Laparoscopic Sleeve Gastrectomy: Bougie or no Bougie, “Follow the End of the Vessels”.

Rabih Nemr, MD, M Kopp, DO, C Vulpe, MD, George Ferzli, MD. lutheran medical center

Introduction

Laparoscopic sleeve gastrectomy (LSG) has been extensively performed worldwide; however, standardization of the technique is lacking. The variability of the surgical technique and subsequent sleeve shape usually depends on the bougie used and the starting point of resection in relation to the pylorus. Our study evaluated a new technique that relies on patient-specific anatomic landmarks, following the lesser curvature vessels, to guide the surgeon in shaping the gastric tube. This technique leaves a stomach remnant individualized to each patient based on his or her specific anatomy.

Methods and Procedures

The patient is placed in a supine position. No urinary catheter is inserted. Pneumoperitoneum is established using the Veress needle approach. Standard trocar placement is done but may be changed per surgeon preference. The pylorus is identified by its color as well the prepyloric vein. The greater curvature of the stomach is mobilized using the LigaSure device up to the angle of His. The resection starts approximately 2 cm proximal to the pylorus. The surgeon staples the stomach along the end of the lesser curvature vessels up to the angle of His using buttressed staples. Extreme care is taken not to narrow the incisura angularis. As the gastroesophageal junction is approached, a 32-Fr tube is inserted, thus ensuring that the resection is at the edge of the junction fat pad without incorporating it.

We analyzed retrospectively collected data of all patients who underwent LSG from June 2010 to December 2012. Patients with incomplete charts and follow-up of less than 180 days were excluded. The procedure was performed by either of two surgeons. Age, sex, height, ethnicity, preoperative weight, last available postoperative weight, OR time, intraoperative and postoperative complications, length of hospital stay and length of follow-up were recorded. BMI and percent excess weight loss were calculated. Microsoft Excel was used for data recording and statistical analysis.

Results

Data from 95 patients (79 women, 16 men) were analyzed. Mean age was 39 years (range 19 – 66 years). Mean preoperative BMI was 46.9 kg (range 37.8 – 76.8 kg). The average percent excess weight loss at 180 days after surgery was 46% and at 360 days 47%. Mean OR time was 79 minutes. There were no reported intraoperative complications. 2 patients had postoperative port site bleeding requiring blood transfusion. 1 patient had intra-abdominal hematoma secondary to splenic bleed. None of the patients required return to the OR. The average length of hospital stay was 2.5 days.

Conclusion

Standardization of the sleeve gastrectomy by following the “end of the vessel” technique offers patient-related landmarks rather than bougie-related sizing. It is safe and produces acceptable and similar weight loss compared to published data.

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Starting line

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Gastric tube with forming fold

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Posterior view

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GE Junction view

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