Single port sleeve gastrectomy using internal retractors (Endograb™) and needlescopic grabber

Tubular gastrectomy is a new technique for single port approach. This is the case of a patient presenting with a BMI of 42. A single port access is proposed. To do so, a 2cm mini-laparotomy is carried out at the level of junction of the upper two thirds and the lower third of the xiphoumbilical line. A Quadriport™ system is used.

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Single port sleeve gastrectomy using internal retractors (Endograb™) and needlescopic grabber

Authors

EM Targarona, C Balagué, Luis Pallarés, M Trías

Abstract

Tubular gastrectomy is a new technique for single port approach. This is the case of a patient presenting with a BMI of 42. A single port access is proposed. To do so, a 2cm mini-laparotomy is carried out at the level of junction of the upper two thirds and the lower third of the xiphoumbilical line. A Quadriport™ system is used.

Catégorie

single port, contribution

Mots-clés

Single port, sleeve gastrectomy, tubular gastrectomy, internal retractors, Endograb™, needlescopic grabber, Quadriport™

Type de vidéo

Vidéo chirurgicale

Durée

09'25''

Publication

2010-11

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Nov 2010;10(11).
URL: http://www.websurg.com/doi-vd01en3115.htm

Single port sleeve gastrectomy using internal retractors (Endograb™) and needlescopic grabber

1. Introduction 00'18''

Tubular gastrectomy is a new technique for single port approach. This is the case of a patient presenting with a BMI of 42. A single port access is proposed. To do so, a 2cm mini-laparotomy is carried out at the level of junction of the upper two thirds and the lower third of the xipho-umbilical line. A Quadriport™ system is used. It allows for different caliber accesses.

2. Dissection of greater curvature 01'04''

The surgical procedure is started by performing a devascularization of the greater curvature. This is achieved by using a conventional straight forceps and an ultrasonic scalpel in order to divide the gastro-omental vascular pedicles. This step of the intervention can be easily carried out by using two instruments. However, as the dissection of the greater curvature moves upwards, the adequate demonstration of the gastrosplenic short vessels becomes more and more difficult. This is why a mechanism allowing to retract the different structures should be used to perform this type of procedure. In this case, it will be an EndoGrab™. This is an intracorporeal instrument allowing to suspend the structure to be dissected in any place of the abdominal wall. The EndoGrab™ will be placed by means of an applicator. It will be fixed at the exact place of the stomach to be suspended. The other extremity will be anchored to the intra-abdominal peritoneum, searching for an appropriate angle allowing for an adequate demonstration.

3. EndoGrab™ application 02'43''

In this case, two EndoGrab™ devices are used. They allow to perform a lateral traction and to better expose the gastrosplenic short vessels. Sometimes, it is possible to carry out this intervention by using only the intra-abdominal instruments. Another technical option demonstrated in this video consists in the use of thin caliber instruments. In this case, a retractable forceps is used to move the left hepatic lobe. This single port surgical procedure can be smoothly continued by simultaneously using these two minimally invasive systems, allowing for adequate exposure and traction of the different structures.

4. Dissection of short vessels and gastroesophageal junction 04'22''

Dissection is carried on. The division of the short vessels and the freeing of the gastroesophageal junction are the most difficult steps of the intervention. The left crus is visualized so that the endostapler can be later applied. The small caliber forceps also allows for exposure by retracting the gastrosplenic omentum to the right, thus allowing for a better access to the upper part of the short vessels. This type of intracorporeal retractors can be easily removed and replaced in the anatomical area of the abdomen (or any other relevant organ) for an appropriate demonstration.

5. Antral dissection 05'52''

At this time in the procedure, the greater curvature is exposed to demonstrate the antral and prepyloric portion in this area in order to complete the devascularization of the whole stomach and to start the tubular gastrectomy. This type of endoretractors is almost atraumatic and can be fixed to the area of the stomach to be removed later. Therefore, the risk of an injury to the organ is almost nil. This step of the procedure is concluded by performing the devascularization until reaching an area situated 5-7cm away from the pyloric region. Once the devascularization is complete, the endoretractors are placed again in order to start the division by means of the endostapler. Now, the main purpose is to suspend the area of the stomach to be removed and to keep it horizontal.

6. Calibration tube insertion 07'58''

A 34-French Faucher tube is introduced. Attempts are made to insert it in the pyloric area. This will indicate the volume of the reservoir after tubular gastrectomy.

7. Gastrectomy 08'18''

The tubular gastrectomy is initiated by means of a green cartridge endostapler, which will be protected by a Seamguard® reinforcement in order to protect the hemostasis of the suture line. The EndoGrab™ and the small forceps previously introduced allow for exposure and for an excellent visualization of the division line despite the fact that a single port system is used. The last firing is carried out parallel to the esophagogastric junction.

8. Suture line control and specimen extraction 09'07''

Once the tubular gastrectomy is complete, the suture line and its patency are controlled. The specimen is removed through the incision.