Contemporary SurgeryVIDEO REVIEW
How we do laparoscopic sleeve gastrectomy
Associate Director, The Bariatric and Metabolic Institute, Section of Minimally Invasive and Endoscopic Surgery
Director, The Bariatric and Metabolic Institute, Section of Minimally Invasive and Endoscopic Surgery, Cleveland Clinic Florida, Weston, FL
Initially a first-stage or bridge operation to gastric bypass, LSG may become a primary treatment.
Watch the accompanying video
Laparoscopic sleeve gastrectomy (LSG) is a controversial and relatively new primary procedure for weight loss. It has been used successfully as a first step in the super morbidly obese patient in staged duodenal switch and gastric bypass.
LSG combines the principles of gastric restriction and hormonal appetite suppression by removing the fundus of the stomach and thus the majority of the oxyntic glands that produce the appetite stimulating ghrelin hormone.1 This approach creates a “sleeve” or tubular stomach along the lesser curvature.
Although long-term data is lacking, growing evidence has supported LSG as a safe and efficacious primary procedure.
Sleeve gastrectomy has been described as a first-stage or bridge operation before more complex procedures such as biliopancreatic diversion (BPD) or Roux-en-Y gastric bypass (RYGB).2-5 It is also an option in revisional bariatric surgery.6 In our institution, LSG serves as a one-stage treatment in selected morbidly obese patients.
The attraction of LSG
Although long-term data is lacking for weight-loss maintenance and comorbidity resolution, growing evidence has supported LSG as a safe and efficacious primary procedure.3,7,8 Laparoscopic sleeve gastrectomy is an attractive alternative without the fear of marginal ulcers, internal hernias, malabsorption issues, adjustments, or foreign-body complications of RYGB, BPD, and laparoscopic adjustable gastric bands (LAGB), respectively.
We present the minimally invasive technique for sleeve gastrectomy and our results in 164 patients. We do not delve into credentialing of surgeons, reimbursement issues, or Center of Excellence criteria, which also play an important role in achieving LSG success.
Who’s right for LSG?
Candidates for LSG must first meet the widely accepted guidelines for bariatric surgery. The National Institutes of Health (NIH) Consensus Conference established that bariatric surgery is indicated for individuals with a body mass index (BMI) greater than 40 kg/m2 or greater than 35 kg/m2 with significant comorbidities.9
However, the indications for LSG have not been clearly defined. In our institution, LSG selection is based upon meeting NIH standards along with one of these other criteria:
Patient preference for LSG over LRYGB or LAGB.
Contraindications for LRYGB, such as a prior malabsorption procedure, risk of stomach cancer or ulcer or both, inflammatory bowel disease, and adhesions.
High-risk for marginal ulcers (heavy smoking, H. pylori infection, chronic NSAID use).
Extremes of age—adolescents as well as elderly.
First step to non-bariatric procedures (orthopedics, transplant recipients, recurrent hernia repair).
The procedure is usually not indicated for the patient with:
A strong history of gastric reflux.
Gastric mucosa pathology along the greater curvature.
Esophageal or gastric varices.
Congenital or acquired gastric telangiectasia.
Autoimmune connective tissue disorders such as scleroderma or lupus.
The preoperative examination
Preparation for LSG is similar to other traditional bariatric surgery options. Patient selection and screening is paramount to a successful outcome, and thus, patient evaluation requires a comprehensive multidisciplinary approach. Psychologists, nutritionists, primary-care physicians, and specialists all participate.
Candidates for LSG must first meet the widely accepted guidelines for bariatric surgery.
A detailed history and complete physical examination are essential. Particular attention should be given to a history of heart disease, obstructive sleep apnea, and abdominal surgery. Our routine laboratory screening includes a complete blood cell count, chemistry panel, liver function tests, coagulation profile, and urinalysis. All patients should also have a chest x-ray and electrocardiogram. We have a low threshold for cardiology, pulmonary, or specialty referral for perioperative recommendations and medical clearance.10
Keeping patient expectations real
Under Institutional Review Board (IRB) approval and informed consent, the patient must clearly understand the investigational nature of this procedure and its inherent risks and benefits, as well as the paucity of long-term data. Realistic expectations for weight loss, comorbidity resolution, symptoms, and lifestyle impact will ease the patient’s postoperative adjustment.
Two weeks before surgery, we advise the patient to lose weight by starting a liquid diet of low-carbohydrate protein shakes. This shrinks an enlarged fatty liver and allows for a less technically demanding procedure.11
The operative technique
The entire abdomen is prepped and draped in a sterile fashion. The patient is placed in a slightly reverse Trendelenburg position to aid exposure. An orogastric tube is inserted to decompress the stomach and then removed. The surgeon stands to the patient’s right. A seven-trocar technique is used (FIGURE 1).
FIGURE 1 Port placement
The 7-trocar technique involves five 12-mm trocars and two 5-mm trocars. (Courtesy: Cleveland Clinic Foundation)
Access to the abdominal cavity is gained through a 1-cm supraumbilical incision using the Optiview trocar (Ethicon Endosurgery, Cincinnati, OH). Pneumoperitoneum is generated with CO2 insufflation to 15 mm Hg pressure. Four additional 12-mm and two 5-mm bladeless trocars are inserted under direct visualization.
The patient must clearly understand the investigational nature of LSG and have realistic expectations.
