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Surgical videos on WeBSurg
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English - 17'00''
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This video demonstrates a routine case of laparoscopic sleeve gastrectomy for morbid obesity. This is usually the first stage of a two-stage procedure. The surgeon starts at the mid portion of crow's foot about 7 cm from the pylorus and mobilizes all the greater curvature vessels and attachments using bipolar cautery. After full mobilization of the greater curvature up to the angle of His, the gastric sleeve is constructed using a linear stapler. A bougie is used to calibrate the diameter of the gastric sleeve. The specimen is removed from an enlarged trocar site. The surgeon in this case placed a drain.
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| 00'10'' | Patient and trocar placement
The patient’s head is here. The umbilicus is there. I first place the umbilical trocar and then place the other trocars under visual control.
The thing with the gastric sleeve is that you have to deal with the higher and lower parts of the stomach. The position is as for a Nissen procedure but a little bit lower in order to have a good access to the lower part of the stomach. We will use a 30 degree scope. |
| 01'20'' | Beginning of procedure
The patient is in reverse steep Trendelenburg position, more than 30 degrees.
Now we start with exploration of the stomach. We’re first going to the hiatus since we can have problems with a hiatal hernia. There is none here but I prefer to get a good view of the operating field and first of the gastrophrenic ligament which appears normal. This procedure consists in modification of the stomach in order to keep the antral pyloric system completely clear and normal and to have a gastric tube on the lesser curvature starting with the antrum in place and calibrate it until the angle of His. I ask the anesthesiologist to keep out the nasogastric tube. Conventionally we begin exactly at the level of the craw’s foot. I’m going to the greater curvature to find the place to start with the tubulization. If you start opening the lesser sac here, you will have problems. The best thing to do is to start a little bit higher. |
| 03'50'' | Opening of lesser omentum
I use cautery to start with and this is the starting point to reach the lesser sac and I remain very close to the stomach. I have reached the lesser sac and I can start dissection on the greater curvature using the Ligasure Atlas® device, very accurate and useful for this operation. We start dissection from the lower part to the higher part and I can stay close to the stomach. For the greater curvature, there are 2 options. The first option is to go this way until you reach the angle of His and the other option is to begin making the vertical partition before it. Let’s see how it goes. We’re advancing a lot without encountering this 2-layer part of the greater omentum. At this stage, you feel that the stomach is turning a little bit so I can change position. Here you can see the lower clamp a little bit higher. Let’s take a complete look at the stomach and continue the dissection higher. Out of security, I will dissect the ligament. We’re now approaching this angle. The stomach takes its natural position. If you intend to have this operation as a first-step operation for gastric bypass but more for duodenal switch, it’s essential to keep close to the stomach in order to preserve the vascularization of the antral pyloric part of the stomach. I think I reached the correct place. Is there a philosophy behind that point of beginning of the transection?
I think that the lesser sac is better reached from a higher position and on another side, if you have a problem for hemostasis at this stage, it may be a problem for the vascularization of this so I prefer to go up first, and then to go lower because there I’m sure that I can be along the stomach without problems. And so there is no issue about the size of the stomach or the volume of the tube? No.
The 1st thing is to keep the antral pyloric part and then second thing we should perform a calibrated tube along the small curvature from the angle of His to this area here.
At the moment, you’re essentially trying to preserve the vascularization of the antrum and the volume also. |
| 09'20'' | Start of gastric tubulization
Yes indeed. You see the pylorus is there and we hold this. I’m in a vertical position. I must reduce my first bite to let the passage. Why don’t you put the calibrated tube already? This is a true problem. If you put the tube at this moment, it takes long to pass it along the lesser curvature and it shall come there. And so, if you begin by a little bite here, and maybe a second one, you can guide the tube more accurately. Now we can start to put the calibrating tube. At this moment, I have blocked the nasogastric tube. I can correct the direction and I can go a little bit higher making sure that the tube is in place. Immediately we can take the same cartridge for the next. I’m trying the next bite in the same fashion and now we have to change the direction. Now we’re reaching the standard position of the gastric bypass shape of our stomach.
Then I stop and we can make a posterior and anterior examination to be sure that we’re in the right position. We will explore the hiatus.
Was there a reason why you didn’t divide the short gastric to begin with? There are 2 ways for doing it. The 1st is to go completely to the end of the short gastric vessels but we got used dissect the posterior part of the stomach. I think we have the opportunity to reach the hiatus from posteriorly here and then to cut the last short vessels more safely from posteriorly when the stomach is completely divided. I see exactly where I have to go in a stepwise manner.
Now having cut it, you can have a very good view on the last attachment and I can do it with the Ligasure Atlas® device. Let’s check where the attachments are now. I’m turning around the fundus. Let’s take a look at the other side now. The piece is completely cut. It’s easier to manage at this point.
Here you have the view on the tube. |
| 16'50'' | End of tubulization
The rest of the operation is that we take this out and I always put a drain. That’s the end of our operation. |
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