Sleeve Tube: Novel Tool to Standardize Laparoscopic Sleeve Gastrectomy (lsg)

Objective: Laparoscopic sleeve gastrectomy [LSG] has been increasingly accepted as a definitive weight loss surgery. LSG is less complex than Roux En Y Gastric bypass with lesser complication profile but comparable outcome. Complications arising out of LSG are results of technical failures: misidentification of vital surgical landmarks, use of improper staple heights, inadvertent traction, unguided imbrications of the staple line, spiral coiling of the stomach and failure in identification of safe diameter at most vulnerable areas like antrum and GE junction. Review and analyses of such complications lead us to develop this novel tool.

Method/device: Laparoscopic sleeve gastrectomy is routinely performed with bougie of different sizes 34F-50F in situ and initial staple fire starting at 3-6 cm’s proximal to the pylorus. The Sleeve tube (ST) is a latex free transparent tube with pliable inflatable balloon at its tip and is available in different sizes from 40 Fr and above. ST has channels for the insertion of endoscope, for inflation of distal balloon as well as for suction/irrigation. Internal calibration markings enables surgeon to precisely measure the distance from pylorus for first staple fire.

Technique: ‘Sleeve-tube’ device is inserted into the patient’s stomach in an oro-gastric fashion with the endoscope in the lumen of the clear ‘Sleeve tube’ and can be advanced across the pylorus. The balloon at the distal end of the Sleeve tube is inflated to occlude the pyloric channel and prevents small bowel distention. Endoscopic visualization of the markings inside of the tube will guide the surgeon to start the transection at a precise distance proximal to pylorus with avoidance of the risk of encroaching on to the pylorus. Endoscopic visualization will help in identification of the technical errors such as excess traction, coiling of staple line, bleeding from the staple line, early identification of evolving hematoma of the staple line, compromise in the size of lumen during staple line imbrications and more importantly identify precise site of transection well away from GE junction. Intra operative air leak test can be performed with this tube. ST will also aid in endoscopic application of fibrin glue, as some evidences suggest it to decrease the incidence of leaks.

Conclusion: Sleeve Tube is a safe, cost effective tool to decrease the technical failures during LSG. This novel tool is more appropriate in the current setting of world wide increase in the performance of LSG as an effective bariatric procedure. Sleeve tube will increase the comfort level of trainees and aid in shorter learning curve.

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