The initial step after liver retraction is to identify the pyloric channel. The short gastric vessels of the greater curvature are taken down about 5 cm proximal to the pyloric channel, using the Harmonic scalpel (Ethicon Endosurgery) (FIGURE 2). Dissection is continued along the greater curvature up to the gastroesophageal (GE) junction (FIGURE 3).128
FIGURE 2 Starting the dissection
Dissection of the short gastric vessel along the greater curvature (white arrow) starts about 5 cm from the pyloric channel (yellow arrow).
FIGURE 3 Continuing the dissection
Taking down the angle of His helps delineate the gastroesophageal junction (white arrow). The diaphragm is also visible (yellow arrow).
FIGURE 4 Creating the sleeve
Firing of the first 4.5-mm linear stapler along the antrum defines the lower end of the gastric sleeve.
FIGURE 5 Completing the transection
To transect the fundus to create the sleeve (white arrow), 3.5-mm linear staplers are used. The resected stomach is to the right (yellow arrow).
Creating the sleeve
A 40-Fr bougie is placed transorally into the pyloric channel under direct vision. The thick antrum of the stomach is vertically transected using three applications of 4.5 Endopath linear cutters (Ethicon Endosurgery) around the bougie to create a gastric tube (FIGURE 4). Transection of the stomach is completed using 3.5 mm linear cutters up to the level of the GE junction (FIGURE 5).
Finally, a gastric sleeve with an estimated capacity of 150 ml is created. The staple line is over sewn and inverted over the bougie from each direction for hemostasis and prevention of leaks. One suture is used for the superior staple line; a second suture is used for the inferior portion. The sutures are tied together at the staple-line midpoint (FIGURES 6 and 7).
Placing drain, removing specimen
We routinely place a 19-Fr round drain in the sub-hepatic space near the staple line at the conclusion of the procedure to identify postoperative bleeding or leaks or both (FIGURE 8). We place the resected stomach in a specimen bag (FIGURE 9) and extract it through the horizontally extended supraumbilical trocar site. A single nonabsorbable suture in a figure-8 fashion closes the fascial defect. Subcuticular sutures approximate all skin incisions.129
FIGURE 6 Over sewing the upper staple line
The first 2-0 silk suture is started from the superior end of the staple line.
FIGURE 7 Over sewing the lower staple line
A second 2-0 silk (white arrow) suture is started from the lower end of the staple line. Both sutures are tied together at the middle portion of the sleeve.
FIGURE 8 Placing the drain
We place a single drain in the sub-hepatic space.
FIGURE 9 Specimen removal
We use an Endobag to remove the specimen via an extended supraumbilical trocar site incision.
Morbidly obese patients should be admitted to an intermediate care or intensive care unit. Early postoperative ambulation and generous use of incentive spirometry is encouraged. Adequate postoperative analgesia is essential to improve mobility and decrease pulmonary related complications. We initially use a patient-controlled analgesia pump, and then convert to a morphine elixir after the first postoperative day.
One study concluded that weight loss and loss of feeling of hunger was more optimal after LSG than LAGB.
A Gastrograffin upper-gastrointestinal series should be performed on the first postoperative day to confirm the absence of a leak, after which a clear liquid diet is initiated. The patient is discharged on postoperative day 2 or 3 once passing flatus and tolerating liquids. The abdominal drain is removed prior to discharge.
What the early results show
Sleeve gastrectomy was first applied in humans as a component of Douglas S. Hess’ biliopancreatic diversion with duodenal switch (BPD-DS) in 1988.12,13 The concept of the “street of the stomach” along the lesser curvature as a primary surgery was also developed by David Johnston as part of the Magenstrasse and Mill operation.14 Transition to LSG as a first-stage procedure is credited to Michel Gagner.15
A few series have promoted LSG as a single-stage procedure with reported excess weight loss (EWL) of 46%–57% at 1 year with complications rates of 0%– 23%. However, these studies are either small or involve super obese and high-risk patients.3,7,8,16-18 Long-term maintenance of weight loss has not yet been established.
Our results with LSG
Our team performed 164 LSG procedures from November 2004 to April 2007. Our findings:
Patient population. Mean age was 44 (16–79) years, and included 118 (72%) women. Mean BMI was 44 (35–64) kg/m2; 98% were completed laparoscopically.
Operative data. The mean operative time was 80 min (65–130 min) and the mean length of hospital stay was 2.8 days (2–25 days).
Weight loss. The mean EWL was 43% and 58% at 3 and 6 months, respectively.
Complications. We encountered 4 major postoperative complications in primary LSG, for a complication rate of 2.9%. These included a leak, an abscess, a hemorrhage, and a sleeve stricture. We had no mortalities.—SS, NR, PFL, IS, RJR
LSG versus lap gastric banding
A prospective randomized study concluded that weight loss and loss of feeling of hunger after 1 year and 3 years, respectively, were more optimal after LSG than after LAGB.19
A comprehensive review of all published series in the English literature regarding LSG, including more than 775 cases, indicates only 3 mortalities within one month postoperatively.17,18 Larger series from experienced centers are needed to evaluate the safety and efficacy of this procedure as a definitive primary treatment for morbid obesity.
Early results are encouraging, but follow-up beyond 3 years is needed to evaluate long-term outcomes.
Dr Szomstein has been affiliated with Ethicon Endo-Surgery, Covidien, and Karl Storz.
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- NIH Conference.
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