AIS Channel
2016
Case
A 47-year-old male with a history of morbid obesity and a BMI of 37.7Kg/m2 (Height 1.70 meters, weight 109 Kg). He is a multipathological patient as he suffered from: High blood pressure (treated with 3 drugs), type two diabetes mellitus (treated with 26 insulin units per day plus metformin) HbA1c 7,8, dyslipidemia, positive for HCV, asthma, BPD Gold B and severe OSA that required CPAP, also chronic kidney failure due to microscopic polyarteritis that required a kidney transplantation and correct graft function.
He underwent an exploratory laparotomy three years ago at another hospital due to a suspected intestinal ischemia. No bowel was resected at that time but as a complication he had a large incisional hernia.
At the preoperative study the upper gastroscopy was normal, no hiatal hernia was found, and the biopsy was negative for helicobacter pylori. The abdominal ultrasound was compatible with liver steatosis. ASA score III.
Treatment
The patient was placed in the supine position with legs wide open. The leading surgeon stood between the patient's legs with one assistant on each side. A total of 6 ports were used: the first one was a 12mm port located at the right flank. Then a 12 mm periumbilical port was placed to the right of the incisional hernia. Two 5mm ports were located in a subxiphoid position; a very lateral port was placed at the left flank; a 12mm port was located at the left flank; and the last port was placed at the epigastrium.
After the placement of the first trocar the camera was introduced to explore the abdominal cavity. Notice that there was a large amount of small bowel attached to the anterior abdominal wall. A portion of the major omentum was also attached and pulling up the transverse colon.
A 12mm port was introduced under direct laparoscopic supervision very low in the right flank. The camera was changed in that port which made it possible to introduce the scissors at a nice angle to perform adhesiolysis in order to clear the surgical field and place the rest of the ports.
We use the LigaSure™when we are sure that the gut is at a distance. This enables faster dissection and improves hemostasis control. Here we are taking down the major omentum. Soon the surgical field will be free to perform the sleeve gastrectomy.
Then we continued with the standard procedure, opening a window with the hook at the gastrocolic ligament to access the lesser sac. The LigaSure™is used to complete this mobilization as it seals the tissue and sections it. The assistant surgeon helps by pulling the gastrocolic ligament, thus improving the exposure and ensuring visualization of the limit of the major curvature.
We always verify the limits of the dissection. It is crucial to identify the pylorus and make sure that the major curvature is released at least 5 cm from it. The adhesions on the posterior wall should be removed to allow correct traction of the stomach during the placement of the mechanical sutures. This maneuver should be performed across all the stomach that will be involved in the gastrectomy.
Sharp dissection using the hook is recommended, taking care to preserve the short vessels in the lesser curvature. Now we are moving towards the fundus. Once again, the transaction between the leading and the assistant surgeon achieves the exposure by opening the surgical field like a book.
A nice maneuver to fully dissect the fundus involves the assistant surgeons grabbing the stomach and performing traction with the clinch. This allows the leading surgeon to perform extra traction of the stomach with his left hand while dissecting with the Ligasure™. We mobilize until the left crus is identified.
Then the anesthesiologist introduces a 35 Fr bougie to calibrate the gastrectomy. We assist with the placement of the bougie. The gastrectomy begins. We use mechanical sutures. As a precaution we count 20 seconds before firing it. This improves hemostasis.
The combination of stomach traction and articulation of the mechanical suture provides the correct angle to build an untwisted and symmetrical gastrectomy, which ensures good outcomes for patients.
In the last firing we make sure that we are 1 cm away from the angle of His and that the mechanical suture involves all the gastric tissue. This prevention maneuver prevents leaks. We don't make a prolene running suture, but only make knots from the gastroepiploic ligament to the stapler line to avoid twisting and reinforcing bleeding zones if required.
We always check for bleeding from the stapler line, placement of clips may solve this issue.
Outcome
The surgery was uneventful and took 105 minutes. No drainage was left. The patient started oral intake and left hospital on the second postoperative day with no complications.
One month after the procedure he has lost 10Kg. There is no reflux or abdominal pain, and no insulin is required.
