Laparoscopic sleeve gastrectomy: integral procedure

This is the case of a 56-year-old woman with a BMI of 44. This patient wanted to have surgery for morbid obesity and after giving her explanations about the sleeve gastrectomy and gastric bypass, she preferred to have a sleeve gastrectomy. This is a real-time recorded video in which all aspects and tricks of a correct sleeve gastrectomy are clearly presented.

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Laparoscopic   sleeve   gastrectomy:   integral   procedure

Authors
M Vix, J Marescaux
Abstract
This is the case of a 56-year-old woman with a BMI of 44. This patient wanted to have surgery for morbid obesity and after giving her explanations about the sleeve gastrectomy and gastric bypass, she preferred to have a sleeve gastrectomy. This is a real-time recorded video in which all aspects and tricks of a correct sleeve gastrectomy are clearly presented.
Mots-clés
integral laparoscopic sleeve gastrectomy
Type de vidéo
Durée
25'00''
Publication
2010-01
Popularité
Favoris
Favorites Media
Audio
en
Sous-titres
en
E-publication
WeBSurg.com, Jan 2010;10(01).
URL: http://www.websurg.com/doi-vd01en2807.htm

Laparoscopic   sleeve   gastrectomy:   integral   procedure

3. Freeing of cardia 01'24''
So the first step is to free the cardia, the anterior aspect of the cardia and so I put one grasper held by my assistant here on the upper part of the greater curvature and next I’ll remove here this little fat pad I have in front of the cardia. I do it with the hook to be very precise and be sure that I don’t burn the anterior aspect of the cardia to avoid heat injury of the anterior part of the cardia here. See very gently I remove the fat pad. I let the CO2 go inside the pneumoperitoneum to help me obtain more space. I will go up. The objective is to free the angle of His and I begin to see the left crus. Very gently, here you have some vessels here inside. Here I free adhesions to the diaphragm and I will remove this little fat pad here. When you do that, it’s an opening of the window you need to have just on the left part of the cardia and so when I’m far away from the stomach, then I can use the Ligasure, the new 5mm Ligasure device you see here, with little teeth on the jaws on each side that allow to take some tissues and have a better grasping of tissues here. It’s cutting well at the tip and all the surface is an active one to perform the sealing. It’s like a little finger. Joel Leroy says that with the 10mm Ligasure is like a little finger that you can put inside and we will begin with the opening of the lesser sac. Here you have a view on the spleen and here you see the region where we will stop the dissection and we will open the lesser sac here.
5. Identification of the starting point of greater curvature resection 06'17''
Usually the resection of the greater curvature begins 6cm over the pylorus, that means quite on these 2 vessels. And if you have a look here, you will see the Latarget’s nerve that you can see very well here. And here you will have the ending of the Latarget’s nerve, and usually the dissection of the stomach begins here just in front of the ending of the Latarget’s nerve. This is the nasogastric tube and so here I have good vessels’ landmarks. I will try to get down at this moment. I do the dissection of the lower part. The second reason to do that is the direction of my working instruments, of the Ligasure because if I begin opening the lesser sac just in front of the point where I’ll begin my section of the stomach, afterwards it’s quite difficult to go upwards because the direction is quite wrong and so you can sometimes have to change the Ligasure going from the right to the left hand. Here I can keep it in the right hand, see it’s quite easy. I can see the posterior aspect of my dissection of the lesser sac. The fat here is a little bit bigger than where I opened the lesser sac. I will ask the anesthesiologist to remove the nasogastric tube. The landmark of ending is here and so I have to make one or two more coagulations. Just have a look at the landmarks, I think here it’s enough. Before we do the section of the stomach, we have to finish at the upper part. The reason is why I stop here to go to the lower part is to really make a rotation access for the stomach and you see here that I can turn from the lower part to the upper part of the stomach and so I can see very easily the posterior aspect and the lesser curvature here with the vessels, which are very important here because it’s the only vascularization that will remain on the gastric pouch. The dissection that I will perform is quite on the posterior aspect of the stomach. I will ask the assistant to take again the omentum and there very gently pushing up vertically like Bernard Dallemagne doing the Nissen procedure. I will free the