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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_832_Библиотеки_им_академика_М_И_Перельмана
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Laparoscopic Assisted Robotic Sleeve
https://t.me/med1917
Gastrectomy, Laparoscopic Assisted
Robotic Roux-en-Y Gastric Bypass
GiviBasishvili andCarlaHolcomb
1 Indications
The most common indications for bariatric surgery are based on the 1991 NIH consensus statement.
1. BMI>40kg/m2 OR
2. BMI>35 to 39.9kg/m2 with obesity related comorbidities which include
(a) Type 2 Diabetes
(b) Hypertension
(c) Obstructive Sleep Apnea
(d) Dyslipidemia
(e) Cardiovascular Disease
3. BMI 30 to 34.9kg/m2 with metabolic syndrome or diabetes that is uncontrolled
with medical therapy
However, new criteria for eligibility for metabolic surgery has been recently revised
by the American Society of Bariatric Surgery (ASMBS) as well as the International
Federation for the Surgery of Obesity (IFSO) to be as follows [1]:
1. BMI>35kg/m
G. Basishvili
Valley Health Metabolic & Bariatric Program, Winchester, VA, USA
e-mail: Givi.Basishvili@UTSouthwestern.edu
C. Holcomb (*)
Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
e-mail: Carla.holcomb@utsouthwestern.edu
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_17
2
195© The Author(s), under exclusive license to Springer Nature
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2. BMI > 30 with comorbidities, including: Type II diabetes (T2DM), hypertension, sleep apnea and other respiratory disorders, non-alcoholic fatty liver disease, osteoarthritis, lipid abnormalities, gastrointestinal disorders, or heart disease
3. BMI>27.5in Asian populations.
G. Basishvili and C. Holcomb
2 Sleeve Gastrectomy Vs. Roux-en-Y Gastric Bypass
Generally speaking, the choice between a sleeve gastrectomy and a Roux-en-Y gastric bypass (RYGB) is left to the patient. However, there are factors that inuence
surgeon’s recommendation when choosing a weight loss procedure. Outcomes
between the two have been studied in several randomized controlled trials. Excess
weight loss (EWL) was not signicantly different between the two operations at
5years postoperatively [2], but found to be slightly higher at 7 and 10years in those
with RYGB (%EWL difference approximately 8% higher in RYGB) [3, 4]. The rate
of type II diabetes remission is reported in studies to be higher with RYGB [5],
although dyslipidemia and sleep apnea remission rates are similar. Hypertension
has been consistently shown to be better managed with RYGB [3, 4]. A joint decision should be made between the surgeon and patient based on their goals and
obesity-related comorbidities.
A serious concern after sleeve gastrectomy is gastroesophageal reux disease
(GERD). Studies have revealed 20–30% of patients undergoing sleeve develop de
novo GERD symptoms or worsening of pre-existing reux symptoms [2, 6] and a
signicant amount of those have esophagitis on postoperative endoscopy [4]. This
affects quality of life but can also lead to ulcerative esophagitis, Barrett’s esophagus, and eventually esophageal adenocarcinoma. On the other hand, RYGB has
been shown to improve GERD symptoms in patients with pre-existing reux, and is
therefore the procedure of choice for those with moderate to severe GERD symptoms or evidence of severe esophagitis on EGD (LA Grade C or D) preoperatively.
Another consideration in selecting which operation to pursue is the presence of
a hiatal hernia. This can be found either on preoperative upper endoscopy or esophagram. It is suggested that up to 40% of morbidly obese patients have a hiatal hernia
[7]. If it is a small (<2cm) sliding type hiatal hernia, it is reasonable to offer a sleeve
gastrectomy or RYGB. With any hiatal hernia larger than 2cm, it is the preference
of this author to offer a RYGB over a sleeve gastrectomy. This is because the tubularized stomach after a sleeve is at higher risk for herniation compared to the gastric
pouch, which is somewhat tethered in the abdomen by the roux limb. Any visible
hiatal hernia should be repaired intraoperatively at the time of the weight loss procedure with a true mediastinal dissection to gain 2.5cm of intra-abdominal esophageal length and a posterior cruroplasty (techniques described in anti-reux
procedures and paraesophageal hernia chapters).
