels here, the pancreas, the left crus, and so we will oversew the staple line here.

9. Specimen insertion in Endobag 12'05''

We put the bag inside and we will put the specimen in the bag first, my assistant will take one part of the bag and I will pull.

10. Oversewing the staple line 12'22''

We will oversew the staple line that can take a long time, you can use some other material, but here I prefer to do that with a needle so that I give a chance to our younger colleagues to use a needle inside and make a suture inside. Make sure that you haven’t stitched the tube to the stomach and everything will be easier. We have finished with the oversewing of the staple line. For the postoperative management, the patient will drink a glass of water this evening and will begin a liquid diet the next day. Then soft food for another month before these patients can eat and chew normally. In one month, such patients can lose 10 to 15kg.