Tips and Tricks in Sleeve Gastrectomy

Abstract

Obesity has become a serious health problem worldwide. Surgery is seen as the most important weapon in the fight against obesity. Laparoscopic Sleeve Gastrectomy is the most widely practiced obesity surgery technique worldwide. Today, this surgery is safely applied to a large number of patients. With the development of technology and surgical experience, the mortality and morbidity of obesity surgeries have decreased considerably. However, these surgeries still require serious experience and knowledge. In this book chapter, we have compiled the technical tips of laparoscopic sleeve gastrectomy, key points that will increase the comfort of the surgeon and the patient, and tricks that will facilitate the operation and shorten the operation time.

1. Introduction

Obesity is considered a serious health problem all over the world. Surgery is the most effective method in the treatment of obesity. Although many surgical methods have been tried in the treatment of obesity, some of them have been abandoned due to the difficulty of application and high complication rates. Today, Sleeve Gastrectomy (SG) is the most widely used surgical technique in the treatment of obesity worldwide. SG has become the most preferred surgery because it is relatively easier to perform than other techniques, has a low complication rate, and has similar benefit rates to other techniques. With the development of the technique, improvement in the quality of the materials used, and the demonstration of long-term results, SG has become a more reliable and predictable operation [1]. As the experience and knowledge about this operation, which is performed so frequently worldwide, increases, experienced surgeons recognize that there are many tricks that facilitate the operation, increase the comfort of both the surgeon and the patient, reduce postoperative complications, shorten the hospitalization period, and increase patient satisfaction. In this book chapter, we aim to share the algorithms and technical details that we have applied in our clinic with over 2000 cases of SG experience.

2. Patient selection and indications

Patients with a BMI between 30 and 34.9 kg/m² (Class 1 Obesity) with comorbid diseases and patients with BMI >35 kg/m² (Class 2 and Class 3 Obesity) are candidates for bariatric surgery regardless of the presence of comorbid diseases [1].

Of course, patient selection cannot be based solely on body mass index. The patient’s psychological state, eating habits, socioeconomic level and treatment compliance, comorbidities, and many other parameters significantly affect the success of treatment and are very important in patient selection for bariatric surgery.

3. Preoperative evaluation and consultations

A multidisciplinary approach is one of the most fundamental steps in preparing patients for surgery. The patient’s suitability for surgery should be determined by a multidisciplinary team. In our clinic, cardiology, pulmonologist, psychiatry, anesthesiology, and endocrinology consultations are routinely performed for all patients before LSG and surgery plans are made in line with the recommendations of all branches [2].

In addition to the expert evaluation of the relevant branches, all patients undergo preoperative upper gastrointestinal system endoscopy (UGISE) and preoperative upper GIS pathologies are also investigated.

All patients receive thromboembolism (TE) prophylaxis with anticoagulant at 8 hours postoperatively and preoperative compression stockings.

4. Peroperative approach

4.1 Position of the patient and surgeons

The secret of success in obesity surgeries is a uniform surgery and an established system. All surgeries are performed by specialized surgeons who have received special training in bariatric surgery and have adopted the same surgical technique. Patients are placed in the French position and surgeons and equipment are arranged as shown in Figure 1 [3].

Figure 1.

Operating room layout [3].

4.2 Trocar entry sites and placement of materials

For LSG, 5 trocars are routinely used in our clinic. One 12 mm, one 10 mm, two 5 mm, and one liver retractor are used. Liver retraction is routinely performed with Nathanson Retractor in every case. Trocar placement is very important for the surgeon’s ergonomics during surgery. For this reason, entering the trocars too close to each other during trocar insertion will cause the instruments to interfere with each other during the operation and will hinder the surgeon. In addition, entering the trocars in a direction other than the surgical site will make it very difficult to use the instruments in obesity patients with high subcutaneous adipose tissue. Therefore, these points should be considered during trocar entry.

