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Laparoscopic Sleeve Gastrectomy

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MohamadH.Alaeddine,
GhassanA.Shamseddine, andBassemY.Safadi

Indications 3. Initial port placement is through the umbili-


cus. In some super obese patients, placing
Morbid obesity with body mass index greater an optical port under direct vision may be
than 40kg/m2. easier than using an open approach. In such
Morbid obesity with BMI greater than 35kg/ patients the initial port placement is about
m2 with serious comorbidities. 20cm below the xiphoid process to the left
Select cases of obesity (BMI 3034.9kg/m2) side of the midline.
with serious metabolic disease. 4. Place two other ports in the left upper quad-
Super obesity (BMI >50kg/m2) as a first stage rant of the abdomen and one in the right
of the duodenal switch. upper quadrant. The operation can be per-
Patients should have been evaluated in a mul- formed with three ports. Additional ports
tidisciplinary bariatric surgical program and may be needed for difficult cases.
deemed appropriate for such surgical 5. Retract the left lateral segment of the liver.
intervention. 6. Identify the pylorus.
7. Identify the anterior vagal branches along
the lesser curvature and crows feet.
Essential Steps 8. Start sealing and dividing all the vessels
along the greater curvature of the stomach
1. Place the patient in the supine position; split- from a point around 26cm proximal to the
leg position is optional. pylorus and all the way to the angle of His.
2. Reverse Trendelenburg positioning helps 9. Lift the stomach and divide all posterior
expose the esophagogastric (EG) junction. attachments to the pancreas.
10. Expose the EG junction well to ensure there
are no missed hiatal hernias. Excising the
EG junction fat pad aids in the exposure.
M.H. Alaeddine, MD 11. Ask the anesthesiologist to place an orogastric
Department of Surgery, American University tube or bougie (3442Fr) into the esophagus
of Beirut Medical Center, Beirut, Lebanon and lying along the lesser curve to the antrum.
G.A. Shamseddine, MD B.Y. Safadi, MD (*) 12. Alongside the tube, staple and divide the

Department of Surgery, Division of General Surgery, stomach in a vertical fashion aiming to the
American University of Beirut Medical Center,
Beirut, Lebanon angle of His. Approximately 60120ml of
e-mail: bs21@aub.edu.lb gastric volume should remain.

Springer Science+Business Media, LLC 2017 131


J.J. Hoballah et al. (eds.), Operative Dictations in General and Vascular Surgery,
DOI10.1007/978-3-319-44797-1_36
132 M.H. Alaeddine et al.

13. We recommend firing the first stapler from Postoperative Diagnosis Same
the right-sided port and the rest from the
umbilical port. Indications This ____-year-old female/male
14. Use appropriate thickness cartridges as the had morbid obesity with BMI above 40kg/m2/BMI
stomach is thickest in the antrum and above 35kg/m2 with significant comorbidities
decreases in thickness as you proceed toward and failure of medical weight loss.
the cardia.
15. Align these staple lines parallel. Avoid
Description of Procedure Time-outs were per-
crossed staple lines and avoid twisting. Avoid formed using both preinduction and pre-incision
narrowing the sleeved stomach at the inci- safety checklist to verify correct patient, proce-
sura angularis. dure, site, and additional critical information
16. The last stapler fire at the angle of His is par- prior to beginning the procedure. The patient was
allel to the esophagus. Avoid leaving a dog placed in the supine position and general endo-
ear, and keep <1cm of the stomach at this tracheal anesthesia was induced. Preoperative
level. antibiotics were given. The patient received 5,000
17. Hemostasis at the staple line is improved units of heparin subcutaneously prior to induc-
with staple line reinforcement, oversewing, tion. The abdomen was prepped and draped in the
or clips. usual sterile fashion. A 20-mm incision was made
18. Extract the stomach in a bag. through the umbilicus and the fascia was exposed.
19. Test the sleeved stomach by filling it with Under direct vision a 15-mm port was placed and
methylene blue or by intraoperative CO2 pneumoperitoneum at 15 mmHg was estab-
endoscopy. lished. Then under direct vision, two 12-mm tro-
20. Close the fascia at the gastric extraction with cars were inserted in the left upper quadrant
nonabsorbable sutures. along the midclavicular and anterior axillary
lines. A 12-mm port was placed in the right upper
quadrant at the midclavicular line just above the
Note These Variations umbilical level.

Hiatal hernias can be repaired simultaneous The operating table was placed in reverse
with the sleeve gastrectomy. Trendelenburg position, and the left lobe of the
An alternate approach is to perform the sta- liver was retracted cephalad using a fixed retrac-
pling and division of the stomach first fol- tor Nathanson through a 5-mm subxiphoid
lowed by gastric resection. incision to expose the esophageal hiatus.
Using an energy device (LigaSure, Harmonic
Scalpel, or Ultrasonic Shears), the lipoma of
Complications the gastroesophageal junction was excised and the
peritoneum overlying the cardia was incised, and
Bleeding the plane between the cardia and left crus of the
Staple line leak with resultant abscess or diaphragm was bluntly opened to expose the left
fistula diaphragmatic crus. Then the pylorus was identi-
Pulmonary embolism fied, and a point 26cm proximal to the pylorus
Gastroesophageal reflux along the greater curvature of the stomach was
marked with cautery. Then all the vessels along
the greater curvature and all the short gastric ves-
Operative Dictation sels were sealed and divided completely freeing
up the greater curvature and the fundus of the
Preoperative Diagnosis Morbid obesity stomach. The stomach was lifted up and all poste-
rior attachments to the pancreas were divided
Procedure Laparoscopic sleeve gastrectomy sharply. Then a 40-Fr orogastric tube was placed
36 Laparoscopic Sleeve Gastrectomy 133

by the anesthesiologist and oriented toward the u mbilical port which was widened a bit. Then the
antrum snug along the lesser curvature. Alongside ports and liver retractor were removed under
the tube the stomach was stapled and divided vision. The abdomen was deflated. The fascia at
sequentially in a vertical fashion heading toward the umbilical port site was closed with three inter-
the angle of His. We used a total of six cartridges rupted nonabsorbable sutures. The wounds were
60mm in length with 4.8-mm staple height. The closed with 4-0 monocryl continuous subcuticular
staple line was reinforced with a running 2-0 PDS sutures. A debriefing checklist was completed to
serosa-serosa imbricating sutures. Intraoperative share information critical to postoperative care of
endoscopy revealed no areas of stenosis and no the patient.
leak along the staple line. The stomach was placed The patient tolerated the procedure well and
in a plastic bag and was extracted from the left the operating room in good condition.