Laparoscopi December

29
c Sleeve 200
Gastrectom
y 8

Surgical
Treatment WEBSU
RG
of Morbid
Obesity
Contents
1. Introduction..........................................................................................................4
2. Basics of Procedure..............................................................................................5
2.1 Definition and principles................................................................................5
2.2 Physiology......................................................................................................5
2.3 Results...........................................................................................................6
2.4 Weight Loss Failure........................................................................................6
3. Anatomy...............................................................................................................7
3.1 Anatomical Relations.....................................................................................7
3.1.1 Greater Curvature...................................................................................7
3.1.2 Lesser Curvature.....................................................................................8
3.2 Vascular Supply.............................................................................................8
4. Indications and Contradictions.............................................................................9
4.1 Standard indications:.....................................................................................9
4.2 Specific indications:.......................................................................................9
4.3 Absolute Contraindications:.........................................................................10
5. Preoperative Period............................................................................................10
6. Operating Room Set-up......................................................................................11
6.1 Patient.........................................................................................................11
6.2 Team............................................................................................................12
6.3 Equipment...................................................................................................12
7. Pneumoperitoneum............................................................................................12
8. Trocar Placement...............................................................................................13
8.1 Trocars.........................................................................................................13
8.2 Optical Trocar..............................................................................................13
8.3 Reverse Trendelenburg................................................................................14
8.4 Operating Trocars........................................................................................14
8.5 Retracting Trocars.......................................................................................14
9. Instruments........................................................................................................14
10. Exposure and Dissection.................................................................................15
10.1 Identification of the Pylorus.........................................................................15
10.2 Cardia dissection.........................................................................................15
11. Gastrolysis......................................................................................................16
12. Resection........................................................................................................17
12.1 Beginning of the Staple Line........................................................................17
12.2 Calibration of the gastric pouch...................................................................17
12.3 Gastric Resection.........................................................................................18
12.4 Staple Line Reinforcement...........................................................................18
13. Extraction........................................................................................................18
14. Postoperative Period.......................................................................................18
15. Advantages / Disadvantages...........................................................................19
16. Complications.................................................................................................20

Complications
 Laparoscopic Sleeve Gastrectomy
Surgical Treatment of Morbid Obesity

1. Introduction
Laparoscopic sleeve gastrectomy (LSG) as a
standalone procedure for the surgical
management of morbid obesity represents 2%
of the bariatric operations in the United States
of America. In the USA, this technique was
developed as a modification of the
biliopancreatic diversion in 1988; and in the
United Kingdom, the concept of LSG evolved
as a modification of the Magenstrasse and Mill
procedure.
It’s acceptance as an alternative surgical
treatment for obesity in the last years is due
to the fact that it is a rapid and less traumatic
operation and thus far is showing good
resolution of co-morbidities and good weight
loss. A further second surgical step is then
easily feasible, if necessary.
 An excessive weight loss (EWL) of 54 to 81%
on average by 12 months have been reported
(Himpens et al., 2006; Tucker et al., 2008), as
well as the improvement in co-morbidities of
obesity (2004 ASBS Consensus Conference on
Surgery for Severe Obesity, 2005).

