A Problem of Pandemic Proportions: Surgical Solutions for Obesity

by Brie Eteson, Digital Surgery

Laparoscopic Sleeve Gastrectomy

Obesity is rapidly becoming a major issue across the world. At least 2.8 million people are dying each year from obesity-related comorbidities.1 In 2016, 2 billion adults were recorded as being overweight, and of those, 650 million were obese. This figure has almost tripled in the last 40 years.2

In severe cases of obesity, surgery can be performed to mitigate it. Laparoscopic sleeve gastrectomy is one of the most commonly performed bariatric procedures worldwide, accounting for 61% of all bariatric procedures performed in the US in 2018.3 Potential benefits of this surgical procedure are long-lasting and substantial weight loss, as well as resolution to obesity-related comorbidities postoperatively.

The new simulation, available for free from Touch Surgery™, demonstrates how to perform a laparoscopic approach to a sleeve gastrectomy. Unlike a gastric bypass, the stomach is resected along the greater curvature, to form a tube-shaped stomach with a considerably smaller residual volume, leaving the remainder of the stomach intact.

Weight loss is promoted by both endocrine and mechanical effects. The reduction of stomach volume causes early satiation, while the removal of the gastric fundus reduces the release of ghrelin, the appetite stimulant.4 This procedure has been shown to be successful for excessive weight loss in multiple studies.5,6

The Key Surgical Objectives of laparoscopic sleeve gastrectomy are outlined below. For a full breakdown, and the entire simulation, search in the Touch Surgery™ app today:

Patient Positioning for this surgery is demonstrated on a bariatric table with the patient’s arms abducted on armboards, they are then prepped and draped accordingly.

Port Insertion

  • Palmer’s point lies 3 cm below the costal margin at the midclavicular line. This is where the laparoscope is inserted.
  • After insufflation, the laparoscope is inserted into a new port, at the dome in a working port.
  • Another port is inserted left and lateral to the scope, in line with Palmer’s point, infiltrated with local anesthetic before insertion of the trocar.
  • After infiltration, a trocar is inserted into the right upper quadrant, inferior and lateral to the falciform ligament.
  • A final port is infiltrated with anesthetic, and inserted over the left lobe of the liver, inferolateral, and to the left of, the xiphoid process.
Picture of abdomen with trocar insertion points labeled.

1. Palmer’s point; 2. Working camera port at abdomen dome; 3. Left flank port; 4. Right upper quadrant; 5. Over the left lobe of the liver

Exposing the angle of His

Reflection of the stomach superomedially to expose the short gastric vessels 

Gastric Dissection

The table is tilted to be positioned in reverse Trendelenburg, approximately 50° to 70° head up and 5° to 10° right tilt, improving exposure to the key anatomical structures, such as the greater curvature of the stomach, spleen, and liver. To completely empty the stomach, a 34 Fr esophagogastric tube is inserted into the stomach, and compressed from the outside of the stomach so that all gastric contents are pushed out through the tube.

The stomach is first retracted inferiorly, and the peritoneum is dissected away to expose the angle of His. An O’Reilly retractor is inserted through the space just dissected to allow pneumoperitoneum to enter the lesser sac. Retracting the stomach away from the omentum superiorly while retracting the omentum facilitates lesser omentum dissection, and a window into the lesser sac is created across from the pes anserinus via dissection through the greater omentum. This dissection continues just below the greater curvature, finishing the distal dissection 3 to 5 cm proximal to the pylorus. The dissection is reorientated to follow the greater curvature proximally away from the gastrocolic ligament to the previous dissection at the angle of His. The stomach is reflected to expose and ligate the short gastric vessels, including any remaining short gastric branches, to free the whole fundus. At the angle of His, the peritoneum is dissected to expose the left crus and phrenoesophageal ligament.

