Sleeve Gastrectomy

In case of high risk patients, the sleeve is used as a first Stage to induce weight reduction allowing for the more demanding intestinal dissection to be performed under healthier conditions. In the sleeve gastrectomy, trocars are placed as for a gastric bypass.

Dissection

The stomach is lifted and the surgeon starts the devascularisation of the greater curvature with the help of the Ultracision device. Once the lesser sac has been entered, dissection is continued in a cephalad direction and the lower pole of the spleen is quickly reached.

At the level of the spleen’s lower pole, the peritoneal sheets are farther apart and the tissue in between is thicker and harbours tortuous vessels (the short gastrics) which must be coagulated separately, by using small bites of the Ultracision. Eventually the dissection reaches the root of the left pillar of the hiatus. When the upper pole of the fundus has been freed, the surgeon can lift the stomach anteriorly and to the right very much like turning a page of a book.

Care should be taken not to damage the left gastric vessels which in an obese patient are always closer (lower) than one would anticipate. Once the stomach has been freed, division can be performed.

Linear Gastrectomy Sleeve Resection

The linear stapler-cutter device, blue load is introduced in and oriented so that the tip of the devascularised stomach lies between the jaws; the tip of the instrument is oriented towards and just to the left of the visible endings of the lesser curvature vessels. The greater curvature is pulled laterally and the device is fired.

Hence a pyramid shaped portion of stomach is partially detached from the stomach body and only attached to it at its base.

Before further firing, a 34 French plastic tube is introduced perorally by the anaesthetist and advanced into the stomach. The stapler is reopened without firing and repositioned so that it loosely pushes the nasogastric tube against the lesser curvature. Hence the diameter of the tube will be at least 34 French. The instrument is fired, reloaded and the manoeuvre repeated.

Finally, after some five or six firings of the stapler, the greater curvature is completely detached from he stomach. It is pulled out of the patient’s abdominal wall, through the trocar hole in the left upper quadrant. The gastric suture line is secured by the placement of Medium Large clips over the entire length. Alternatively a running suture of polypropylene 2/0 can be sewn in reinforcement of the staple line. After a final check for bleeding, the abdomen is rinsed and a Penrose drain is introduced. No nasogatric tube is left inside the stomach. The patient is taken to the recovery room and from there back to the room.