4.3 Entry of the first trocar

The entry site and shape of the first trocar is the most important step in the ergonomics of the entire operation. Due to obesity, the thickness of the subcutaneous fatty tissue is very high, which causes the standard trocar size to be insufficient. Therefore, we routinely choose a 12 mm long trocar as the first trocar in our clinic. There are many techniques for introducing the first trocar; however, we routinely use the direct trocar method (Hasson technique). In the absence of a long trocar, pneumoperitoneum can be created with the help of a Verres needle before the first trocar is inserted and the subsequent insertion of the first trocar will reduce the risk of injury [4].

4.4 Pneumoperitoneum

Following the insertion of the first trocar, we wait until pneumoperitoneum is achieved. The pressure value we routinely use for LSG is 14 mmHg. Since the intra-abdominal pressure is higher in patients with obesity, performing the operation at the lowest pressure level that can be achieved will be advantageous for the patient in many ways. After reaching the desired pressure, the working trocars are entered [5].

4.5 Intra-abdominal exploration

Following the placement of the camera trocar, intra-abdominal structures must be evaluated with the help of a camera. Pathologies that may interfere with surgery may be encountered. For this reason, intra-abdominal exploration should be performed prior to intra-abdominal exploration in order to avoid wasting other trocars. Conditions such as intra-abdominal adhesions, solid organ tumors, and anatomical anomalies due to previous operations should be revealed, and the surgical plan should be revised if necessary.

4.6 Liver retraction

In patients with obesity, the size of the liver can be considerably larger than expected. Although there are clinics that apply a diet for a certain period of time before surgery to reduce this, we do not routinely apply such a diet. Regardless of the size of the liver, we use a retractor for liver retractor in all cases (Figure 2).

Figure 2.

Nathanson retractor placement.

Although there are many types of retractors that can be used for liver retraction (Nathanson, Pretzelflex, and Crow’s foot retractors), we routinely use the Nathanson Retractor (NR), which is fixed to the operating table and does not require assistance. After intra-abdominal exploration, we decide the size of the NR to be used according to the size of the liver [6].

4.7 Emptying the stomach with an orogastric tube

It is very important to routinely empty the stomach with an orogastric tube before starting the operation in order to facilitate the manipulation of the stomach, to increase the field of view in the left crus dissection, and to select the appropriate stapler during the transection phase. In addition to the use of the orogastric tube to determine the remaining gastric volume after gastric transection, its use in gastric aspiration following trocar insertion is also facilitated by the fact that it is wider and easier to apply than aspiration tubes.

4.8 Dissection of gastrocolic ligament

Dissecting the gastrocolic ligament is one of the first and important steps of the operation (Figure 3). Bleeding that may occur during this process contaminates the surgical field and can distort the surgeon’s view by causing accurate plans to be lost. It is best to start the dissecting of the gastrocolic ligament at the level of the incisura angularis or slightly superior to it. This is because that the easiest access to the lesser sac. Dissection should start as close to the stomach as possible and continue in that direction. The reason for this is to avoid damaging the gastroepiploic vessel, which is located very close to the stomach and whose tracing can easily enter the dissection area.

Figure 3.

Dissection of Gastrocolic ligament.

4.9 Inferior dissection border

In gastrocolic ligament dissection, the distal gastric transection limit should be decided and dissection should be performed up to that region of the stomach. Excessive dissection may cause disruption of blood supply in this region of the stomach. It is generally known that gastric transection can be started at a distance of approximately 2 cm to 6 cm from the pylorus. However, we should keep in mind that the closer we transect to the pylorus, the more postoperative nausea and vomiting will occur and the greater the possibility of pyloric deformation will be [7]. Therefore, starting gastric transection with a distance of 4 cm to the pylorus is the ideal approach.

4.10 His angle and crus dissection

This step is one of the most important steps of the surgery. It is one of the indispensable steps for the complete release of the great curvature of the stomach; that is, the gastric fundus should not be left wide. Failure of the releasing His angle and failure to expose the left crus and completely release the fundus may lead to failure of the surgical technique and an increase in the regain rate [8]. Therefore, in our clinic, we routinely perform left crus dissection in all patients and make sure that we completely free the gastric fundus before transection (Figure 4).

