Laparoscopic Sleeve gastrectomy

Transcription

1 Restrictive procedure Laparoscopic Sleeve gastrectomy Dr. R. Peterli Professional Education 1

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3 Introduction Gastric sleeve resection is the restrictive part of the biliopancreatic diversion duodenal switch, first performed by Marceau and Hess in the 90s. It is also a modification of a restrictive operation called the Magenstrasse or Mill procedure. The first laparoscopic sleeve resection was performed in 2000 in a staged concept by Gagner and co-workers in patients where the laparoscopic biliopancreatic diversion duodenal switch or even a gastric bypass could not be performed due to massive obesity. Laparoscopic sleeve resection was performed to induce weight loss allowing the completion of the operation later on. In some of these patients the weight loss was already sufficient and the second stage did not have to be performed. Laparoscopic sleeve resection as an isolated operation has become popular, but until now no long-term results concerning weight loss and resolution of comorbidities are available. The average excessive weight loss two to three years postoperatively vary between 50 to 80 percent. Compared to the standard operation in bariatic surgery the laparoscopic proximal Roux-Y-Gastric Bypass laparoscopic sleeve gastrectomy has potential advantages: the innervation of the gastric remnant remains intact, the endoscopy of the gastric remnant including the duodenum is still possible. There is no need for anastomosis, it may be technically easier and faster to perform. There might also be a reduced risk of dumping syndrome and bowel obstruction. At the other hand, laparoscopic sleeve gastrectomy is not reversible, long-term results are lacking and there may be an increased overall failure rate of 10 to 30 percent as an isolated operation. The main advantage of laparoscopic sleeve gastrectomy is the possibility to either complete the laparoscopic biliopancreatic diversion duodenal switch or change to a laparoscopic Roux-Y-Gastric Bypass in a staged concept. After sleeve gastrectomy a certain risk of gastro-oesophogeal reflux exists, especially when hiatal hernias are overseen and not properly treated during the operation. Early morbidity of laparoscopic sleeve gastrectomy is estimated to vary between 5 and 10 percent. This includes bleeding of the staple-line or the spleen and leaks which can be difficult to treat, especially in laparoscopic sleeve gastrectomy as a redo surgical procedure after failed gastric banding or other previous bariatic operation, due to scar tissue at the angle of His or at the oesophageal-gastric junction. In case the sleeve is too slim there is also a risk of kinking with consecutive obstruction and dysphagia. As long-term complications a certain risk of enlargement of the sleeve with consecutive weight regain or insufficient weight loss has to be mentioned. In such cases a second stage procedure can be added, preferably by laparoscopic completion of the biliopancreatic diversion duodenal switch. 3

4 Instrument overview The following is an overview of selected instruments used at the St Clara Hospital Basel, Switzerland, when performing laparoscopic sleeve gastrectomy surgery. Echelon 60 ENDOPATH Stapler* 60 mm stapler Reloads: ECR60D Gold, ECR60G Green, ECR60B Blue, ECR60W White Product Code: EC60 Company: Ethicon Endo-Surgery * use either Echelon 60 or ETS 45 HARMONIC ACE Curved shears with ergonomic handle, hand control and gray torque wrench. 36 cm long, 15 mm active blade, 5.5 mm diameter Product Code: ACE36E Used in combination with Harmonic Generator 300. Company: Ethicon Endo-Surgery ENDOPATH XCEL Bladeless Trocars Bladeless Trocar, 12 mm in diameter, 100 mm in length. Product Code: B12LT Bladeless sleeve, 12 mm in diameter 100 mm in length. Product Code: CB12LT Company: Ethicon Endo-Surgery Dismantlable Endoscopic Clip Applier 10 mm in diameter; 33 cm in length Product Code: AP4010S Company: Ethicon Endo-Surgery Liver retraction Hook Company: Medic Service, Switzerland Bougie (32-35 Fr) Company: Unomedical, DK Grasping Forceps Company: Micro, France Needle Holder Company: Olympus Agon Beamer Company: Erbe For detailed product information please read the instructions for use. 4

