A 41 year old female patient with a previous history of obstructive sleep apnea, HBP and asthma suffered from morbid obesity with a BMI of 85.81 Kg/m2 and weighed 209 Kg. No previous abdominal surgeries.
The patient received a low-calorie diet prior to surgery presenting a weight loss of 14 kgs (195 kg , BMI 84.42 Kg/m2 ).
We decided to perform a laparoscopic sleeve gastrectomy in this case.
The patient was placed in the supine position with open legs. A total of 6 trocars were used. The configuration was a 12-mm port in the supra umbilical position for a 30º scope, two additional 12-mm ports at the left flank and in the umbilical position, a 10-mm port at the right flank, a 5mm port located at the epigastrium for retraction of the liver, and a final more lateral 5-mm port at the left flank to perform traction of the omentum and the stomach.
Once inside the abdominal cavity the liver was highlighted due to its large size and steatosis. We had to use two separators liver to work.
To begin we created the inferior landmark for section of the major omentum.
Using the hook a window was opened at the omentum bursa and then the LigaSure™ was used for secure section close to the gastric wall.
It is important to release the adhesions of the gastric backside for good mobilization of the stomach. The stomach should be individualized from the retroperitoneal organs to achieve correct exposure during the gastrectomy.
Then we performed the dissection of the major curvature with the LigaSure™. The assistant should perform traction from the omentum. Sometimes we use clips for the section of short spleen vessels.
The dissection ends in the superior landmark. This maneuver must be carefully performed to avoid bleeding at the level of the spleen and the short vessels. The goal is to expose the cardias and the left crus.
We then performed the gastrectomy. The first mechanical sutures are green because the tissue near the pylorus is thicker. The section started 5 cm from the pylorus. We must avoid subsequent stenosis and ensure correct weight loss.
After that we performed the calibrated gastrectomy. A 32 French bougie was used to control the diameter of the remaining stomach. The assistant surgeon is crucial for this step, as correct traction exposes the stomach and enables the leading surgeon to prevent an angled or rotated gastrectomy.
We had to avoid placing the mechanical suture too close to the bougie to prevent bleeding, stenosis and leakage. Then the final section of the stomach was performed, 1 cm away from the angle of His as vascularization at this height is poor.
Finally rotation and bleeding was prevented by means of continuous PDS suturing. We checked for hemostasis and placed a drainage, ending the surgery.
The surgery took 70 minutes. The patient started oral intake 24 hours after the surgery and left the hospital on the 3rd postoperative day.
The patient currently has a successful outcome. She presented improvement in her respiratory disease and HBP. Two years ago she weighed 82 kgs with a BMI of 33.6 Kg/m2. After that, the patient did not attend medical examinations, so we have no further follow up.
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