with Dr. Salvadora Delgado, Dr. Antonio M. Lacy
A 49-year-old female patient with a previous history of obstructive sleep apnea, HBP, dyslipidemia and morbid obesity with a BMI of 51.38 kg / m2 (weight: 152 kg, height 172 cm).
She was admitted for elective surgery of morbid obesity. Sleeve gastrectomy was performed with no complications.
The steps of a standard sleeve gastrectomy were performed.
The patient is placed in the supine position with open legs. The surgeon stood between the legs with one assistant one each side of the patient.
A total of 5 trocars are recommended. The classic configuration is a 12mm port in the supraumbilical position for a 30º scope, two additional 12mm ports at each flank to serve as the working channel for the leading surgeon, two 5mm ports located at the epigastrium for retraction of the liver, and a final more lateral port at the left flank to perform traction of the omentum and the stomach.
An inferior landmark is created for section of the major omentum. Then the major curvature is dissected. The superior landmark is then created. This maneuver must be carefully performed to avoid bleeding. The spleen and the short vessels should be kept in mind. The gastrectomy is then calibrated. The gastric transection is performed, avoiding placing the mechanical suture too close to the bougie to prevent bleeding, stenosis and leakage. Finally the stomach is sectioned and bleeding is prevented by means of continuous suturing.
In the immediate postoperative period, the patient presented with a hypovolemic shock with hypotension and tachycardia.
The blood test showed a fall in hematocrit to 20% (from 37% ) and abundant hematic material through the abdominal drainage.
The patient required vasoactive support with volume and drugs and immediate reoperation.
Surgical revision was carried out through a laparoscopic approach. The patient was placed in the same position as in the first surgery, with the same trocars.
When we entered the abdominal cavity we objectified an abundant hemoperitoneum and proceeded to aspirate it. First we tried to locate the source of the bleeding. Once located, it is important to have a good exposure of the surgical field. The first surgeon located the injury while the assistant surgeon separated the liver. We can see a major arterial bleeding, probably a branch of the splenic artery. At that point the bleeding was controlled by means of a clamp. After that, we placed a gauze to improve vision and aspiration of hemorrhage. We decided to place another trocar on the left side of the patient for better access to the area of bleeding.
Then we changed the position of the clamps and proceeded to control bleeding by means of a vascular EndoGIA™. Now the bleeding has been controlled.
Finally, we used a clip to ensure hemostasis. Then we placed a TachoSil in the affected area. Our recommendation is to introduce it twisted into the abdominal cavity and then unroll it.
To conclude, we washed the abdominal cavity and placed drains, ending the surgery.
The second surgery took 62 minutes. During the postoperative period the patient presented with fever on the sixth postoperative day, with no other complications.
We performed a CT aimed at splenic infarction of more than 50%.
Conservative treatment was provided with an antibiotic.
The patient was discharged on the 12th postoperative day, with good tolerance to an oral diet and no drains.
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