Munenori Uemura, Tetsuo Ikeda, MD, PhD. Department of Advanced Medical Initiatives Graduate School of Medical Sciences
Conclusion: Using the devised techniques, a Japanese gastroenterological surgical department was able to safely perform bariatric surgery on patients with BMIs of 35 – 75.8 (kg/m2).
Background: Laparoscopic sleeve gastrectomy (LSG) is gaining popularity worldwide as a definitive bariatric procedure. However, there are still some controversial issues associated with the technique, such as methods of the reliably dissection of gastric fundus, the prevention of the gastric tube strictures and the reinforcement method of staple line. The aim of this study to evaluate our “stand the stomach technique” on the preoperative course of LSG.
Methods: Between November 2013 and March 2015, 43 morbidly obese patients submitted for LSG were performed. Sixteen case were performed LSG using this technique.
Surgical Technique: All of the procedures were performed under general anesthesia. Patients were placed in the supine position with opening legs. Initial trocar placement was accomplished through the umbilicus, under direct vision, using a 12-mm optical trocar with an attached balloon. Pneumoperitoneum was achieved with carbon dioxide to a pressure of 12 mmHg. Four additional ports were then placed under direct vision.
The dissection was begun by dividing the gastrocolic ligament along the greater curvature of the stomach approximately 1 cm proximal to the pylorus using a 5-mm EnSeal (Ethicon Endo-Surgery, Blue Ash, Ohio) attached to a SILIGATOR (auto irrigation silicon tube, Fujisistem Kanagawa Japan). This dissection was continued towards the gastroesophageal junction. The left crus was completely freed of any attachments in order to avoid leaving a posterior pouch when constructing the sleeve in this region. With the stomach held in the cephalad direction, the gastric transection was started approximately 1 cm proximal to the pylorus using a 60-mm green endo-stapler (Echelon Flex 60 Endopath), making a circle with the gastric angle as the major axis, and the greater curvature was resected approximately 1 cm from the gastroesophageal junction. Following the transection of the stomach, the staple line was oversewn using 2/0 and 3/0 Endo Quick Suture (Akiyama, Japan) interrupted or continuous intracorporeal suture. At this time, similar to when the gastrosplenic ligament was detached, the assistant lightly pulled sutures. Finally, for the resection of the remaining pylorus-proximal region of the stomach towards the caudal side, the staple line was grasped with the left hand and was simultaneously held upright along with the lateral segment of the liver and this segment was sutured.