Live laparoscopic sleeve gastrectomy for morbid obesity

Sleeve gastrectomy (SG) patients have been shown to experience significant weight loss and improvements in their health. This video shows a live procedure in which all steps are well discussed.

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Live   laparoscopic   sleeve   gastrectomy   for   morbid   obesity

Authors
M Vix, J Marescaux
Abstract
Sleeve gastrectomy (SG) patients have been shown to experience significant weight loss and improvements in their health. This video shows a live procedure in which all steps are well discussed.
Keywords
Laparoscopic sleeve gastrectomy, SG, morbid obesity
Media type
Duration
25'30''
Publication
2012-01
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, Jan 2012;12(01).
URL: http://www.websurg.com/doi-vd01en3555.htm

Live   laparoscopic   sleeve   gastrectomy   for   morbid   obesity

3. Greater curvature dissection 01'38''
The sleeve gastrectomy –the steps, is to first remove all the omentum from the greater curvature, and then we will begin from here to cut the stomach and to remove a part of the body and the fundus of the stomach, and the control of a calibration tube. Here that is an epigastric trocar; the optical trocar is about one handbreadth’s and a half under the xiphoid process and it’s a 15mm trocar in order to place a green cartridge of Endo-GIA™. Here on the left side, on my left side, right side of the patient, I have a 5mm trocar for my left hand; for my right hand, I have a 12mm trocar just on the mid-clavicular line, and on the anterior axillary line, I have a 5mm trocar for my assistant. So this is the configuration with five trocars, it’s done with 5 trocars so that we can show very easily all the steps, and we can expose very nicely for you. Usually, we can perform it with 3 trocars; if the left liver lobe is a bit too large, we can use a Berci needle and a gauze to push the liver on the side and have a nice view on the cardia. We begin to remove all the vessels from the lesser curvature, we can keep quite close to the stomach here, because you know that you will remove that part of the stomach afterwards, and so it’s quite easy to perform this dissection, and this is the reason why a lot of surgeons like to do the sleeve gastrectomy. The problem in the sleeve gastrectomy is that we found a lot of fistulas at the upper part very close to the region of the cardia, and that is not totally explained because in the gastric bypass, we do exactly the same dissection and we are cutting the stomach exactly in the same place, and we don’t have that amount of leaks at the upper part of the stomach, but we have that in the sleeve gastrectomy. I continue the dissection. Very nice exposure of your operative field. So this is safer for dissection. What are your tricks for having such a nice exposure? There is no trick, there is no special trick. Do you put the patient in a particular position on the table? The patient has a little bit the legs down and that is enough to have this nice view on the upper part, you see that we retract the liver on the side, and here you need to have a cameraman that is following you, with a 30-degree scope, it’s quite easy to perform, and you see here we are arriving quite close to the cardia. I’m making my dissection between the spleen and the stomach. The spleen is not a big concern here. I don’t look for the spleen. I try to stay close to the stomach, but not too close. I just remove that sheet of short gastrics that will be close to the spleen, and when you’re able to do that, you see that the space between the spleen and the stomach is increasing. At the end of the procedure, I will check again the hemostasis on the omentum side, because there is a reason for having postoperative hematoma in the sleeve gastrectomy. Not only on the staple lines but on the Ligasure™ line. That’s a 5mm Ligasure™ with a round tip, from Covidien, it’s a very nice instrument to use. You don’t need a 10mm one. The 5 one is very well adapted especially for the upper part of the stomach when you’re close to the cardia. I think that the 10mm one in this case is a bit too large, so you see I remove all the vessels until I arrive on the landmarks here. And I will choose the first vessel or the last vessel I will keep in place, the last vessel will be here, and so I can remove a bit more fat here. The first step is done. We clean the greater omentum, the greater curvature here, and a little trick here is just to have a look on the posterior aspect of the stomach, and sometimes you see some adhesions here. I will use the scissors. So you see here this is the fat from the lesser curvature, with the vessels of the lesser curvature here that are just some adhesions of fat you have in front of the pancreas. And you need to remove that to open that, to be sure that you will be on the good position for removing the stomach, and having a good gastric pouch, a good gastric tube afterwards. Here you see by transparency the pancreas here, and again here. Don’t remove please.
5. Calibration tube 08'38''
Putting the calibration, we will put a calibration tube, but for the first time, I don’t suggest to take the calibration tube because it’s quite difficult to put in place, and we will introduce the calibration tube at this time. I just cut a little part between the antrum and the fundus in order to begin the way. And you have to choose, due to the thickness of the stomach, if you will have a new load with a blue or a green cartridge. Here I think that a blue one will be correct, and we will introduce the calibration tube here. The calibration tube is a 36 French tube, it’s brought down by the anesthesiologist through the mouth of the patient, it’s not quite easy to put in place, because they are under the draping. There’s a reason why I don’t put the calibration tube for the first firing, as it’s very difficult to put in place, and I will show you a little trick. At the beginning of the experience, you put the calibration in that corner, and after that you have just to take that corner this way, and you push it up, and you push up, you turn this corner upwards, and when you’re coming. Move back the tube. OK, not too much, because you need to have pressure on the tube. Good. The tube is in place here. At the beginning of the experience, I tried to push the tube down to the duodenum, but that gives a curve, and this curve changes the calibration a little bit, so I prefer to take it straight and to keep it here in place. You see here, the tube is in place, we have a real channel between what I cut and the remnant, and so I can continue to apply the staple lines.
6. Completion of gastrectomy 11'01''