2. Basics of Procedure
2.1 Definition and principles
The sleeve gastrectomy is also known as
the greater curvature gastrectomy, vertical or
longitudinal gastrectomy. A gastric tube of 60
to 120mL is created by resecting the greater
curvature of the stomach. The volume of the
gastric pouch varies according to the gastric
calibration tube (< 40 French).
2.2 Physiology
The sleeve gastrectomy (SG) induces weight
loss by 2 mechanisms:
1) Mechanical restriction by reducing the
volume of the stomach and impairing
stomach mobility;
 2) Hormonal modification by removing a
great part of the Ghrelin production tissue.
Ghrelin is a 28 amino-acid -peptide,
secreted by the oxyntic glands of the
gastric fundus (Ariyasu et al., 2001). It is a
potent orexigenic (appetite-stimulating)
peptide mediated by the activation of its
receptors in the hypothalamus or pituitary
area (Mognol et al., 2005; Himpens et al.,
2006). The gastric fundus contains 10 to
20 times more ghrelin per one gram of
tissue than the duodenum. In the SG,
resection of the fundus removes the major
site of ghrelin release, therefore appetite
decreases.
1.1 Results
The sleeve gastrectomy is an effective
primary bariatric procedure in the short term;
the overall excessive weight loss (EWL) at 6
and 1 2 months ranges from 35 to 71% and
33 to 81% respectively. The EWL at 3 years
has been reported to be similar to that after
RYGB (Gumbs et al., 2007; Baltasar et al.,
2005; Lee etal., 2007).
Long-term results are influenced by the size
of the bougie used as a guide. Its size must be
inferior to 40 French. The volume of the
gastric remnant will then be reduced (Weiner
et al., 2007).
1.2 Weight Loss Failure
Weight regain after a sleeve gastrectomy is
associated with the dilatation of the gastric
remnant. Differences on surgical techniques
can explain why this event may happen to
any patient:
 Excessive large bougie;
 True gastric dilatation over time;
 Inadequate resection of posterior gastric
folds;
 Excessive pressure against the pouch wall
by large meals, repeated vomiting or
distal obstruction;
 This weight loss failure can be surgically
managed by (Baltasar et al., 2006; Gagner
and Rogula, 2003):
 Laparoscopic re-sleeve gastrectomy again
reducing the gastric pouch;
 Gastric bypass;
 Laparoscopic Duodenal Switch (LDS).

1. Anatomy
1.1 Anatomical Relations
1.1.1 Greater Curvature
It contains different anatomical relations.
Superiorly: greater curvature is fixed to the
diaphragm by the gastrophrenic ligament, it is
a real suspensory ligament to the stomach.
Medially: the gastric body corresponds to the
vertical segment of the greater curvature. It is
attached to the splenic hilum by gastrosplenic
omentum, which contains the short gastric
vessels.
 1.1.2 Lesser Curvature
It is located deeper than the greater curvature
 Lesser curvature
 Greater curvature
 Spleen
1.1 Vascular Supply
The vascular supply of the stomach largely
depends on the coeliac trunk and its
branches: left gastric, splenic, and hepatic
artery.
1) The arterial arch on the lesser curvature
shaped by the larger left gastric artery
and the smaller right gastric artery;
2) The arterial arch on the greater curvature
shaped by the right and the left
gastroepiploic arteries;
3) Four or five short gastric arteries leaving
the terminal branches of the splenic artery
close to the spleen, ant the left
gastroepiploic artery.
  Left gastroepiploic artery: branch of
the inferior division of the splenic
artery,
 Short gastric vessels: they originate
from the splenic artery and mainly
irrigate the gastric fundus, in a number
of 6 to 8.

1. Indications and Contradictions

1.1 Standard indications:
• As for all morbid obesity surgery, standard
rules apply:
• BMI > 40;
• BMI > 35 with co-morbidities;
• Medical treatment followed by the patient
for one year fails;
• Regular physical activity.
1.1 Specific indications:
The SG is preferred over a gastric bypass or
a biliopancreatic diversion in the case of:
• Hepatic cirrhosis;
• Inflammatory bowel disease;
 • Major bowel adhesions;
• Major co-morbidities;
• ASA iii or iv morbidly obese patient;
• Gastric polyps; gastric endocrine tumors.
The SG will be the first stage of the
procedure, followed by a gastric bypass or a
biliopancreatic diversion when:
• BMI > 60;
• BMI > 50 with ASA III -IV patients.
1.1 Absolute Contraindications:
• BMI <35;
• Contraindication to general anesthesia;
• Pregnancy;
• Severe psychiatric disorders;
• Drug and alcohol addiction;
• Untreated esophagitis;
• Giant hiatal hernia.

