Gastric Sleeve Surgery

Hi, this is Dr. Matthew St. Laurent, and today I will be presenting a laparoscopic vertical sleeve gastrectomy. We utilize a 5 trocar technique. On initial entry into the abdomen, a cursory exam is preformed where a hiatal hernia is identified. We begin our dissection 2 centimeters prior to the pylorus. The short gastric vessels along the lateral surface of the stomach are taken down using ultrasonic shears. This helps us control bleeding during the process of the operation. Once we're in the posterior space, we then work our way downstream, taking down these blood vessels until we have taken down the entire lateral surface distally where the pylorus is seen. Here we can identify the distal aspect of the stomach, which is the pylorus, which is the muscular valve that separates the stomach from small intestine. We then continue our dissection in an upstream fashion, again taking down the small blood vessels along the lateral surface of the stomach. We utilize the harmonic scalpel during this whole process to control hemostasis during the procedure. We use good lateral traction to expose these vessels so that they're easy to take down. As we continue the dissection superiorly, we then encounter the spleen. We take great care during this part of the procedure not to injure the spleen or any of the blood vessels supplying it. Here you can see the upper part of the stomach is closely attached to the spleen. These filmy adhesions are taken down carefully to separate the two structures from each other. Once these attachments are taken down, the left part of the hemidiaphragm begins to come into view. We continue the dissection taking down the filmy areolar attachments until the entire upper part of the stomach has been mobilized off the left hemidiaphragm. We continue with this dissection until the medial border of the left hemidiaphragm comes into view. Here the stomach, the diaphragm, and the spleen are seen. Once this part of the dissection is accomplished, we then direct our attention to the right side. The lesser omental window is opened up with the harmonic scalpel and the right side of the diaphragm is then visualized. We then divide the peritoneal attachments between the medial boarder of the diaphragm and the esophagus. These phrenoesophageal attachments are taken down until the esophagus and stomach are completely mobilized from the posterior diaphragm. Once we have good posterior control we then insert an articulating band retractor behind the esophagus and stomach to help with facilitate the remaining dissection. We continue to dissect and take down the posterior areolar attachments until both leaflets of the diaphragm are individually mobilized. Once both leaflets of the diaphragm are well mobilized from the surrounding tissue, a primary posterior repair of the diaphragm can then be performed. We utilize interrupted sutures of 2.0 silk that are placed in a figure of eight pattern to re-approximate the defect. Oftentimes multiple sutures are needed to completely close the actual defect and complete the repair. It's important to aggressively look for these defect in the diaphragm and repair them, otherwise there is a dramatic increase in the risk of a patient developing post-operative reflux or migration of the stomach into the chest cavity. Here you can see an additional suture is required in order to completely close this defect. Once the suture is placed we can see that the defect is now nicely closed around the esophagus. Once the diaphragm has been completely repaired we can then proceed with resecting the stomach for our gastric sleeve. Our first staple line is created approximately one to two centimeters proximal to the pyloric valve. We utilize a linear stapling device that places three rows of staggered staples on each side of the tissue, and then divides the tissue in between. A tissue reinforcement strip is incorporated into the linear stapler. This helps decrease any bleeding that may occur at the staple line as well as reducing the risk of a gastric leak. The first two rows of staple lines are placed without the aid of a calibrating tube. This helps reduce the risk of the actual sleeve kinking or twisting. Our third staple load is then introduced into the abdomen and used to clamp on the stomach. We then advance a 34 French bougie calibrating tube into the distal stomach. This is utilized to prevent narrowing at the angular junction of the stomach. Once this staple line is created, we then continue with successive loads tightly hugging the bougie calibrating tube in a vertical fashion. We continue with this resection and upstream fashion until we reach the junction of the esophagus and stomach. We make sure that we do provide good lateral traction on the stomach in order to create a slender vertical tube. We also do this to identify the angle of His, which is the junction of the esophagus and the stomach. It's important that we do not place any staples on the actual esophagus as it will increase the risk of the patient developing a leak. Here you can see that we have well-lateralized the stomach, making sure to resect any of the redundant lateral portion. Our final staple load is in place, again, making sure not to be on the esophagus. Once the stapler is fired, the resection is complete and the redundant portion of the tissue reinforcement strip is then divided. The resected stomach is then removed from the right 15 millimeter port site. Once the resected stomach has then completely removed from the abdomen, the 15 millimeter trocar is reintroduced. The bougie calibrating tube is removed, leaving behind a nice, slender vertical tube that has no twisting or kinking. We then perform an upper endoscopy. This is to test the integrity of the staple line. We placed the actual stomach and staple line under a saline bath and proceed with the upper endoscope examining the intralumen and the integrity of the staple line. An air insufflation test if performed distending the stomach and looking for any air bubbles. Once we have confirmed that there's no leak, the remaining air in the stomach is aspirated and the endoscope is removed. Once this is accomplished, we then proceed with removing all the excessive irrigation that was placed on the abdomen. We also perform a cursory exam, look at all the internal organs, making sure that there has been no injuries during the procedure itself. We then place the omental fat along the lateral border of the staple line to provide additional reinforcement and control of any oozing or bleeding. The Nathanson retractor is then removed and we proceed with the abdominal closure. We insert a closure device and close the 15 millimeter port site, making sure that the defect is well re-approximated to prevent any herniation at this site. The remaining trocars are 5 millimeters and don't require any closure. Once the fascial defect is completely closed, we then aspirate any remaining air and remove the remaining trocars and the laparoscope. This completes the actual procedure. The patient's post-operative course was unremarkable. An upper GI was performed the same day of the surgery, which was negative for a leak. She was started on a clear liquid diet the next day and then discharged home.