Figure 4.

Dissection of left crus.

4.11 Routine crus dissection and investigation of hiatal hernia

After LSG, lower esophageal sphincter insufficiency is predisposed due to impaired His angle and increased gastric mobilization. In addition, bile reflux may also be seen due to increased intragastric pressure after LSG. These conditions may turn into a misery for patients. Therefore, it is very important to perform hiatus repair by crus dissection in patients with hiatal hernia and lower esophageal sphincter insufficiency in preoperative UGISE. In patients in whom UGISE was not performed preoperatively, intraoperative crus dissection should be performed to investigate the presence of hiatal hernia [9]. In our clinic, we routinely perform hiatal repair in all patients in whom hiatal hernia is detected during routine preoperative upper GI endoscopy (Figure 5).

Figure 5.

Peroperative hiatal hernia repair.

4.12 Release of posterior gastric adhesions

Adhesions located in the posterior part of the stomach may occur for many unknown reasons. These adhesions encountered during surgery prevent full mobilization of the stomach and may cause shifts and rotations in the staple line. Therefore, these adhesions in the posterior part of the stomach should be opened by treating the small curvature vessels with care and the stomach should be fully mobilized. This will prevent rotations in the staple line and distortions in the formation of the B formation. Since bleeding can be seen during the separation of these adhesions, they should be separated with energy devices and the tissue should be treated very carefully. Blunt dissection should be avoided as much as possible [10].

4.13 Placement of the orogastric tube

It is preferred that the anesthesiologist in charge of obesity surgeries has special training and experience in this field. The anesthesiologist is expected to master the interventions performed by the anesthesiologist at some stages of the surgery. Before transection of the stomach, an orogastric tube extending to the pylorus is inserted into the stomach to ensure lumen patency. Since passing the orogastric tube through the pylorus may cause deformity and curvature in the stomach, it should be left at the transection start line. While the orogastric tube is brought to this area, the anesthesiologist and surgeon should work in coordination and the surgeon should guide the orogastric tube to the position where it should be with the dressing method.

The size of the orogastric tube depends entirely on the surgeon’s choice. It is known that thin tubes can cause strictures and thick tubes can cause insufficient weight loss. Therefore, very narrow and very wide orogastric tubes should not be chosen. It would be appropriate to choose orogastric tubes with thicknesses between 32 and 40 French [11]. In our clinic, 36 French orogastric tubes are routinely used (Figure 6).

Figure 6.

Orogastric tube-guided transection of the stomach.

4.14 Stapler selection and transection of the stomach in accordance with gastric wall thickness

It is known that gastric wall thickness may vary depending on many factors (age, gender, body mass index, infectious pathologies of the stomach, etc.). It has been determined in many studies that the antrum is the thickest part of the stomach wall and the thickness decreases as you go to the fundus. Therefore, it is necessary to make sure that the stapler to be used in the antrum is compatible with thick tissue and the stapler to be used in the fundus is suitable for thinner tissues. Staple thickness is distinguished by colors and different companies have different color options. Regardless of the manufacturer’s preference, staples with the ability to close thicker tissues in the antrum region where the gastric wall thickness is the highest and staples with the ability to close thinner tissues as they approach the fundus region should be preferred [12]. In our clinic, we complete the gastric transection by using the thickest cartridge for the first staple (Figure 7) and a medium-thick cartridge for the remaining gastric tissue.

Figure 7.

Inserting the first cartridge.

When determining the superior border during transection of the stomach, a distance of 1 cm to the esophagus must be left (Figure 8). Structured tissue corresponding to this distance should be separated from the stomach and prevented from entering the staple line.

Figure 8.

Inserting the last cartridge.

4.15 Hemostasis in the stapler line

After complete transection of the stomach, bleeding seen on the stapler line should be stopped with the help of clips. Bleeding control should be done very carefully. Bleeding from the stapler line may occur due to postoperative hypertension or increased intra-abdominal pressure. Continued suturing of this line is another option to control bleeding in the stapler line [13, 14]. In our clinic, both clip application and continue suturing of the stapler line are routinely performed. Sheathed staples can also be used to control bleeding.