1. Preoperative Period
Laboratory evaluation: basic chemistry
panel, full blood count, thyroid function tests,
serum Cortisol, urine Cortisol, serum
cholesterol, serum triglycerides,
measurements of vitamins (A, B1, B6, B9,
B12, C).
Upper endoscopy:
- Rule out inflammatory ulcerous gastric
pathology, search and treat H pylori infection
when present.
Ultrasound of the abdomen:
- To rule out cholelithiasis, which would
indicate cholecystectomy along with the
gastric sleeve.
Psychiatric evaluation:
- To rule out any behavioral abnormalities that
would contraindicate limited food intake.
Endocrine evaluation:
- Rule out an endocrine abnormality as the
etiology of morbid obesity.
Dental Evaluation.
 2. Operating Room Set-up
2.1 Patient
Standard Position:
• Supine position with both legs abducted;
• Intermittent pneumatic leg compression
for preventing deep vein thrombosis;
• Both arms extended;
• Stirrups for feet positioning;
• All contact zones are carefully checked
and padded to avoid nerve and arterial
compression or pressure sores.
1.1 Team
Standard Position:
• The surgeon stands between the patient's
legs.
• The first assistant stands on the patient's
right.
• The second assistant stands on the
patient's left.
• The scrub nurse stands on the surgeon's
right.
 • The anesthesiologist stands at the head of
the patient.
1.1 Equipment
1) Operating table: conventional operating
tables should accommodate a weight up
to 250 Kg.
2) Anesthetic equipment
3) Laparoscopic video unit
4) Two high-resolution monitors
5) Electrocautery device

1. Pneumoperitoneum
The pneumoperitoneum is established in a
standard fashion, with the usual precautions,
at a maximal intraperitoneal pressure of
15mmHg.
Insufflation pressure:
Due to the thickness of the wall, it may be
necessary to increase the pressure of the
pneumoperitoneum to 14 or even 15mm Hg.
The anesthesiologist should be warned of the
increase in insufflation pressure and asked to
monitor the capnograph.

2. Trocar Placement
2.1 Trocars
Principles:
Due to the abdominal wall's thickness and
the depth of the surgical field, trocar
placement is of utmost importance. This
technique is usually performed with 5 trocars:
A: optical trocar
B and C: operating trocars
D and E: retracting trocars
2.2 Optical Trocar
The optical trocar is the first one. Its position
is one and a half hand's breadth below the
xiphoid process. The main difficulty in this
region is the presence of the large, fatty,
round ligament that can be avoided by just
placing the trocar slightly to the left of the
midline.
 2.3 Reverse Trendelenburg
The patient is then placed in reverse
Trendelenburg position, lowering the
abdominal viscera and freeing the operative
field in the upper abdomen.
2.4 Operating Trocars
The other trocars are then introduced under
visual control. Trocars B and C are operating
trocars.
2.5 Retracting Trocars
Trocar D accommodates the liver retractor.
Trocar E accommodates the stomach
retractor.

3. Instruments
1) 30° laparoscope
2) Hook dissector
3) Scissors
4) Bipolar grasper
5) Fenestrated grasper
6) Suction-irrigation device
7) Linear stapler
8) Needle holder
 9) Circular liver retractor
10) Ligasure device

1. Exposure and Dissection

1.1 Identification of the Pylorus
The gastric resection starts at 6cm proximal
to the pylorus. The pylorus has to be carefully
identified. Another anatomical landmark is
achieved by the vertical division of Latarjet's
nerve.
The pyloric region is exposed by retracting
the anterior surface of the gastric antrum. All
the omentum must be pushed aside.
The pylorus is then easy to palpate. 6 cm of
pylorus are then measured proximally. This
corresponds to the location of the Latarjet's
nerve vertical division.
The greater omentum is then opened to
enter the lesser peritoneal sac. This prepares
the gastrolysis of the greater curvature.
 1.2 Cardia dissection
Liver retraction:
The left lobe of the liver is retracted
cephalad and laterally to visualize the upper
part of the stomach and the hiatal region.
The contact area between the retracting
device and the liver must be large enough in
order to avoid rupture of the fibrous capsule
of the liver.
Any bleeding will impair visualization of
the operative field and will absorb part of the
light intensity.
Cardia dissection:
After having exposed the starting point of
the gastrolysis, we expose the hiatal region to
dissect and free the angle of His. This step
prepares for the last part of the gastrolysis
and the gastric section.
 2. Gastrolysis
Division of the greater omentum is
performed from distal to proximal, with the
aid of the Ligasure® device. The greater
omentum is divided close to the stomach. In
the upper third, we run into the short gastric
vessels. The freeing of the greater curvature
is continued up to the angle of His.