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6 Step Port placement c d b a e (a) An optic view port is inserted in the upper quadrant one hand width below the xiphoid, paramedian left. (b) On the left lateral part of the anterior abdomen a working port for the right hand of the surgeon is inserted. (c) At the level of the xiphoid process a 5 mm trocar tip is inserted. Through this channel a liver retractor is put in place that is connected to an octopus arm which is fixed to the operating table on the upper left of the patient. The surgeon needs another working port (d) placed just right of the midline. A triangulation is thus created with the camera port (a) between the working port (e) and (d). On the left lateral part of the abdomen the assistant port is inserted as depicted (e). Occasionally another port slightly to the right and above the umbilicus helps if the antrum is very low. 6

7 Step Dissection of the greater curvature 1 The dissection starts in the middle of the stomach. The assistant pulls the gastrocolic ligament laterally and the surgeon pulls the stomach to the right. The gastroepoploic vessels remain within the gastrocolic ligament and the greater curvature is freed all the way up to the left crus of the diaphragm. 7

8 Step 2 Preparation of the left crus It is important to visualise the left crus by disecting the short gastric vessels. One has to be careful not to apply too much heat close to the oesophagus, especially in redo cases, where there may be scar tissue. 8

9 Step Reduction of a hiatal hernia closure of the hiatus To prevent postoperative reflux symptoms it is important to reduce any hiatal hernia and close the hiatus. If preoperative diagnostics did not show any hiatal hernia it can also be tested intraoperatively. With a small sponge and by pulling the stomach into the abdomen one can check if there is a dimple between the fat pad and the oesophagus. In cases with hiatal hernia the right crus is visualized by opening the pars flaccida. The hiatal hernia is then reduced and the two pillars are 3 approximated with one to three non-absorbable sutures over a bougie (for example 35 french) inserted in the oesophagogastric junction. 9

10 Step 4 Dissection towards the pylorus The assistant pulls the fundus upwards and the dissection of the greater curvature in direction of the pylorus can be continued. It is important to identify the pylorus as it is not necessary to fully dissect towards the pancreatic head. It is usually sufficient to end with the dissection two to four centimetres before the pylorus. 10

11 Step Mobilising of the posterior gastric Wall 5 To prevent dilatation of the sleeve which usually occurs at the posterior gastric wall, it is important to free the posterior gastric wall from adhesions to the retroperitoneum. The pancreatic capsule should not be injured. 11

12 Step 6 REsection along the lesser curvature A bougie of french is inserted under visual control and its tip placed in the antrum. Linear staples are applied beginning at the antrum aproximately 4 6 cm before the pylorus. Green cartridges should be used as the wall of the antrum is thicker than the rest of the stomach, where golden or blue cartridges can be used. In redo surgery it is better to apply green cartridges where there is scar tissue. It is important not to get too close to the pylorus and also not to get too close to the 12 bougie itself, which could compromise the oversewing of the staple-line. It is dangerous to staple into the oesophagus.

13 Step Oversewing of the staple-line 7 Some surgeons use buttress material to secure the staple-line. For haemostasis the use of an argon laser beamer is advisable. A single layer running suture with a 3/0 mono-filament absorbable thread is placed beginning at the angle of His, which is secured with Laparty allowing the tightening of the suture. Two or three sutures of cm length are usually necessary. It is important to avoid a telescoping of the sleeve. We do not recommend to retrieve the bougie before the oversewing is finished. 13

14 Step 8 REmoval of the resected stomach A plastic retrieval bag helps to take out the resected stomach through one of the working ports by enlarging the size of the incision. The plastic bag protects the subcutaneous tissue and makes it easy to slide the stomach out with the help of a couple of forceps. A silicon drain is placed along the smaller curvature. A nasogastric tube is inserted and remains the first twelve hours. 14

15 View of the final Result 15

16 Ethicon Endo-Surgery bariatricedge sm Always refer to the Instructions for Use/Package Insert that come with the device for the most current and complete instructions. The decision to apply this technique in an individual case or not is left to the discretion of the surgeon responsible. Ethicon Endo-Surgery is not liable for any harm to the patient resulting from the application of this technique in an individual surgical procedure. This document is provided for general reference only and does not constitute medical device by Ethicon Endo-Surgery. The information above is provided to you by the surgeon listed on this document. Ethicon Endo-Surgery (Europe) GmbH Hummelsbütteler Steindamm Norderstedt Germany 2008, Ethicon Endo-Surgery (Europe) GmbH BR