• Trocar sites are identified, and trocars inserted to gain access to the abdominal cavity and stomach. Generally, 4-5 trocars are required. 
  • Initial Access to the abdomen is generally obtained by either:
    • Veress needle technique
    • Direct trocar view technique
  • Upon identifying the Pylorus, the dissection begins at 4-6cm proximal to the Pylorus
  • Attachments to the Greater curvature are mobilized with an energy device such as ENSEAL™ X1 Curved Jaw Tissue Sealer or HARMONIC™ 1100, including the short gastric vessels. The greater curve is mobilized completely to the diaphragm. If an ultrasonic energy device is used, completely encompassing the vessel that is being sealed, and allowing the device time to seal the vessels before lifting against the cutting blade, generally aids in achieving better hemostasis.
  • A bougie (typically 34-44 Fr) is inserted along the lesser curvature for sizing of the Sleeve pouch.
  • Generally, the dissection begins 4-6cm from the pylorus.  
  • Stapler is generally placed at least 2cm from the incisura as stapling too close to the incisura can result in a stricture, severe GERD and increased risk for a more proximal leak.  

NOTE:

  • The thickness of the stomach typically decreases from distal to proximal. Likewise, there is variability between patients with regard to thickness of the stomach tissue.
  • Cartridge selection with different stapling heights to adequately staple the tissue while remaining perfused without oozing can vary based on clinical judgement of stomach thickness.
  • Other options including staple line reinforcement (buttress), such as ECHELON ENDOPATH™ Staple Line Reinforcement and oversewing may be utilized depending on surgeon preference.
  • Hemostasis along staple line and surgical site can be controlled in many ways if needed.  Suturing, clips, or hemostatic agents such as Vistaseal™ Fibrin Sealant (Human), are all options to control small areas of oozing. 
  • A provocative leak test is performed. Leak test can be performed in variety of ways including endoscopy, methylene blue pressure test, air-leak test. 
  • A hiatal hernia is a common finding during bariatric surgery. One of the long-term potential complications of a sleeve gastrectomy is GERD. Surgeons are generally prepared for the identification and repair of a hiatal hernia during bariatric procedures. 
  • Specimen is removed through 15mm trocar site.
  • Closing the fascia in 15mm trocar defect is generally recommended.
  • The intra-abdominal pressure is reduced, and trocar sites observed upon removal to check for bleeding.
  • The wounds are closed using synthetic absorbable monofilament, such as Monocryl® Plus Antibacterial suture, and a topical skin adhesive such as DERMABOND PRINEO® Skin Closure System or any appropriate dressing. 
     

Potential complications include but are not limited to:

  • Surgical bleeding
  • Staple line Leak
  • Stricture
  • Pseudo-Stricture (narrowing at Incisura, twisting of staple line during creation)
  • DVT/ Pulmonary Embolism
  • Surgical site infection (deep or superficial)

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