Technical considerations for a sleeve gastrectomy by SILS and NOTES

This video is focused on the technical aspects for a transvaginal and single incision laparoscopic sleeve gastrectomy.

The patient is placed in a supine position with the legs wide opened. The vagina is the route of access for the NOTES procedure, the pneumoperitoneum is accomplished with a Veress needle and a 12mm trocar is placed at the umbilicus. A 12mm transvaginal trocar is placed under direct laparoscopic vision for a flexible endoscope.

For single access approach the device is placed at the umbilicus, it allows 1 trocar of 12mm for a 30º scope, two trocars of 5mm for working channels.

Two extra trocars of 2mm were placed (epigastrium and right flank) to assist the transvaginal procedure.

The first step is to dissect the greater curvature and the posterior wall of the stomach. Devices like LigaSure™ allows this part of the surgery.

There is difference of visualization between the approaches. At the transvaginal procedure, the endoscope brings an image in parallel position to the instruments and it is more difficult to perform maneuvers. There is better definition of the image at the transumbilical sleeve.

The instruments are also different, for NOTES procedure 2mm instruments were used that can lack in strength at some phases of the surgery. Reticulated instruments were used for the single access Sleeve. The main problem is the learning curve of the surgeon to achieve triangulation and work properly.

A 32 F foucher is placed to calibrate the gastrectomy, following the principles of the technique, the gastric section stared at 4cm from the pylorus. Reinforced mechanical sutures were used to try to diminish the risk of bleeding. During the transvaginal sleeve the mechanical sutures were introduced through the 12mm umbilical trocar. For the single access technique the route of entry was the 12mm umbilical trocar. One limitation is that in some cases, an additional trocar may be necessary to accomplish the gastric section at the upper part.

The surgical specimen was extracted through the vagina or the umbilicus. No specific wound protection was used; in its place careful lavage with iodine solution was done.

The colpotomy was closed with separated knots and the fascia of the abdominal wall closed under direct vision with a running suture.

As take home messages:

A pure NOTES is not feasible for a sleeve gastrectomy.

Placement of an additional trocar may be required to fully accomplish the gastrectomy.

Technical improvements are necessary for better visualization and dissection maneuvers.

Both approaches are feasible and safe in experienced hands, but lacks of universal application.