The second staple line here I will use is a 60mm blue cartridge. Of course, sometimes when you feel that the stomach wall is very thick, you can use a green one, it’s not a mistake, but the problem is that you need to make more hemostasis, and you have more oozing after that. You see the tube is here, I pull a little bit on the stomach, not too much, to be close to the tube, here again you see why I remove the fat behind, and here also you can feel the tube here. The tube is in place, and just beware at the upper part that you don’t have too much gastric bulge outside. Here it seems to be well in place. When you fired, have a look on your staple line to feel if the staple line is correct, if you have no open stapler, if the staples you see are not squared, because if when they are squared, it means that they didn’t close and that you will have a leak. So we remove that, after that all the time I have a little look for the next staple line. And you see here I have place to do it and I will put once more, a 60 again blue cartridge, that is one of the easiest part also for the sleeve gastrectomy, it is to staple sometimes, it is coming really in a straight line, sometimes you have to fight a little bit with the stomach and with your staple line to be sure that you are in a good position. If you have a crossing of staple lines, of course you need to put some stitches and we will discuss afterwards. I go again in the mid-site trocar. You can have a look also inside, you can see the posterior channel here very easily, and you can see that I don’t have a lot of stomach on the inner side but all the bulge of the stomach is on the outside. Each time I staple, I stabilize the staple line with my grasper in order not to push away the tissues at the beginning of the stapling. Here you see also no crossing of the staple lines and I will ask my assistant to take the staple line a little bit higher and we have a short part of stomach. And you see here we have a short part of stomach. I just arrange a little bit the liver retraction. I choose not to take a liver retractor so you see that it’s not totally mandatory, and here I can cut very easily the last part. One of the rules that I give to our chief residents and residents is when you have to cut a part of stomach in the gastric bypass or in the sleeve gastrectomy, take a 60 cartridge because when you will close your cartridge, you’ll enlarge the tissue that you have to cut. Here it seems that it’s very short, and you’ll see that it’s not so short when I’m applying the cartridge. I am on the other side and when you have a look here, you see that the part that is free is not so long. It’s long enough but I prefer to have a long part that is not on the stomach. At this time, you can see that the assistant wants to remove the stomach. You ask them not to do that because in the dissection sometimes you have some parts on the posterior aspect that were not removed—here it’s totally free but sometimes you have some adhesions here, and when you pull on the stomach at this time, you can have an injury of the short gastrics. Do you leave the pouch inside the abdomen once for all? Absolutely. I will remove that in a bag. I will introduce the bag. See I took the lower part of the stomach and I put the bag at the mid-part of the specimen I have to retrieve, and I push it inside this way, and so very gently, you can see that the specimen is going inside the bag. One important thing is that you keep just in front of the opening of the bag a part of the staple line because the staple line has the most solid part of the stomach and so you will pull on it when you remove the specimen. I propose that you put a loop around and you keep the loop outside and then you will be able to pull on the suture. Yes, but I never had any trouble with removing the specimen so I’m not sure that making one more technical thing is easy at the beginning of the experience. What you’ve just said is the same when we want to remove a specimen such as colon is to have an extremity. Look, just a little surprise here, see: this is an accessory spleen. So the question is at that time: is it finished or not? For me, I prefer to oversew the staple line, why? First, to make a better hemostasis and not to perform the hemostasis using bipolar cautery. Secondly, I think it’s more secure for me to avoid the leaks, especially at the lower part of the stomach. It doesn’t change anything at the upper part if you have a leak, even with buttressing material or with oversewing, it doesn’t matter, and here you’ll see that we use a special thread to make that. At the upper part, it’s quite difficult to make a knot. It’s interesting to see that you did uneasy procedures in less than half an hour, about 20 minutes. It is a well-standardized procedure.
7. Staple line oversewing 19'00''
This is a V-loc™, it’s a barbed wire, and you can try it in the lab. So you have to go inside, see the little loop for closing. I tried not to go through the loop but this loop is not large enough to keep on the tissue. What is the length of the suture? We have 3 lengths. We have 15, 23, and 30; for the sleeve gastrectomy, I use a 23 long thread. And you can use that in the lab. That’s Maxon®. Because there are 2 types of V-loc™, the first one is Maxon®, and the other is Biosyn®. And the length of resorption is longer for Maxon® than for Biosyn®. See I’m quite close to the staple line. I take a very small part of stomach. You pass 3 stitches and no more and you pull your sutures afterwards. The first thing with this thread is that you cannot go back. If you want to re-open your oversewing line, it’s not possible with the V-loc™, and if you make more than 4, you’ll have too much resistance, and you can sometimes break the thread when you do that. So I’m at the origin of the cardia here. Do you sometimes or always do tests to evaluate dehiscence or weakness of the stapling line if you have a doubt or when you do, do you do it and what do you do if you have to do it? It’s difficult to do it in a sleeve gastrectomy, because the tube is long, the volume is great, and it’s difficult to really put some air or some water inside to make a blue test. I never did it because it’s quite difficult and usually when I think that I have a problem with my staple line, it’s when I’m putting the staples in place. After that I can check and if really I have a problem, I can try to do an endoscopy or an air leak test. Just routinely, we never found something that was not expected. And here you see you take a little bit of this. How do you do the end of the sutures? Here I take the thread inside. You cut it close to the stomach, closer. So I take the needle out. Perfect, so it’s done. See no bleeding at all, just a little bit of oozing here that came before I oversewed the staple line. We’ll have a look on the liver but usually in bariatric procedures, when you have an injury of the liver, do nothing, just make a little compression so you can see it stops very easily. Here we’ll do a little bit of cautery just because we have to go away. Fat liver, the liver is fatty and such patients are very fragile. Just by using bipolar cautery, I think we can solve this.