[General Surgery Laparoscopy] 4K ultra-high definition laparoscopic sleeve gastrectomy

Laparoscopic sleeve gastrectomy is a surgery performed under laparoscopy. Its basic method is to remove 80% of the stomach longitudinally to reduce the size of the stomach and resemble the shape of an intestinal tube. This kind of surgery can reduce the amount of food entering the stomach and the digestion and absorption in the stomach, thereby reducing appetite and achieving weight loss.

1. Body position, trocar position and equipment

An incision is made in the left lower abdomen, a cannula is inserted, and the abdominal wall is penetrated layer by layer under the guidance of the camera. Along the way, you can see yellow fat, pink muscles, and white tendons.

It is difficult to reveal the fundus of the stomach well with laparoscopy through the umbilical cannula. In addition, it is more difficult for obese people to insert a cannula through the umbilicus. For such patients, a longitudinal incision is usually made from the xiphoid process to the umbilicus, with a length of about 3 to 4 cm. Cut layer by layer until the peritoneum is opened. Purse-bag sutures were made on the peritoneal layer, a 10 mm trocar was inserted, and the purse-string sutures were tightened to complete the placement of the first trocar. After the operation, the trocar is removed, the purse string sutures are tightened, and each layer of the abdominal wall is sutured in sequence. This operation is easier and safer. A 5 mm trocar was placed under the xiphoid process to traction the liver and assist in exposure. The main operating hole is located at the midclavicular line on the left side, above the umbilical plane, and is used to insert an ultrasonic scalpel for separation. Its exact location depends on the patient's height and abdominal circumference. For those who are taller and have a larger abdominal circumference, the operating hole needs to be placed at a higher position for easy operation. A 12 mm trocar was placed above the right midclavicular line and above the umbilicus to assist traction and a linear cutting stapler was inserted for gastric incision. Likewise, its specific location depends on the patient's height and abdominal circumference. For those with taller height and larger abdominal circumference, the position of the cannula needs to be raised, otherwise it will be difficult for the stapler to reach the higher part of the stomach fundus. For those who are overweight and have difficulty with the operation, an additional 5 mm trocar needs to be placed in the right upper abdomen to facilitate the insertion of instruments to assist in exposure.

2. Greater curvature side freeing

The greater curvature dissection starts from the avascular zone in the middle of the gastroepiploic vessels. The assistant pulls the gastric wall upward, and the surgeon uses the instrument of his left hand to pull the gastrocolic ligament downward. Use an ultrasonic scalpel to open the gastrocolic ligament and dissociate it along the stomach wall toward the pylorus to 2-6 cm away from the pylorus, and further dissociate the adhesions between the posterior gastric wall and the pancreas. The opening length of the grasping forceps used by the author is 3cm, which can be used as a reference for measuring this distance. After the distal dissection is completed, turn upward and start proximal dissection on the greater curvature of the stomach. Obese patients often have a very thick omentum and clear exposure is crucial. The assistant pulls the gastric wall, and the surgeon's left instrument pulls the greater omentum to the left. Use an ultrasonic scalpel to dissociate upward along the edge of the gastric wall on the greater curvature of the stomach. This is located within the gastroepiploic vascular arch, with the fewest blood vessels and the thinnest tissue, and there is usually no bleeding during dissection.

3. Sleeve gastrectomy

After the dissection of the greater curvature of the stomach is completed, the anesthesiologist will insert a 36F gastric support tube through the mouth. Because this gastric tube is relatively thick, the gas in the stomach can be seen to be sucked out after entering the stomach, and the stomach will immediately deflate. Usually the recommended diameter of this gastric support tube is 32-36F. If the diameter is less than 32F, the remaining stomach is prone to stenosis and the chance of gastric leakage increases; if the diameter is greater than 36F, the remaining stomach will be retained too much, which will affect the weight loss effect.

