Single port Sleeve Gastrectomy

Technique Description:

• 1. First we will make a 2cm lateral incision inside the navel and a 3cm incision in the aponeurosis. Once we have our entry point, we introduce the single port device with the help of the rigid tube. When the ring is released inside the abdomen, we stretch the plastic to bring both rings as close as possible.
• 2. We know that the distance between the two jaws of our clamp is 2cm. So we use it to measure 4 cm from the pylorus to start dissection. We seal the vessels in the great curvature using the thunder beat; first with bipolar energy and then cut with ultrasound in order to progress safely toward the angle of His.
• 3. We ask the anesthesiologist to insert the 36F bougie. To facilitate the introduction of the bougie, we will raise the stomach upwards and help the bougie to slide through the gastric lesser curvature. Once we have the bougie placed in the pylorus we can start the gastric section. We are going to use a motorized stapler with a 60mm reinforced purple cartridge. The front and back of the stomach must be pulled equally to prevent the gastric tube from twisting.
• 4. The removal of the specimen is very simple because we are able to do it through the single port device, with the wound protected by the plastic of the device itself. We remove the quadport plus by pulling the white ribbon One of the criticisms of the single port technique has been the possible incidence of umbilical hernias, in order to avoid them it is important to visualize the aponeurosis well and close it carefully. We prefer loose stitches. We can close the skin with an intradermal suture so that the scar is less visible.

Procedure Steps:

• 1. Make a 2cm lateral incision in the navel and a 3 cm incision in the aponeurosis and insert the single port device.
• 2. Seal the vessels in the greater gastric curvature starting 4cm from the pylorus and progress to the angle of His.
• 3. Insert a 36F bougie and make the section of the stomach with an endostapler and reinforced cartridges. Pull equally the back and the front of the stomach to prevent twisting
• 4. Check the staple line with methylene blue; remove the specimen trough the protected wound and remove the single port device. Carefully close the aponeurosis and the skin.

Learning Points:

• Firstly, select a comfortable single port device and have longer instruments available, such as a 45cm thunder beat and longer clamps.
• Secondly, use 3D vision whenever possible to gain accuracy and reduce surgical time.
• Thirdly, you must perform a balanced vertical gastrectomy avoiding twisting and stenosis paying special attention to the area of the incisura angularis and the angle of His.

Clinical History:

• Female.
• Age: 41 years old.
• BMI of 41 and a long story of obesity since she was a teenager.
• She tried different medical treatments and diets but finally she asked for bariatric surgery. She was evaluated by the multidisciplinary team and an upper endoscopy with no findings was performed before surgery.
• She has no reflux distance.
• Xifoumbilical distance is 21 cm.
• We suggested that she undergo a single-port sleeve gastrectomy.