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A 56 year old female with previous history of high blood pressure, T2DM, dyslipidemia, and a thyroidectomy to treat a papillary thyroid carcinoma.
She suffered from morbid obesity with a BMI of 43 Kg/m2(weight 106 Kg) and underwent a sleeve gastrectomy by laparoscopy (big left hepatic lobe), at the postoperative period she developed a leak manifested as a collection with air content, neither upper GI series or gastroscopy revealed the suture defect. This complication was managed with antibiotics and a nasojejunal tube for enteral nutrition that were stopped after a CT Scan confirmed its resolution.
The patient missed her follow up and experienced increased dysphagia and vomiting re-consulting two years after surgery.
At the revaluation she had lost 42 Kg and actual BMI was 26 Kg/m2 with good metabolic response (T2DM and dyslipidemia was solved). Further investigation was performed with a CT Scan that revealed a relapse of the collection, there was no leak of oral contrast, this collection was not suitable for radiological-guided drainage. A gastroscopy only saw a mucosal erythema at the greater curvature and a upper GI series revealed an angled stomach with a hiatal hernia.
Once again conservative treatment was performed with antibiotics and nutritional support through a nasojejunal tube. After two months of follow up the collection was solved and conversion to a Roux-enY gastric bypass by laparoscopy was proposed.
A total of six trocars were used. One of 12mm in supra umbilical position for a 30 degree scope, three trocars of 12mm for working channels and a liver retractor located at each flank and epigastrium, one of 5mm for traction, placed more laterally at the left flank and the last of 12mm at the umbilicus that is used to at the inframesocolic phase of the by-pass.
The liver retractor is placed and recognizement of the structures begin, the stomach is attached to the posterior wall of the left lobe of the liver, this region was previously occupied by the collection. These structures must be individualized.
Sharp dissection is made by using the hook, careful identification of the plane must be done to avoid gastric perforation, liver or spleen injuries that may require conversion to open approach in order to fix them. The suction can be used for blunt dissection and improve the exposure of avascular planes for future section with the hook.
With those maneuvers the mid third of the stomach is separated, to work at the upper part is more challenging because the organs are more fused. If there is more blood than the expected it is recommended to check for incidental lesions. A superficial laceration of the spleen was made but was opportunely identified and controlled with the hook.
Now the anterior wall of the stomach is free, the crura is dissected to identify the limits during the creation of the pouch. The gastrohepatic ligament is opened respecting the left gastric artery to gain access to the lesser sac.
A trick to help in the procedure is to place a Foucher, with this maneuver the stomach turns into a different consistency and allow its differentiation from the fused spleen during the lateral dissection. At this part of the surgery the surgeon attempts to create an orifice that will be the target of the retro-gastric dissection.
Blunt maneuvers are preferred to separate the posterior wall of the stomach from the pancreas, traction and countertraction movements were made with the suction and a Goldfinger, remember to be delicate during this part of the surgery. This device can be used as a guide to place the mechanical suture.
A total of two purple cartridges of StriStapler were used to built the pouch. After corroboration of a complete transection the pouch and the stomach were separated using a LigaSure™.
The anvil shaft is attached to a nasogastric tube and passed through the mouth until the pouch with the assistance of the anesthesiologist and is set for the gastroenteric anastomosis.
The rest of the procedure was made as a conventional Roux-en-Y gastric bypass.
There were no postoperative complications, oral intake started the first day after surgery and she left hospital at the second postoperative day. The last follow up is two months after the procedure, she maintained the weight-loss, there is no pain, fever or dysphagia.
