Laparoscopic Sleeve Gastrectomy in a patient with Heterotaxy Syndrome

Selma M Siddiqui, MD, Rami E Lutfi, MD. St. Joseph Hospital

Today we discuss a patient with heterotaxy syndrome who presented for sleeve gastrectomy. She had a prior cholecystectomy at which situs inversus was noted, so CT scan was obtained for operative planning. We see dextrocardia with a left sided liver noting a prominent right lobe. We see the right sided gastric body without the normal duodenal sweep; we also note right sided polysplenia.

This guided trocar placement with a mirror image approach: we placed the 12mm trocar in the left upper quadrant with the remaining 5mm ports reversed across the midline. The operating surgeon stood to the patient's left.

Upon entering the abdomen with the 5mm 30degree laparoscope, we noted the right sided greater curvature with prominent right lobe.

We placed a 10mm port in the epigastric location and the 10mm fan liver retractor was introduced. We then had adequate exposure.

We proceeded to enter the lesser sac in our usual fashion. It is our practice to use the Harmonic Ace Plus shears for the dissection of the omentum off the greater curvature of the stomach

This patient’s anatomy presented a C- shaped greater curvature of the stomach. The sharp angulations required to approach these curves became challenging as we moved proximally along the gastric body and we switched the port sites used for the harmonic shears more frequently than we typically

As we approached the upper fundus, it appeared that each splenule individually contributed a ligamentous attachment containing short gastrics. Fortunately we did not encounter any significant bleeding from the short gastric vessels.

We identified the Gastrophrenic ligament and were able to divide these attachments with our energy device. When this was cleared, the right crus was identified and no significant hiatal hernia was noted.

We then ensured we had divided the gastrocolic omentum to a distance of 5cm from the pylorus distally

To guide division of the stomach, we place a 34 french bougie all the way to the pylorus. Using the 60mm loads on the Echelon Flex Endopath staplers we divide the stomach all the way up while retracting laterally to avoid twisting of the pouch. We construct the sleeve leaving some distance between the stapler and bougie at the incisura and the angle of His to avoid problems with emptying. To reduce the risk of leak along this lengthy staple line, we use Seam guard buttress on all firings.

We leave the posterior attachments of the gastric body to the transverse mesocolon to as these attachments prevent tristing of the sleeve and subvert the need for omentopexy

We routinely perform endoscopy to visualize the internal staple line and assess for bleeding and to perform a leak test of our pouch. We noted the unique angulation and 6’oclock rather than 12 o’clock position of our staple line on this endoscopic evaluation.

The patient tolerated this procedure well and her post operative Upper GI showed no obstructions or leak on her right sided gastric pouch. She began a liquid diet and was discharged on post operative day one.

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