Fig. 11.1
Sleeve gastrectomy diagram
Table 11.1
Mechanism of the sleeve gastrectomy
• Decreased gastric volume |
• Restriction by the pylorus |
• Decreased ghrelin |
• Increased gastric emptying |
• Decreased small bowel transit time with malabsorption |
• Increased glucagon-like peptide 1 and YY |
Historically, the SG evolved over time from other procedures. In 1988, Doug Hess performed the first sleeve gastrectomy as part the duodenal switch [7]. Anthone in 1997, while performing a duodenal switch in a young patient with common bile duct stones, limited the procedure to only a sleeve gastrectomy due to the complexity of the procedure. In this specific patient, he observed excellent weight loss results with the sleeve alone. Subsequently, between 1997 and 2001, he completed 21 sleeve gastrectomies with similar results [8]. Gagner [9] is credited with performing the first laparoscopic sleeve gastrectomy (LSG) in very high-BMI patients as a first stage with subsequent laparoscopic gastric bypass Roux-en-Y (LGBYP).
Recently, the American Society for Metabolic and Bariatric Surgery (ASMBS) updated their position statement on sleeve gastrectomy as a bariatric procedure [10]. Based on several prospective randomized controlled trials and matched cohort studies, the ASMBS recognizes the SG as an acceptable primary bariatric procedure and as a first stage for a Roux-en-Y gastric bypass (RYGB) or a duodenal switch (DS). Furthermore, the SG has been found to have a risk/benefit profile somewhere between that of the laparoscopic adjustable band (LAGB) and the RYGB [11–13]. The sleeve gastrectomy has several advantages and few limitations (Table 11.2). Although long-term results are not available as they are for the LAGB and the RYGB, Sarela et al. [14] published very favorable results at 8–9 years with 69 % excess weight loss.
Table 11.2
Considerations for the sleeve gastrectomy
Advantages | Limitations |
|---|---|
• Relatively simple and quick procedure • Short learning curve • Access to stomach maintained • Good early results • Extremely low morbidity and mortality • Can use for failed LAGB • Can convert to RYGB for severe reflux • Can convert to duodenal switch (DS) or RYGB for insufficient weight loss | • No long-term results • Infrequent complications are difficult to treat • Irreversible • Early and late GERD |
Although complications are rare, they can be very problematic to treat. Gastric leaks following a sleeve gastrectomy can be a very difficult and complex management problem. The average reported leak rate is approximately 2.7 % [15]. For revisional surgery, it can be greater than 10 % [16]. The most common area for leak occurrence is at the gastroesophageal junction. Leaks are caused by local tissue ischemia combined with increased intraluminal pressure of the sleeve. A tight sleeve is a risk factor for a leak, and it is thought that the size of the bougie used is inversely proportional to the rate of leakage [17]. Patients with a distal stricture or a functional obstruction caused by a spiraling staple line are also at a greater risk. Leaks can be repaired surgically, however, usually requiring a multidisciplinary approach, which includes percutaneous drainage, endoscopic stenting and clipping by the gastroenterologist, and maximization of nutrition to enhance healing.
Stricture or stenosis is most common at the incisura angularis. Proper creation of the sleeve with lateral traction and appropriate bougie size when stapling at incisura is key in preventing strictures. Treatment options for stricture can be endoscopic dilatation, seromyotomy, or conversion to a RYGB.
One of the most recent advances in the field of bariatric surgery has been the introduction of the da Vinci robotic platform (Intuitive Surgical, Sunnyvale, CA). Although the role of the robot in bariatric surgery has been found to be advantageous in the RYGB [18, 19], its role in the SG is less clear. Ayloo et al. [20] presented their initial experience with robotic-assisted sleeve gastrectomy (RASG), concluding the RASG can be performed safely with excellent outcomes. Diamantis et al. [21] reported their limited series also with similar results.
Our group originally adopted the use of the da Vinci system with the intent of reducing the high complication rates for revisional bariatric surgery in patients with previous RYGB or vertical banded gastroplasties (VBG). The Michigan Bariatric Surgery Collaborative, in a large multivariate analysis, found that the LSG had less risk for serious complications when compared with RYGB (OR 2.46 versus 3.58, respectively). Although the rate of staple-line dehiscence is low in laparoscopic sleeve gastrectomies, these complications are feared and extremely problematic. Having taken care of some of these troublesome complications, it was our thought that the current limitations of laparoscopic surgery (such as limited range of motion, poor ergonomics, lack of depth perception, and surgeon fatigue) could be risk factors for these rare but serious complications. Thus, we also adopted the da Vinci system for the sleeve gastrectomy.
