Laparoscopic three trocars sleeve gastrectomy

Traditionally a sleeve gastrectomy is performed with the aid of 5 to 7 abdominal trocars. By reducing the number of trocars, parietal trauma, pain and hernia risks can be minimized. We present a video of a 3-trocar laparoscopic sleeve gastrectomy performed in a female patient with a BMI of 37. Despite an adequate view and exposure of the operative field, a high surgical skill is required as well as an adequate patient selection.

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Laparoscopic three trocars sleeve gastrectomy

Authors

M Vix, C Solano, D Varela

Abstract

Traditionally a sleeve gastrectomy is performed with the aid of 5 to 7 abdominal trocars. By reducing the number of trocars, parietal trauma, pain and hernia risks can be minimized. We present a video of a 3-trocar laparoscopic sleeve gastrectomy performed in a female patient with a BMI of 37. Despite an adequate view and exposure of the operative field, a high surgical skill is required as well as an adequate patient selection.

Catégorie

new techniques

Mots-clés

Laparoscopy, sleeve gastrectomy, three trocars, 3 ports

Type de vidéo

Vidéo chirurgicale

Durée

05'50''

Publication

2008-11

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Nov 2008;8(11).
URL: http://www.websurg.com/doi-vd01en2327.htm

Laparoscopic three trocars sleeve gastrectomy

1. Clinical case presentation 00'22''

We present the case of a 46-year-old woman with a BMI of 37 and associated co-morbid conditions. Her past surgical history was significant for 2C section. In this patient, we opted for a sleeve gastrectomy.

2. Patient and trocar placement 00'42''

The patient was placed in steep reverse Trendelenburg position with legs abducted. The surgeon is standing between the patient’s legs and the assistant on the surgeon’s left side. Three trocars are used: a 12mm trocar, 7cm below the xiphoid process, a 12mm trocar on the left mid-clavicular line for operating instruments and stapling devices, and a 5mm trocar on the right mid-clavicular line used for a 5mm 0 degree laparoscope, which later changed in position according to the surgeon’s needs.

3. Vascular division 01'20''

Now to the procedure. Division of the vascular supply of the greater curvature began 6cm proximal to the pylorus, just next to the terminal branches of the nerve of Latarjet. The gastro-epiploic vessels were divided using a 10mm Ligasure device, allowing the entrance to the lesser sac. Gastro-epiploic division was then carried out cephalad in order to separate the greater curvature from the omentum.

4. Short gastric vessel division 02'40''

With adequate patient positioning and organ retraction, a good view and exposure was achieved despite the fact that no hepatic retractor was used. Proper gastric retraction allowed safe exposure and division of the short gastric vessels without any injury to the spleen.

5. Gastrophrenic ligament division 03'10''

Once the greater curvature of the stomach is completely free, the division of the gastrophrenic ligament is carried out with the help of a hook dissector and Ligasure device.

6. Intragastric calibration tube insertion 03'58''

A 36 French calibration tube was introduced trans-orally into the stomach and aligned medially along the lesser curvature.

7. Gastric sleeve creation 04'11''

The gastric sleeve was created using first an Endo-GIA stapler with a green cartridge inserted through the midline trocar. Visual control of the posterior side of the staple line was achieved. The division of the greater curvature was then completed with sequential firing of a 3.5mm stapler. A running suture of non-absorbable material was then performed over the staple line. In order to obtain a better liver retraction and view at the level of the GE junction, the left side grasper may be used as a liver retractor to place the first sutures. Once the first suture is placed, the rest of the suture line is easier to perform.

8. Specimen extraction 05'48''

The specimen was placed in an Endo-catch bag and retrieved through the umbilical trocar.

9. Gastrograffin swallow 05'54''

The postoperative gastrograffin swallow performed the next day was normal, with no evidence of leak or fistula.