1. Step-by-step instructions for our three-port-technique of laparoscopic sleeve gastrectomy
Patient positioning and location of the trocar ports
Patients are positioned supine with spread legs, in shape comparable to the Chinese letter "大". The surgeon stands between the legs of the patient. The camera guide is positioned on its right and. A further surgical assistant the left side of the patient. The assisting nurse stands at the end of the left lower limb. The two monitors are located above the patient´s head and left side. Anti-embolism stockings, in order to prevent deep venous thrombosis (DVT) are always in use (Fig. 1-1).
Trocar ports: Camera trocar port is positioned at the umbilical region. Kapnoperitoneum pressure is adjusted to 12-15mm Hg. A 5mm trocar is set in the left middle clavicular line and serves as main operation port. The 12mm trocar, serving as port for the stapler is set in the right middle clavicular (Fig. 2). After adjusting the position of all the trocars, the table can be angled to 30-50 degrees high or to 10-15 degrees low reverse Trendelenburg, according to the surgeon’s comfort.
Identifying the pylorus and dissecting the greater omentum
After entering the abdominal cavity, a diagnostic laparoscopy is performed. Tour nurse helps to put 36-40 Fr stomach oro-gastric tube (bougie) through the mouth and sucks the stomach empty (Fig. 3-A). Dissection at the greater curvature is started around 3 cm from the pylorus (Fig. 3-B). Use an ultrasound knife to make an opening in the avascular area and in the middle of the gastrocolic ligament/greater omentum. After entering the omental sac, the gastrocolic ligament along the gastric wall inside the omental vascular arch of the great curvature of the stomach is further dissected (Fig. 3-C). Attention is acquired during dissecting of the omental blood vessels to prevent a damage of the right gastroepiploic artery [7].
Dissection of the gastric fundus of stomach and exposing the left crus of diaphragm
At the spleen´s hilus, the gastro-colic ligament petered out into the gastro-splenic ligament, which is formed by the two peritoneal layers, which also cover the anterior and posterior gastric wall. There ligament harbours the short gastric arteries (Aa. gastricae breves), the left gastroepiploic artery and its accompanying vein. Dissection is initiated by coagulation of the short gastric vessel (Fig. 4-A). Near the left diaphragmatical angle, attention has to be paid to a short gastric artery that usually enters the stomach through the rear of the fundus close to the small curvature. This blood vessel should be dissected to ensure complete mobilization of the gastric fundus. The space between the stomach and the hilus of spleen is usually very limited. This requires special attention in order not to get too close to the stomach wall and thus compromise its blood supply, (Fig. 4-B) while simultaneously avoiding damage or bleeding from the spleen [8]. Thermal damage of the gastric wall may increase the risk of postoperative leakage [9]. Dissection is continued by separating the gastro-phrenic ligament in upward direction (Figure 4-C); The gastro-esophageal junction and the left phrenic curs have to be properly exposed. The resulting complete exposure of the left diaphragmatic angle thereby confirms achievement of the necessary complete mobilization of the gastric fundus. Final attention of this step requires the unconditional protection of a phrenic blood vessel, located at the basis of the phrenic muscle [10].
Dissecting the posterior gastric wall
The posterior wall of the stomach is successively dissected by moving upward off from antrum to the left crus (Fig. 5-A, B). For a proper exposure of the mobilized stomach, membranous structures between posterior gastric wall and pancreas have to be disengaged and dissected (Fig. 5-C). During this step, attention has to be paid, in order to protect the left gastric artery and its lymph nodes. Therefore, the surgeon’s left-hand gastric grasping forceps pulls the gastric wall forward while assisting the exposure. In principle, the dissection level must not be too deep in order to avoid the complication of a total gastrectomy becoming necessary with impaired blood supply from the left gastric artery (Fig. 5-D), [11].
Resection of the excess volume along the greater curve while forming a sleeved stomach
The inserted oro-gastric tube is advanced into antrum as a guide for calibrating bougie. The distance of 2-6 cm to the pylorus of the initial stapler placement should ensure reduction of the antral volume while preserving pylorus function (Fig. 6-A). During dissection, further attention has to be paid to the resulting width of the sleeve at the incisura angularis. If here the diameter becomes too tight, this results in the most common reason for postoperative stenosis. (Fig. 6-B). Thus, it is necessary to avoid distortion with a resulting (Fig. 6-C) discrepancy between anterior and posterior wall of the stomach (Fig. 6-D). After passing these two neural points - antrum and angulus fold - the sleeve is formed further upwards under constant calibration. The position of last stapler is suggested to be placed with a distance of 0.5-1cm away to the angle of His and apart of the gastroesophageal junction`s fat pad, again to ensure sufficient (Fig. 6-E, F) blood supply of the upper sleeve area, in order to avoid an increased risk of leakage [12].
Selection of staple cartridge: Staple cartridges with a height not less than 2 mm are appropriate for the dissection from antrum level up to the angulus fold (e.g. green cartrige, Johnson & Johnson) A height of minimal 1,5 mm should be selected for the dissection from the angulus fold upwards to the angle of His (e.g. blue cartrige, Johnson & Johnson) [13]. The tissue should be kept pressed between the cartrige branches for at least 15 seconds before the stapler may be fired. With a manually stapler in use, at least 5 seconds are sufficient. In case, the left hepatic lobe is voluminous thus obstructing the surgeon´s view, it may be lifted and thus retracted with the surgeon’s left-hand gastric grasping forceps, therewith enabling the inspection of the staple line.
Over-Sewing of Staple Line and fixation of the greater omentum to the staple line
An additional running suture along the staple line with an absorbable threat prevents bleeding and possible even the risk of leakage (Fig. 7-A) thereby re-attaching the previously disconnected omentum (Fig. 7-B). During the over sewing, the oro-gastric tube should be kept in place, in order to prevent an inadvertent constriction of the sleeve. The use of a non-absorbable suture is not recommended, because of the risk of granuloma formation or initiation of a fistula [9]. During this step, an obstructed view by a big left hepatic lobe, the surgeon’s right-hand gastric grasping forceps may help to retract the liver.
Removing the resected specimen and suturing the trocar port
The salvage of the specimen is the last step of the procedure. Attention must be paid to avoid damage and contamination of the incision. This step can be intraabdominal monitored with the camera. Intraluminal conditions, such as bleeding, can be monitored with Intraoperative gastroscopy and gas insufflation can be used to detect leakage. The leak test is performed as “bicycle tire test” by flooding the sleeve with water while insufflating the gastric lumen with gas during endoscopy. Rising bubbles would indicate a leak.
After this step, the 12mm Trocar is removed under direct vision to exclude local bleeding. Insertion of an intraabdominal drainage is optional. Under laparoscopic monitoring, the 12 mm trocar hole is closed in order to prevent trocar site hernia and then the remaining trocars are also removed under sight and the incisions are closed with sutures [14].