Patient Positioning
The patient is placed in the supine position with the arms extended. The robot is docked straight over the head of the patient, and anesthesia is positioned on the patient’s right side (Fig. 11.2). The bedside assistant stands on the patient’s right side and the robotic monitor is placed across from the assistant on the patient’s left. Because the anesthesia’s positioning to the right of the patient, a peripheral IV should ideally be placed in the right upper extremity. After induction of anesthesia, a Foley catheter is placed, a footboard is properly secured, and straps are placed at the level of the upper thighs. An upper body-warming blanket is placed. The abdomen is then prepped from the nipple line to the suprapubic area. An orogastric tube is then placed to decompress the stomach. Lastly, the patient is draped without the traditional anesthetic barrier in order to allow the robot to be docked over the head. It is important always to ensure that the anesthesiologist has instant and unobstructed access to the head of the patient. Prior to docking the robot, the patient is placed in the reverse Trendelenburg position at approximately 15–20°.
Fig. 11.2
Operating room layout
Trocar Placement
A three-arm technique plus an assistant trocar is utilized. The camera trocar, which is a 12 mm long trocar, is positioned above the umbilicus via a transverse or vertical incision. The two robotic working arms, which can be 5 or 8 mm robotic trocars, are positioned at the anterior axillary line on both sides and just above the level of the camera port (Figs. 11.3 and 11.4). A 12 mm nonrobotic port is then placed approximately halfway between a line from the umbilical port to the right robotic port and slightly inferior. The liver is retracted with a Nathanson Hook Liver Retractor (Mediflex Surgical Products), which is placed just below the xiphoid and held in place with a retractor that is mounted to the bed over the patient’s right shoulder (Fig. 11.5). Finally the robot is docked directly above the patient’s head (Fig. 11.6).
Fig. 11.3
Robotic sleeve gastrectomy port placement
Fig. 11.4
Robotic sleeve gastrectomy port placement
Fig. 11.5
Nathanson retractor position
Fig. 11.6
Robot docked overhead
Step-by-Step Review of the Critical Elements of the Robotic Sleeve Gastrectomy
The first step of the robotic sleeve gastrectomy (RSG) is identification of the pylorus (Fig. 11.7). Approximately 4–6 cm proximal to the pylorus, the vascular attachment of the gastrocolic ligament is divided with the use of an energy source such as the Harmonic scalpel or the EndoWrist vessel sealer. This is typically started a little distal to the midpoint of the greater curvature where it is easier to enter the lesser sac than it is closer to the pylorus.
Fig. 11.7
Locating the pylorus
Once the target area to begin the dissection is decided, the console surgeon grasps the stomach with a double fenestrated bowel grasper and gently elevates it while the assistant provides countertraction of the gastrocolic ligament. We typically use the harmonic scalpel as the energy source (Fig. 11.8). It is important to stay close to the stomach wall in order to avoid injury to the underlying colon. Once the lesser sac is entered, the dexterity of the console surgeon’s left grasper allows easier orientation of the Harmonic scalpel along the greater curvature. Another technique involves tucking the left grasper under the stomach and elevating it for further exposure.
Fig. 11.8
Begin division of gastrocolic ligament
The dissection continues cephalad toward the angle of His and the short gastric vessels. Once the short gastric vessels are located, care must be taken to avoid troublesome bleeding. This is aided by the superior high-definition, three-dimensional view that the robot provides. Alternatively, the short gastric vessels can be divided after completing the gastric stapling portion, which allows the specimen to be retracted laterally and the vessels to be approached medially, which often provides a better and safer exposure for dividing the gastrosplenic attachments and the short gastric vessels. After the short gastric vessels are divided at the upper pole of the spleen (Fig. 11.9), the attachments between the fundus and left crus must be divided (Fig. 11.10) for two reasons: first, to avoid a large fundus at the superior portion of the stomach (neofundus) (Fig. 11.11) and, second, to clearly identify the gastroesophageal junction and to avoid stapling close to this area.
