Bariatric surgery Laparoscopic Sleeve Gastrectomy

1. Bariatric surgeryLaparoscopic Sleeve Gastrectomy By Dr Hosam Ghazy El-Banna Assistant Professor of General surgery Mansoura Faculty of Medicine

2. Introduction • Laparoscopic Sleeve gastrectomy (LSG) is a new restrictive bariatric procedure increasingly indicated in the treatment of morbid obesity. • LSG is a reproducible and seems to be an effective treatment to achieve significant weight loss after 12 months follow-up.

4. Indications • LSG was indicated for weight reduction only for patients with a BMI > 40 or > 35 kg/m2 with severe comorbidity. • Patients assessed by a dietician, a nutritionist, and a psychologist before surgery.

5. Preoperative preparation • Start Atkins diet for 2 weeks before the surgery to reduce the fat around your liver. • Make sure to be on a regular intake of clear fluids 48 hours before surgery. • Stop any medication unless indicated and recommended by your doctor.

6. Operative procedure • Operations are performed under general anesthesia using the supine position. • Each procedure required only 4 trocars. • Two 12-mm ports were placed in the supraumbilical region and in the left upper quadrant. • One 10-mm port was placed in the right upper quadrant for liver retraction. • One 12-mm port used for stapling was placed in the left mid-abdomen, just medial to the mid-clavicular line .

7. Placement of 4 trocars

8. Pneumoperitoneum was induced by primary trocar insertion and maintained at a pressure of 16 mm Hg. • Dissection began on the greater curvature, 6 cm from the pylorus. • The gastrocolic ligament along the greater curvature of the stomach was opened using a coagulator and was freed as far as the cardioesophageal junction. • A 36-F plastic tube was then inserted perorally into the stomach by the anesthesiologist and was directed toward the pylorus.

9. A laparoscopic linear stapler was introduced into the peritoneal cavity and was positioned so that it divided the stomach parallel to the orogastric tube along the lesser curvature. • The instrument was fired, reloaded, and the maneuver was repeated; 60-mm green cartridge was used to staple the antrum followed by 3 or 4 sequential 60-mm gold cartridges to staple the remaining gastric corpus and fundus. • After 5 or 6 firings of the stapler, the greater curvature was completely detached from the stomach.

10. A methylene blue test was performed to exclude staple-line leakage. • The gastric suture line was not systematically reinforced except in the case of bleeding or positive methylene blue test, in which case a drain was placed along the staple line.

11. A nasogastric tube was left in place. • A water-soluble upper gastrointestinal (GI) contrast study was performed on the first postoperative day, and oral fluids were allowed if no leakage was demonstrated. • Patients were discharged except in the case of a complication resulting in prolongation of the hospital stay.

12. Follow up • Patients were reviewed at 1 month and then every 3 months. • Mortality and morbidity were defined as death or complications and reoperations during the first 30 days after the operation or during the hospital stay, respectively.

13. Eating after surgery • Immediately after surgery, the patient is restricted to a clear liquid diet. • The next stage provides a blended or pureed sugar-free diet for at least two weeks. • Post-surgery, overeating is curbed because exceeding the capacity of the stomach causes nausea and vomiting.

14. Advantages • Stomach tends to function normally so most food items can be consumed in small amounts. • Removes the portion of the stomach that produces the hormones that stimulates hunger (Ghrelin). • No dumping syndrome because the pylorus is preserved. • Minimizes the chance of an ulcer occurring. • The chance of intestinal obstruction, anemia, osteoporosis, protein deficiency and vitamin deficiency are significantly reduced. • Results appear promising as a single stage procedure for low BMI patients (BMI 35–45 kg/m2).

15. Complications • Leakage: can be treated easily by performing a second procedure that helps in strengthening the staple lines. • Stapple line bleeding: • Gastroesophageal Reflux: It might be happening because of the changes in the shape of the stomach. • Gastric Fistula: may occur and another surgery may be needed to treat this condition.

16. Narrowing of Stoma: A tube used for dilation is passed from the mouth to pass into the stomach as this expands the stoma. • Hernia: Another surgery may be needed to repair this condition. • Malabsorption of Vitamins and Minerals: • Anemia and vitamin B12 deficiency can cause neurological diseases. • Changes in the absorption of phosphates, calcium and oxalates can result in kidney stone formation. • Similarly, deficiency of vitamin D and calcium can also give rise to different disorders of the bone.

17. Microbial infections : as pneumonia and intraabdominal abscess are most common. • Deep vein thrombosis (DVT). • Hair loss. • Hair thinning. • Mood swings. • General feeling of weakness. • Dry skin .

18. Outcomes of SG & other bariatric procedures

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