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Laparoscopic Sleeve Gastrectomy

Laparoscopic Sleeve Gastrectomy. Dr Girish juneja Head of surgery deptt. Specialist laparobariatric surgeon

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Laparoscopic Sleeve Gastrectomy

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  1. Laparoscopic Sleeve Gastrectomy Dr Girish juneja Head of surgery deptt. Specialist laparobariatric surgeon Al Noor Hospital, abu dhabi, uae

  2. SG was developed as a modification of the biliopancreatic diversion in 1988

  3. 1999 SG was first performed by laparoscopy, as part of BPD-DS, by Michel Gagner • This operation became an independent procedure when it was found that supersuper-obesity (BMI _ 60 kg/m2) and male gender were associated with elevated morbidity and mortality when those patients underwent BPD-DS. • 2000, Gagner first proposed the SG as the first step of a two-stage laparoscopic duodenal switch as an alternative to this high-risk group of patients to decrease morbidity and mortality

  4. LSG • 2003, SG was proposed as the first step of a two-stage laparoscopic Roux-en-Y gastric bypass (LRYGB) • Since then, many surgical teams have already adopted this procedure with good results.

  5. SG produces weight loss by two mechanisms 1- produces early satiety as a purely restrictive procedure 2- reduces plasma ghrelin levels by removing a great part of the Ghrelin production tissue. - Ghrelin is a 28 amino-acid-peptide, secreted by the oxyntic glands of the gastric fundus - potent orexigenic (appetite-stimulating) hormone. - In SG, resection of the fundus removes the major site of ghrelin release, therefore appetite decreases

  6. KEY POINTS • Sleeve gastrectomy causes a volume reduction of the stomach by 80 percent or more. • It decreases serum ghrelin and leptin levels, increases GLP-1 and PYY 3-36,and reverses type 2 diabetes in the majority of cases. • Gastric and intestinal transit time appears to be reduced, causing an early stimulation of the distal GI tract.

  7. LSG

  8. LSG

  9. Gastric sleeve resection technique • Total excision of fundus • Sparing of antrum • Transection of stomach just lateral to lesser curve vessels endings • Oversewing entire staple line? • Staple line reinforcement ?

  10. Technique of SleeveGastrectomy

  11. Anatomy

  12. “Three Angles” Surgeons must pay special attention • 1. The Incisura angularis or the angle of the stricture. • 2. The gastrosplenic ligament or the angle of bleed • 3. The Angle of His or the angle of the leak

  13. LSG

  14. Port placement

  15. start by dividing the greater omentum with the ultrasonic shears at a midpoint along the greater curvature • The branches of the gastroepiploic artery are divided near the gastric wall • We then proceed with the division of the short gastric vessels that is performed up to the fundus

  16. L. S.G.

  17. L.S.G.

  18. LSG-debatable points • First stage or definitive • Sleeve Calibration (bougie size) • Distance from pylorus to initiate sleeve • Oversewing entire staple line? • Staple line reinforcement ? • Section shape at OG junction • Routine use of intraoperative leak testing • Routine versus selective upper GI series for leak test • Higher rate of leaks after revisional surgery

  19. FIRST STAGE OR DEFINITIVE • LSG has become safe & effective both as a first stage bariatric procedure in high risk or superobese pts & as a • primary operation

  20. KEY POINTS • In BPD-DS maximal gastric pouch or tube of 150 to 200 mL • In SG isolated procedure, the gastric pouch size usually varies from 50 to 120 mL, depending on the size of the bougie we introduce into the stomach to perform the SG.

  21. Long term results • Five-year EWL after sleeve gastrectomy is 50 to 55 percent. • A subset of patients will require a second-stage bypass procedure to achieve optimal weight loss after sleeve gastrectomy. • High BMI, high-risk patients can achieve excellent long-term weight loss . STACY A. BRETHAUER & PHILIP R. SCHAUER obesity times 2011;8

  22. Long-term Results After Laparoscopic Sleeve Gastrectomy EWL was 72.8% (±25.6) after three years and 57.3% (±29.1) after 6 years(p=0.0017). BMI increased from 27.3 kg/m2 (±5.0) at three years to 30.1kg/m2 (±6.5) at six years(p=0.0050) JACQUES HIMPENSBariatric Times. 2011;8(5 Suppl):11–12

  23. Long-term Results After Laparoscopic Sleeve Gastrectomy • LSG has a failure rate of 43% after 6+years. • One out of four patients develops GERD symptoms after 6+ years. Treatment can be either resection of a neo-fundus or Roux-en-Y gastric bypass. DS constitutes an effective solution for poor weight loss or weight regain after LSG. JACQUES HIMPENSBariatric Times. 2011;8(5 Suppl):11–12.

  24. LSG-debatable points • First stage or definitive • Sleeve Calibration (bougie size) • Distance from pylorus to initiate sleeve • Oversewing entire staple line? • Staple line reinforcement ? • Section shape at OG junction • Routine use of intraoperative leak testing • Routine versus selective upper GI series for leak test • Higher rate of leaks after revisional surgery

  25. Sleeve Calibration (bougie size)EWL with varying bougie size Parikh surg obesity relat 008;4

  26. Calculation of volume of 25cm long gastric tube based on varying bougie size(excluding antrum) • Bougie diameter volume • 32 f 1cm 20cc • 36f 1.2 cm 26 cc • 40f 1.3cm 32 cc • 50f 1.6 cm 50 cc • 60f 1.9cm 71cc Parikh surg obesity relat 2008;4

  27. BOUGIE SIZE • For all LSG as part of a BPD-DS, used the 60-Fr bougie to ensure adequate protein intake. • For primary LSG, we use a 36-Fr bougie but it could be smaller or greater (28-54 Fr).

  28. LSG Distance from pylorus to initiate sleeve 2cms– 6 cms

  29. LSG • There is a trend towards smaller bougie(32 f) & • Initiating sleeve 2cm px to the pylorus, for a more restrictive effect.

  30. LEAK Meta analysis 4888cases & 29 publications Overall leak rate 2.4% • Superobese BMI>50 2.9% • for BMI < 50 2.2% • BOUGIE 40 F - 0.6% <40F 2.8% • SITE OF LEAK – PX THIRD 89% • Staple height& buttressing material– no effect • Most leaks were diagnosed after discharge surg endosc 2011: dec. 17

  31. STAPLE LINE REINFORCEMENT? *STAPLE –LINE BUTTRESSING SIGNIFICANTLY INCREASED STAPLE LINE STRENGTH *DECREASES BLEEDING

  32. STAPLE LINE REINFORCEMENT? • Reinforcement does not necessarily reduce the rate of staple line leaks after sleeve gastrectomy. Obes Surg. 2009 Feb;19(2):166-72.

  33. STAPLE LINE REINFORCEMENT? IFSO 2010 Michele Gagner reduces rate of leak

  34. OVERSEWING • Full thickness over sewing of staple lines significantly weakened all staple lines • Risk of tearing Baker RS et al,obes surgery,2004,14

  35. Section shape at OG junction At the uppermost portion of the stomach, the transection line is allowed to deviate away from the bougie to avoid severe stenosis at the gastroesophageal junction but going further from the bougie may lead to fundus dilation and weight regain Incorporation of esophagus can weaken the staple line

  36. Section shape at OG junction

  37. Routine UGI contrast study • very low sensitivity(50%) to detect leak • Expansive • Sometimes fails to detect M.schiesser ,obesity surgery,vol-21,1238

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