upper part of the stomach. Here it’s quite easier to perform that as compared to Nissen procedures because I have a large space. I open very largely the lesser sac. On the other hand, I have more fat here and the challenge is the fat as it is sometimes difficult. The stomach is not in our way and it’s quite easy to go until the cardia here. I see the stomach very well. I don’t want to see the spleen. Sometimes the short gastrics are very short and it’s quite difficult because you are really sealing between the stomach and the spleen. And we have just to finish here some short gastrics. Here you see the spleen is coming closer. Here you have to avoid it absolutely. And now you pull very nicely on the stomach, you open the space and you open the little tissues you have close here to the left crus. You need to see the left crus. This is the real landmark you have here. I think here the dissection is large enough. Here you see the posterior aspect of the stomach and the only thing that you can improve here is to finish the dissection here from these vessels. We will stop here. See here on the spleen side, there’s no bleeding. I was never close to the spleen and so I avoided having a splenic injury. Afterwards, I will put the stomach again in this place. See here the dissection point will end here and the cutting point will end here too.
7. Insertion of calibration tube 12'38''
After that, I ask the anesthesiologist again if nothing else is in the gastric lumen, and so we will begin. This is the first staple line, because the cartridge is green, sometimes you have some blood oozing here and we will ask the anesthesiologist to put the calibration tube down and we put the scope in the midline port. We check again, the staple line is quite perfect here. We do nothing inside until we see the tip of the tube. When we see the tip, after that we have to guide it in the remaining channel. There it’s quite easy, sometimes you have to work a little bit more, and we try to push it down to the pylorus. You need to be sure that you don’t have too much tube inside the stomach and so you straighten the nasogastric tube. It protects you from closing completely the gastric lumen. The second staple line will be a blue cartridge, and again we are looking from the side, I introduce my cartridge through the midline trocar. Here I have the nasogastric tube, so I can pull a little bit more to be close to the tube. I want to check the posterior aspect to be sure that I don’t have a posterior bulge of tissue here, so I can also take the stomach to put it close. Again, on the anterior one and I will fire. There’s the second staple line, you look to see if all the staples worked, that’s very important. It’s important to look at the point where you have the two lines that are crossing, here you see it’s quite perfect, you have a straight line. I will push again inside the next cartridge. I close it here so you see where we are, we can pull a little bit here. The important point is to check the posterior aspect of what you are doing and keeping in place so the stomach turns quite easily. You see here that the posterior aspect, there is usually a big bulge of tissue, and so you have to reduce that to be sure that you have an effective channel remaining and not too much space inside the stomach. After that we fire. Check again that all the staples worked. See here the crossing of the two staple lines is quite perfect too, it’s a really nice tube here. So we will change the camera again, coming from the midline. After, the direction of the next staple line will be good. Here you see that we have the upper part of the stomach with a little bulge of stomach that we will have to remove. I think that the dissection here should be very close to the stomach wall. We come up, you see the grasper coming out here on the upper part. You must be sure that this channel is open, and because the channel is well made, usually you need to see where your channel is, and very easily you go inside this channel and you can close. Don’t push too much because you will increase the sickness of the tissue here. I think there is a little part remaining here, we will check it. We move up, here you see the little part that is remaining here, and we will just have to cut this here. The most dangerous part I think is when you are dissecting the short gastrics and you are coming towards the cardia; the second difficult part is to have a perfect staple line at the upper part of the stomach, because here it is quite difficult to come outside and to make a huge pouch at the upper part. Beware, don’t push your stapling device inside the spleen. You cannot pull immediately on the tissue because on the posterior aspect of it we have some remaining vessels and we will have to cut this. You see it is a very short part here, but this is vascularized.