Sleeve to OAGB

Clinical History:

• 2000: Caesarean

• 2005: Abdominoplasty

• 2017: Sleeve Gastrectomy (94 kg - BMI 42      53 kg- BMI 24) 

• Current problem: weight regain 77.4 kg – 150 cm – BMI 34.4 kg/m²

Other History:

• Medication: None

• Co-morbidities: degenerative disc disease, dyspnea, current smoker (3/day)

• Preoperative Gastroscopy: no hiatal hernia, no reflux esophagitis, regular gastric tubulization, gastric mucosal hyperemia (HP-)

Technique Description:

1. Gastric pouch creation

2. Identification of the ligament of Treitz

3. Jejunum loop measurement 200 cm distal to the ligament of Treitz

4. Anti-colic gastro-jejunal anastomosis 

Procedure Steps:

1. Trocar placement

2. Intraoperative Gastroscopy 

3. Greater curvature preparation at body-antrum level

4. Pars-flaccida opening

5. Lesser curvature dissection

6. Identification and sparing of the terminal branch of the anterior vagus nerve

7. Retrogastric passage

8. Gastric transection

9. Identification of the angle of Treitz and measurement of 200 cm of small bowel distal to the angle of Treitz

10. Anti-colic, anti-gastric positioning of the small bowel loop

11. Antimesenteric border of small bowel to greater curvature anchoring

12. Service Jejunotomy and service gastrostomy opening

13. Gastro-jejunostomy linear stapling

14. Stapler access closure

15. Stratafix suture

16. Methylene blue test: negative

17. Nasogastric tube placement

Learning Points:

• The revision of LSG in OAGB may be offered to patients with no hiatal hernia and no reflux esophagitis

• The gastric resection must be performed by sparing the terminal branch of the anterior vagus nerve

• The gastro-jejunal anastomosis must be anti-colic, anti- gastric with anti-mesenteric anchoring of small bowel to the greater curvature in order to limit the occurrence of mesenteric hernia 

• To date there is no indication to perform the Petersen's space closure to avoid internal hernia