Laparoscopic sleeve gastrectomy - general and visceral surgery
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Placing the trocars
Position the camera trocar in the left upper quadrant, ensuring it is at least 15 cm away from the xiphoid.
Insert another two 12 mm trocars in the median epigastrium inferior to the rib cage. Place a 5 mm trocar high up in the median epigastrium.
• Mobilizing the greater curvature I; skeletonizing distad:
Skeletonize the greater curvature of stomach by transecting the gastrocolic ligament close to the gastric wall, while preserving the gastroepiploic arteries. Start the distad dissection with the Ultracision at the inferior gastric body, ending 3-5 cm proximal of the pylorus. Open the lesser sac and take down any adhesions to the pancreas.
Mobilizing the greater curvature II; skeletonizing proximad:
In this way, release the entire greater curvature of stomach. Divide the connection to the spleen, the gastrosplenic ligament, and clip the short gastric vessels. Carry the skeletonizaton through to the angle of His.
Note: Expose the angle of His with the left diaphragmatic crus to rule out any hiatal hernia and parts of the stomach displaced into the mediastinum.
Placing the calibration bougie:
Now introduce a 32 French calibration bougie transorally into the stomach and, with grasping forceps, place it at the lesser curvature.
Note 1: This measure is intended to avoid stenosis or an excessively wide gastric sleeve.
Note 2: Bougies <34 French are associated with a higher fistula rate. However, better restriction is achieved with a narrower gastric sleeve and, accordingly, a better treatment outcome.
Note 3: Charrière (Ch) is a measure of the outer diameter of tubes / cannulas, etc. Three Charrière corresponds exactly to one millimeter (1 Ch = 1/3 mm). This is an eponymous term named after Joseph-Frédéric-Benoît Charrière. In the English-speaking world, this unit is simply known as French (Fr) (because of its French origin).
Stapling along the bougie
Starting at the antrum approximately 3–5 cm proximal to the pylorus, resect the stomach on the side of the greater curvature with a 60 mm Echelon linear cutter while following the bougie which has to be mobile at all times. This resection proximad completely removes the fundus; different cartridges are used to account for differences in tissue thickness (green for the antral region, gold/yellow and blue for the proximal gastric wall).
Note 1: Measured from the pylorus, leave 3–5 cm of antrum in place to preserve unimpeded gastric emptying.
Note 2: Resection should be without any steps to avoid stenosis and subsequent formation of pseudodiverticula.
Retrieving the resected specimen
After successful leakage testing with methylene blue (not shown), place the resected gastric specimen in a retrieval bag in the abdomen and recover it through an extended trocar incision (median, superior to the umbilicus).
Note: Determine the volume of the recovered gastric specimen. Its filling volume should be at least 500 ml.
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