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A 28 year-old female with a history of obstructive sleep apnea and morbid obesity and a BMI of 55 Kg/m2 (146Kg) had failed to lose weight through diet and exercise and decided to undergo bariatric surgery.
This young female patient had several concerns about the esthetic results of the operation. Surgical treatment was provided as a LESS sleeve gastrectomy.
The patient was placed in the supine position with open legs. The leading surgeon stood between the patient’s legs with one assistant on each side. This is the single access port that was placed at the umbilicus. It had two 5mm port and a 12mm port.
4 knots were made to expose the umbilicus and a 25mm incision was made. A veress needle was placed at the right upper quadrant to start the pneumoperitoneum and place the LESS device with a distended abdomen.
The scope was 5mm, with an flexible angle that allows the assistant surgeon to stand apart, making more room for the leading surgeon modified roticulated instruments were used.
The LigaSure™ was used to open a window in the major omentum in order to separate it from the major curvature. From this approach the ports are too close, losing the triangulation and making it hard to move.
An additional 12mm trocar was placed on the right flank to provide an access route to EndoClinch, the suction and the mechanical sutures. Working at the fundus is tricky, as the range of movements is limited, resulting in a lack of traction and exposure.
However mobilization of the major curvature and the posterior wall of the stomach was feasible. A 35 Fr bougie was introduced to calibrate the gastrectomy.
The mechanical sutures were introduced through the 12mm trocar located on the right flank, with the first fire 5cm from the pylorus. Achieving correct exposure of the stomach and a symmetrical stapler line is more difficult.
The cartridges were reinforced and roticulated to ease the gastric transection and avoid other maneuvers to improve hemostasis, such as a prolene running suture. Other strategies had to be followed to separate the left hepatic lobe, as the liver retractor was not used due to the lack of ports. This situation is more evident at the upper phase of the transection.
Clips may be required even if reinforced sutures are used. The resected stomach was extracted through the umbilicus and the fascia was closed under direct laparoscopic supervision.
A drainage was placed for surveillance.
The surgery took 95 minutes and was uneventful. The patient started oral intake the day after the procedure and left the hospital on the second postoperative day with no complications.
4 years after the surgery she maintains a EWL > 50%, and there is no hiatal hernia or GERD.