3. Resection
3.1 Beginning of the Staple Line
The sleeve gastrectomy is begun with
sequential firings of linear stapler (60mm)
placed through the left 15mm trocar, starting
at the level of the crow's foot just distal to the
incisura angularis. The stomach should be
retracted laterally.
The first 60mm stapler (4.8 mm staples,
green cartridge) is positioned approximately
2cm from the lesser curvature in order to
ensure adequate blood supply and avoid
obstructing the gastric lumen. The anterior
and posterior vagus nerves are preserved for
normal gastric emptying.
3.2 Calibration of the gastric pouch
Then a 36 French bougie is inserted into
the stomach by the anesthesiologist and
aligned medially along the lesser curvature
into the duodenum to continue with the SG.
This bougie may be replaced by a
gastroscope allowing for a correct
visualization of the gastric pouch at the end of
the procedure.
3.3 Gastric Resection
Sequential firing of 60mm linear staplers
is performed up to the angle of His (3.5mm
staples, blue cartridges).
3.4 Staple Line Reinforcement
Staple-line reinforcement is used to reduce
the risk of intraoperative bleeding and
leakage. The following materials may be used:
• Continuous absorbable suture;
• Bio-absorbable glycolide copolymer
(Seamguard, W.L Gore & Associates);
 • Fibrin glue.

1. Extraction
The resected specimen is placed in an
extraction bag and removed through the
12mm left lateral port or through the optical
port.

2. Postoperative Period
No nasogastric tube is placed at the end of
the procedure.
A water-soluble upper gastrointestinal study
is performed in selected cases (intraoperative
difficulties), and for patients with clinical
symptoms and signs of leakage (fever,
tachycardia, tachypnea, severe leukocytosis).
If the examination is performed and reveals
no anomalies, the patient is allowed to drink.
From POD2 to POD9, the patient remains on a
liquid diet. Over the next 3 weeks, the food
must be soft or chopped. After this period, the
patient can progressively return to normal
drinking and eating habits, with the
recommendation to chew adequately.
The patient is usually discharged on POD2.
The first follow-up is performed one week
after discharge, when sutures or clips are
removed, and then at 1, 3, 6 and 12 months.

3. Advantages / Disadvantages
Advantages:
 No digestive anastomosis involved;
 No mesenteric defect is created;
 No foreign material is used (no foreign
body complication nor adjustments);
 Digestive tract accessible to endoscopy;
 Low risk of peptic ulcer;
 Vitamins and mineral absorption not
altered;
 Short hospital stay;
 Avoidance of foreign material to create a
restrictive band;
  Maintenance of normal gl continuity with
preservation of antrum and nerve supply
permitting adequate gastric emptying;
 Ability to convert this procedure into
multiple other operations (such as
gastric bypass or biliopancreatic
diversion).
Disadvantages:
 Stapling complications;
 Irreversibility.

1. Complications
Acute (Intraoperatively)
 Hemorrhage;
 Splenic injury;
 Liver injury;
 Abscess;
 Sleeve stricture.
Postoperatively:
 Incisional hernia;
 Gastroesophageal reflux;
 Stenosis;
 Thrombosis;
 Pulmonary embolism;
 Gastric atony;
 Wernicke's syndrome due to thiamine
deficiency from excessive vomiting;
 Leaks;
 Weight regain due to gastric reservoir
dilatation.