4.16 Removal of the specimen

Specimen removal is performed through 12 mm trocars. In the removal of the specimen, the gastric specimen is grasped from the antrum by sending a grasping device through the trocar and pulled out of the abdomen with the trocar (Figure 9). Since the antrum wall is thicker, the strength of this region is stronger. Therefore, the removal process should start from the antrum. During the removal of the specimen, great care should be taken not to open the stomach and not to spill secretions or tissue fragments into the abdomen. The stomach should be taken out of the abdomen in one piece and with the staple line intact [15].

Figure 9.

Removal of the specimen.

4.17 Leakage test

Nowadays, many surgeons have abandoned the traditional methylene blue leak test after transection of the stomach. However, in our clinic, methylene blue leakage test is routinely performed by closing the stomach from the pylorus with an instrument following removal of the specimen. During this test, both the B formation of the stapler line can be easily evaluated and the bleeding that may occur due to increased pressure can be revealed [16].

4.18 Suturing of the stapler line

Suturing the stapler line to the gastrocolic ligament or omentum is practiced by many surgeons because it is effective in both controlling bleeding and preventing the possibility of twist in the postoperative period (Figure 10). Suturing the stapler line from the superior border to the inferior border contributes to the return of the stomach to its former anatomy and reduces the possibility of stapler line adhesion to the liver [17]. In our clinic, the entire stapler line is routinely sutured from superior to inferior to the gastrocolic ligament at the end of surgery.

Figure 10.

Suturing the stapler line.

4.19 Drain placement

Placement of a drain at the end of surgery is not routine. This depends entirely on the surgeon’s preference. However, routine drain placement after every bariatric surgery is not a correct approach. Placing the drain only in cases where there is a possibility of bleeding or when the surgeon needs it for any reason will prevent unnecessary drain complications [18].

4.20 Closure of trocar sites

Patients with obesity are candidates for incisional hernia due to the higher intra-abdominal pressure compared to normal people. Therefore, it is very important to close trocar defects larger than 5 mm. Closure of trocar sites can be quite challenging due to the high amount of subcutaneous fatty tissue. There are many instruments that facilitate closure of fascia defects. Help can be obtained from these instruments [19]. In our clinic, fascia defects larger than 5 mm are routinely closed and Carter-Thomasson Suture Passer is used for this purpose (Figure 11).

Figure 11.

Closure of trocar sites.

5. Postoperative approach

Patients should be provided with adequate analgesia and antiemesis in the postoperative period. In addition, early mobilization and use of anticoagulants for TE prophylaxis are very important. In our clinic, patients are routinely mobilized at the 4th hour postoperatively and anticoagulation with low molecular weight heparin is provided at the 8th hour postoperatively.

Following mobilization, patients are started on oral water. Water and clear fruit juices are given to all patients on the first postoperative day and grain-free soup and liquid foods can be given on the second postoperative day.

Although there are approaches such as X-ray-assisted passage radiographs, computed tomography, and methylene blue test to evaluate the stapler line after surgery, we do not apply any of these to our patients. In our clinic, we perform amylase measurement in the drain fluid, which is both radiation-free and easy to perform. If the salivary amylase level measured in the drain fluid is above 400 U/L and if the amylase level increases in the follow-up, we apply advanced imaging tests to the patients. There are also studies that we have proved the effectiveness of drain amylase measurement in determining leakage in our clinic, and we have brought it to the literature [20]. In addition, we perform additional tests in cases such as tachycardia, hypotension, fever, and severe abdominal pain that may suggest postoperative leakage. Apart from this, we do not perform postoperative leakage test in patients who do not have any postoperative problems and no drain is placed.

Patients are discharged on postoperative day 3, and anticoagulant use continues for 10 days.

Postoperative controls are performed on the 7th day, 1st month, 3rd month, 6th month, 9th month, 12th month, 18th month, and 24th month. Afterwards, annual follow-up is continued. Dietitian, endocrinology, and psychiatry controls are routinely performed for all patients in the postoperative period.