After the support tube is placed into the stomach, the surgeon uses two non-abrasive grasping forceps to adjust the position of the support tube. Move it to the antrum and push it medially to the pyloric area. A linear cutting stapler was inserted through the 12 mm cannula on the right side. Because the gastric antrum is thick, green or gold staple cartridges are usually used for cutting. The first cutting shot needs to start 2-6 cm away from the pylorus. Being too close to the pylorus may cause damage to the pyloric annular sphincter, resulting in pyloric stenosis. If it is too far, a larger gastric antrum will be retained, which will affect the weight loss effect. After determining the starting site for cutting, use the right-hand instrument to traction the gastric antrum, and adjust the position of the head of the nail cartridge so that it contacts the support tube in the stomach. After the stapler cartridge is placed in place and clamped, you need to wait about 30 seconds before firing. In this way, the staple cartridge can compress the gastric tissue to be removed and squeeze out the water. After firing, releasing the staple cartridge can reduce gastric section bleeding. Starting from the second shot, use the blue nail cartridge to cut in the direction of the fundus of the stomach. Place the support tube close to the lesser curvature of the stomach, and the staple cartridge of the stapler close to the support tube. Be careful not to get too close. Just feel that the stapler is close to the support tube. There is no need to lift the stomach repeatedly to see the clamping position of the staple cartridge. As long as the two arms of the stapler cartridge are parallel and close to the support tube, otherwise the front and rear walls of the stomach will be cut unevenly after firing.

Due to its high location, partial resection of the fundus of the stomach is a more difficult part. Whether it can be removed successfully depends on the degree of dissociation. Only by completely separating the fundus of the stomach from the spleen and cutting off the fatty tissue on the posterior wall of the fundus can the fundus be completely resected. For taller patients, the position of the cannula on the right side of the cutting stapler needs to be raised, otherwise the stapler cartridge will have difficulty reaching the resection site. The last resection site needs to be 1 cm away from the esophagus to prevent damage to the cardiac sphincter and cause postoperative gastroesophageal reflux. At the same time, when the cutting site is uneven, it may cause gastric leakage[. In addition, due to the high position here, it is necessary to prevent damage to the spleen and diaphragm when pushing the stapler upward with force.

4. Gastric cross-section treatment and drainage

After the gastric incision is completed, ask the anesthesiologist to remove the support tube from the stomach and insert an ordinary gastric tube. Inject 50 ml of Milan and check whether there is blue stain near the gastric incision line. Some authors do not place a gastric tube, which can make the patient more comfortable after surgery. The author believes that placing a gastric tube can, on the one hand, detect gastric bleeding caused by gastric incision early, and on the other hand, it can help reduce the pressure in the gastric cavity and may prevent gastric leakage. Regarding whether the gastric incision line should be sutured and reinforced, most authors believe that this has no significant effect on preventing gastric leakage, and its significance lies in stopping bleeding. The author only sutures or inserts clips to stop the bleeding at the gastric cut surface. Clip placement is a quick and effective method to stop bleeding. Suturing to stop bleeding is relatively time-consuming and may cause local hematoma. After the hemostasis of the stomach section is completed, the fundus of the stomach and around the spleen need to be flushed, and the blood should be sucked out. Carefully check the stomach section, diaphragm, spleen, left outer lobe of the liver, and surrounding omentum for damage and bleeding. Any bleeding there needs to be done thoroughly and securely. To stop bleeding, don't take any chances. After confirming that hemostasis was reliable, a drainage tube was inserted along the gastric section through the right puncture hole. This drainage tube needs to be placed between the fundus of the stomach and the spleen. The resected specimen was removed through the umbilical puncture hole.

