Laparoscopic Sleeve Gastrectomy

249

Fig. 14.52  Closure of the gastric erosion using an omental patch

The purpose is to create a 60–200 cc pouch removing a major part of the stomach, creating

Laparoscopic

a sleeve and preserving a portion of the antrum (Fig.14.53). The patient is placed in a steep

Sleeve

reverse Trendelenburg position (Fig. 14.54). Good exposure of the stomach, by ensuring

Gastrectomy

the stomach is stretched, is crucial for the dissection of the greater curvature. The har-

monic shear is used to take down all the branches of the left gastroepiploic vessels. The

greater curvature dissection continues approximately two centimeters to the pylorus, then

a distance of five to six centimeters proximal to the pylorus is identified to start the first

firing (Fig. 14.55). The sleeve gastrectomy is performed via sequential firings of a GIA

forty-five starting with a 4.8 mm (green) stapler enforced with bioabsorbable material

Seamguard (W.L. Gore Associates, Flagstaff AZ). The first stapler is fired so that a narrow

1.5 cm gap is left between the tip of the stapler and the lesser curvature (Fig. 14.56). The

second firing is then performed, making sure that there is no occlusion of the gastric

lumen. A 32–34, French bougie is then inserted and advanced along the lesser curvature

into the duodenum to allow the calibration of the sleeve (Fig. 14.57) and then the sleeve

gastrectomy, is completed by the firing of GIA-45 blue cartridges at the angle of His

(Fig. 14.58). It is important to leave some gastric tissue at the upper edge near the angle of

His to avoid injuring the gastro-esophagal junction. Seamguards are used on all firings.

The gastric specimen is then removed through the umbilical port in a specimen bag

(Fig. 14.59). An alternative technique is to divide the stomach before dividing the high

gastroepiploic vessels and the short gastric vessels, thus allowing the stomach to remain

attached and naturally retracted (Fig. 14.60). It is also possible to imbricate the areas of

intersecting staple lines with interrupted stiches as an additional safety measure (Fig.14.61).

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Chapter 14 Bariatric Surgery