Creation of a window into the lesser sac through the greater omentum, extending the dissection distally below the greater curvature

Reorientation and dissection proximally away from the gastrocolic ligament to meet dissection made at the angle of His

Gastric Sleeve Creation

A 34 Fr esophagogastric tube is inserted, adjacent to the lesser curvature of the stomach, and a stapling system is positioned over the distal antrum, 3 to 5 cm proximal to the pylorus. The stomach is compressed with the stapler whilst the anesthetist moves the esophagogastric tube back and forth. This is to ensure the sleeve functions properly postoperatively, and to avoid it getting stuck on the staple line. The underside is also assessed for positioning during compression, prior to each stapling. This continues until the tissue is divided. The staple line is checked for quality and completeness, including the removal of crotch staples or excess staple line reinforcement. A new, gently curved greater curvature is formed with the stapling extending the resection proximally until fully divided. For the final staple, ensure it is not fired too close to the gastroesophageal junction. A final inspection is performed to check if another staple is required to complete the transection.

The resected stomach is moved to the right upper quadrant, where it remains until the end of the operation, due to the extraction site needing to be extended. The patient is brought back to level and the tip of the esophagogastric tube is moved to the gastroesophageal junction. Mean arterial pressure is increased to 80 mmHg to assess the staple line for bleeding. The stomach is clamped just below the staple line.

Firing of the staple line until tissue is divided

Removal of the resected stomach

Firing of the staple line until tissue is divided

Inspection of the staple line and completion of transection

Air leak test

Deflation and removal of remaining port

An Air Leak Test is performed. If bubbles are observed, this suggests a leak in the staple line. The stomach is also assessed for staple line strength under high pressure. The saline can be suctioned away if there is no evidence of an air leak. If a leak is present, the staple line is reinforced at the point of the leak. Hemostatic clips are placed at any bleeding points of the staple line, and the resected stomach is returned to the left upper quadrant. 

Closure

The 15 mm port is extended and the resected stomach is extracted. After observing for injury, the left lobe of the liver is returned to its anatomical position, and the ports are removed under laparoscopic vision. The abdomen is deflated, and the remaining port is removed before carrying out a standard closure protocol. In this simulation, the author, Sanjay Purkayastha, MD, FRCS, closes port sites by infiltrating them with local anesthetic and closing the fascia with absorbable braided sutures on J-needles, which are completed with subcuticular stitches.

To learn more about Laparoscopic Sleeve Gastrectomy, search in the Touch Surgery™ app today.

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How to cite this simulation: Purkayastha S. Laparoscopic Sleeve Gastrectomy. Touch Surgery Simulations. http://dx.doi.org/10.18556/touchsurgery/2021.s0184. Published May. 7, 2021.

References

1. World Health Organisation. Obesity. WHO Website. https://www.who.int/news-room/facts-in-pictures/detail/6-facts-on-obesity. Updated Apr. 1, 2020. Accessed May. 6, 2021.

2. World Obesity Federation. Prevalence of Obesity. Website. https://www.worldobesity.org/about/about-obesity/prevalence-of-obesity. Updated 2019. Accessed May. 6, 2021.

3. Kapur A, Thodiyil P. Primary laparoscopic sleeve gastrectomy versus gastric bypass: a propensity-matched comparison of 30-day outcomes. Surg Obes Relat Dis. Forthcoming 2021.

4. Casimiro I, Sam S, Brady MJ. Endocrine implications of bariatric surgery: a review on the intersection between incretins, bone, and sex hormones. Physiol Rep. 2019 May;7(10):e14111.

5. Fischer L, Hildebrandt C, Bruckner T, et al. Excessive weight loss after sleeve gastrectomy: a systematic review. Obes Surg. 2012;22(5):721-31.

6. Sepúlveda M, Alamo M, Saba J, Astorga C, Lynch R, Guzmán H. Long-term weight loss in laparoscopic sleeve gastrectomy. Surg Obes Relat Dis. 2017;13(10):1676-81.

7. Juodeikis, Žygimantas et al. Long-term results after sleeve gastrectomy: A systematic review. Surg Obes Relat Dis. 2017 Apr;13(4):693-699.

8. Silecchia G, Iossa A. Complications of staple line anastomosis following laparoscopic bariatric surgery. Ann Gastroenterol. 2018. 31(1):56-64.

9. Karaman K, Aziret M, Ercan M, Ebiloglu T, Karadeniz U, Bostanci EB. A Preventative Strategy for Staple Line Bleeding in Morbidly Obese Patients Undergoing Sleeve Gastrectomy. J Laparoendosc Adv Surg Tech. 2017, 27(10):1015-1021.