Sleeve gastrectomy, which is more commonly used in recent years, achieves weight loss and lowering blood lipids by reducing gastric capacity and reducing the secretion of hormones that stimulate hunger without changing the physiological state of the gastrointestinal tract and without interfering with the normal digestion and absorption process of food. , lowering blood sugar and other purposes; and the operation does not require intestinal reconstruction, so there will be no long-term sequelae such as anemia and osteoporosis caused by vitamin deficiency. Laparoscopic-assisted sleeve gastrectomy is a minimally invasive surgery that does not require laparotomy. It only requires puncturing 3-5 small holes of 0.5-1.2 cm in the abdomen for surgery. It has small trauma, less bleeding, fewer complications, and a shorter course of disease. Recovery is fast. Under the rehabilitation treatment of ERAS, patients usually get out of bed and move around on the first day after the operation, and gradually resume their diet on the second day after the operation. In the 2-4 weeks after the operation, the gastrointestinal function of the diet recovers, and they can eat low-salt, low-fat, low-salt foods. Fatty, low-residue food. The three meals should be based on regular, quantitative and balanced nutrition. Generally, patients can lose 40 pounds within half a year after surgery.

Bariatric surgery can not only quickly reduce the patient's weight, but also effectively improve the coexisting blood sugar and blood lipid metabolism disorders in most patients, thereby stabilizing blood sugar and blood lipids and keeping away from diabetes and cardiovascular diseases.

Will the reduced gastric capacity after surgery cause malnutrition?

Will not.

Because the absorption of food in our body occurs in the small intestine, the stomach is mainly a function of the passage. It stirs and secretes gastric acid to help digestion. The absorption is mainly in the small intestine. Therefore, as long as the diet structure and quantity are correct, there will be no problem of malnutrition.

What precautions should be taken after surgery?

Sleeve gastrectomy is a life-changing surgery. It is used to help people lose weight and improve their health. Losing weight reduces the risk of obesity-related medical problems, such as heart attack, high blood pressure, diabetes, arthritis, obstructive sleep apnea, fatty liver disease, back pain, knee pain, and ankle pain.

After surgery, your diet needs to be gradual. There is a transition from liquid to clear liquid at the beginning, to semi-liquid, and then to solid. Finally, it returns to a normal diet, and the amount of food eaten needs to be controlled to a certain extent.

Also, it is not that the surgery is done once and for all. After the surgery, you must pay attention to long-term follow-up, and you must also pay attention to the adjustment of the structure and quantity of your diet. Otherwise, there will still be a risk of regaining weight as time goes by.

After the operation, if I like to eat hot pot, crayfish, ice cream, etc., can I still enjoy it in the future?

That's absolutely fine. Surgery will not change the patient's diet. You can eat cold and exciting delicacies after your body recovers, but the amount will be greatly reduced compared to before.

Does this mean I can have a "sleeve gastrectomy" if I want to lose weight?

At present, many people have high requirements for their body shape, but any weight loss plan has certain indications. You don't just want to ask for this surgery just to lose weight.

Specifically, there are three main aspects:

1. The recommended age for "sleeve gastrectomy" is generally between 16 and 65 years old. The history of diabetes generally does not exceed 15 years. If the waist circumference of men is greater than or equal to 90 cm, and the waist circumference of women is greater than or equal to 85 cm, the recommended level of surgery may be increased as appropriate.

2. The patient needs to be fat enough. BMI is an important clinical criterion for judging whether the patient is suitable for surgery. Generally, a BMI above 37.5 can meet the surgical indicators. However, if your BMI is 32.5 but you have obesity-related complications such as hypertension, diabetes, and hyperlipidemia, surgery is recommended.

3. Those who have reached the obesity index, but have failed to achieve weight loss after long-term diet and exercise management, or have failed to achieve weight loss through medication, and have repeatedly failed to lose weight, may also consider surgical weight loss.

Sleeve gastric surgery is not for beauty, but for health. Sleeve gastric surgery, including all bariatric surgeries, is for the treatment of diseases. Doctors only consider surgery when there are obesity and complications. After the surgery, the most common metabolic diseases include diabetes, hypertension, high uric acid, and lesbians with polycystic ovary and infertility. Infertility, irregular menstruation, etc. all have a significant improvement effect. As the weight decreases after surgery, some corresponding complications can be effectively controlled, and there is even no need to take medicine in the later period.