Laparoscopic sleeve gastrectomy

This video demonstrates a laparoscopic sleeve gastrectomy in a mobidly obese patient. The surgeon starts by mobilizing the greater curvature 7 cm proximal to the pylorus and divides all the vessels including the short gastric vessels to the angle of His. After that a linear stapler is used to construct the sleeve gastrectomy around a 36 bougie. The operation ends with oversewing of the staple line and removal of the specimen.

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Laparoscopic   sleeve   gastrectomy

Authors
JL Alle
Abstract
This video demonstrates a laparoscopic sleeve gastrectomy in a mobidly obese patient. The surgeon starts by mobilizing the greater curvature 7 cm proximal to the pylorus and divides all the vessels including the short gastric vessels to the angle of His. After that a linear stapler is used to construct the sleeve gastrectomy around a 36 bougie. The operation ends with oversewing of the staple line and removal of the specimen.
Classification
routine cases
Keywords
laparoscopy, sleeve gastrectomy, morbid obesity, bariatric surgery
Media type
Duration
13'50''
Publication
2006-07
Popular
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, Jul 2006;6(07).
URL: http://www.websurg.com/doi-vd01en1993.htm

Laparoscopic   sleeve   gastrectomy

5. Start of dissection of the greater curvature 02'09''
Do you consider that starting at 7cm from the pylorus, the entire antrum will be preserved? Yes, I preserve the antral pyloric pump like this. I use the Atlas® Ligasure. I didn’t really open the lesser sac at all. If necessary, I will continue with the hook until I have an opening. Are you using a zero degree telescope or a 30 degree one? We’re using a 30 degree scope because you have at the end of the procedure a very long time for suturing. At the moment, we are not in the lesser sac yet. I think I’m close to the place where I want to go. Is that your preferred instrument at home? Yes indeed, and even for gastric bypass and other procedures. Now the Ligasure is in medial upper position, and this is also very convenient for the vertical part of the greater curvature. So you see that I change once again the position of the Atlas® because the access is changing and now I’m working with the right hand. I think we’re reaching the end of what is possible with the optical system in umbilical position. Now we will change the optic from the lower part to the upper medial one. There we are really in the place of the short vessels. For those of you doing lap Nissens divide short gastrics you are probably not used to going so close to the gastric wall but this is different in that it is safer. Yes indeed. It is a great difference because we know that all this part will be removed. I’ve a look at the posterior wall of the stomach and I think that everything is free except maybe on the very upper part here. At what point do you stop? You can see nicely the pancreas here. Sometimes there are adhesions. In this case, there are none. So normally it’s finished. Now we go back to the umbilicus with the scope. Now I check if I have dissected the greater curvature completely. You see, 1, 2, 3 and the 4th is the liver retractor. Now I have to complete dissection. Here we have an Endo-GIA and only use blue cartridges. You see this is not a good axis. The axis of the Ligasure is not good to staple. This is not a good axis. And the 3rd upper is not a good one too. We will staple for the 3rd stapling by the umbilical one. And I hope that the instrument will be long enough.
6. Start of tubulization of the stomach 06'40''
There are 2 options. The 1st is if you try now to have the nasogastric calibrating tube in place, all the time the tube will have to go there. And it’s very difficult to have the tube in place at this moment. Personally, I prefer to have a little bit less stapling to be sure, you see here 40 or 60mm, I staple the 1st stapler. How do you judge the diameter of your sleeve? Well, the calibrating tube that we will have in place within 2 minutes. So this is the 1st application that is performed without. What are your anatomical landmarks for the 1st stapling? Here is my 7cm. We see the pylorus here, then the antrum, and what about the distance from the lesser curvature? Well, I’ve just said that I was performing a shorter application in order to be sure to leave enough. Now I’ll introduce a 2nd one and I will ask the anesthesiologist now to put the orogastric tube in place. At this point, it’s interesting to have a longer Endo-GIA. Now it’s more convenient to use this stapler to force the tube to get into a proper position. What is the size of your bougie? It’s a 36. We have now to check the tube. I think that I’m ready for a 2nd application. When do you use the green cartridge? Never in this indication. Now we’re reaching a more important part. Once again, I staple. See how convenient it can be. And stapling is complete. This is the specimen. We put it in the left quadrant. Take the tube slowly out for 20cm. To be honest, personally, I leave it as it is. I still have the bougie in place. I’m not afraid to keep it. I will close it now and change my stitch. This oversewing of the suture line, some people believe it’s not just for the leak issue, it’s also for bleeding. Not for bleeding, I think that I don’t change anything. Do you test for your suture air leaks in your bypass surgery or not? No I always perform the Gagner technique with extreme caution and I am used to testing only if the donuts are not complete.