Specimen Extraction after Laparoscopic Sleeve Gastrectomy: No Need to Bag It.

Eric Boyle, MD, Timothy Kuwada, MD, Dimitrios Stefanidis, MD, PhD, Keith Gersin, MD

Carolinas Medical Center

Background: Laparoscopic sleeve gastrectomy (LSG) is an effective and popular bariatric procedure. In contrast to the adjustable gastric band and gastric bypass, LSG is a resectional procedure that requires removal of the relatively large gastric remnant. This often requires enlargement of a trocar site and the potentially contaminated specimen may increase the incidence of wound infection. Various techniques have been described to extract the remnant, many of which incorporate the use of a “protective” extraction bag. However, an extraction bag increases cost and may require a larger fascial incision due to bunching of the specimen, thus increasing pain and the risk of incisional hernia. The purpose of our study is to describe our technique and outcomes for bagless extraction of the stomach during LSG.

Methods: A single center, retrospective review of prospectively collected data from a consecutive series of non-revisional laparoscopic sleeve gastrectomies from 2008-2012 (3 surgeons). Wound infection and cost savings were the primary outcome of interest. Patient demographics, reoperation, leak, incisional hernia and mortality were secondary outcome measures. Disruption (spillage) of the gastric specimen was tracked in 135 consecutive patients by a single surgeon. All patients received 2 gm of intravenous Ancef within 30 minutes of skin incision, but routine postoperative antibiotics were not administered. The resected stomach was extracted at the 15 mm port site by enlarging the fascial defect to approximately 2 cm. The gastric specimen was grasped with a Kelly clamp at the corner of the first antral staple line and gently removed. The fascia was closed with a laparoscopic suture passer (figure of eight absorbable 0 suture). The skin was closed using interrupted 4-0 monocryl suture. The patient’s incisions were evaluated two weeks after surgery by their attending surgeon.

Results: There were a total of 273 patients who underwent LSG during the study period. The mean age, weight and BMI was 44.1 years, 269.6 pounds, and 43.9 respectively. Females comprised 82% of the patients. The overall wound infection rate for the study group was 1.46% (4/273). All wound infections were managed at the bedside with incision and drainage. Four patients (3%) had disruption and spillage from the gastric specimen during extraction. There were no wound infections in these four patients. There were no reoperations, incisional hernias, staple line leaks or deaths. By eliminating the use of a 15mm laparoscopic retrieval bag (Covidien Endocatch II #173049), our hospital saved over $58,000 ($213 USD per bag) in equipment costs.

Conclusion: In our series, removal of the stomach through the 15 mm port site, without an extraction bag, was associated with a low wound infection rate and appreciable cost savings. The incidence of specimen disruption with this technique was low (3%) and did not appear to increase the incidence of wound infection. The potential for reduced pain and incisional hernia by avoidance of a bigger extraction incision due to bunching of the specimen in the extraction bag requires further study.

Session: Podium Presentation

Program Number: S012

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