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3 Preoperative Preparation
All patients meeting criteria for bariatric surgery require additional evaluation prior
to surgery. This includes but is not limited to the following:
1. Nutrition Assessment: Screening for preoperative nutritional deciencies that
should be corrected prior to surgery is an important component of preoperative
evaluation. Dietary counseling and education are an essential component of successful weight loss surgery
2. Mental Health Evaluation: Psychiatric disorders and behavioral health issues are
prevalent in patients with obesity and treatment is required for patients to have
successful outcomes [8].
3. Medical Clearance: Screening and risk mitigation for cardiovascular and pulmo-
nary diseases helps ensure patient safety in undergoing bariatric surgery
4. Imaging: There is a growing consensus that patients undergoing bariatric surgery
should have a screening upper endoscopy prior to surgery given the high rates of
silent gastroesophageal reux disease in this specic population. Findings of
hiatal hernia and esophagitis may alter surgical planning.
4 Positioning andAnesthesia
Safe positioning of patients with obesity is a critical step. Devices specically designed
to transfer patients with obesity (Hovermatt Air Transfer System®) to the OR table can
help decrease injuries for both patient and staff. Additional equipment such as the
Pigazzi® Pink Pad can stabilize the patients on the table and prevent slippage during
reverse Trendelenberg positioning. The patient should be placed in supine position with
arms abducted and secured to the table at the level of the chest and hips with proper
padding and straps. A foot board is placed at the bottom of the bed. General anesthesia
and endotracheal intubation are used. The author prefers the use of the ViSiGi 3D® exible gastric tube to both decompress the stomach and to use as a calibration guide for
both vertical sleeve gastrectomy (40 Fr) and Roux- en- Y gastric bypass (36 Fr). If using
an esophageal bougie for sizing, then an orogastric tube can be placed at the beginning
of the case for decompression and removed prior to bougie placement.
5 Vertical Sleeve Gastrectomy
5.1 Port Placement andAbdominal Entry
The Xiphoid process and costal margins are marked. Additional markings for port
placement include: 1 port at 18cm below the Xiphoid process and 2cm to the left
of midline, 2 ports on the left mid abdomen, and 1 port on the right mid abdomen,
all separated by at least 8cm (approximately width of a palm) from one another.
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G. Basishvili and C. Holcomb
5mm - Liver
Rectractor
18 cm
#1
12mm
Bipolar/
Stapler
Fig. 1 Port placement for robotic sleeve gastrectomy
#2
8mm
Camera
#3
8mm
Vessel
Sealer
#4
8mm
Tip-up or
Caudiere
A 40 French ViSiGi® tube is introduced into the stomach and placed to suction.
Laparoscopic entry is obtained into the abdomen via the Veress needle at Palmer’s
point, and the abdomen is insufated. At this point a laparoscopic transversus
abdominis plane (TAP) block can be performed to decrease postoperative pain and
narcotic requirements. Ports are placed as depicted in Fig.1. Three 8mm ports on
the right side, one 12mm port on the upper left side (below the falciform ligament),
and one 5mm incision for the liver retractor.
5.2 Description ofProcedure
The patient is placed in 15–20° of reverse Trendelenburg. The liver retractor is
placed to the left of the ssure of the liver and directed to the tip of the hiatal opening, revealing the angle of his and any undiagnosed hiatal hernia. The robot is then
docked. The camera is placed in the periumbilical port #2 and targeted to the midstomach. Instruments are placed in the remaining ports; it is the preference of this
author to place graspers in port # 1 and # 4 and a vessel sealer in #3. The ViSiGi® is
taken off suction, advanced to the tip of the stomach along the lesser curve, the
stomach is laid out at, and Bougie is placed back to suction.
The mid-portion of the stomach is elevated, and the vessel sealer is used to divide
the branches of the gastroepiploic vessels inserting on the greater curve of the stomach to enter the lesser sac. The gastro-epiploic branches are divided distally along
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the greater curve of the stomach until 5–6cm away from the pylorus. The dissection
is carried proximally along the greater curvature toward the angle of His where the
short gastrics are divided. As the dissection is carried up towards the region of the
spleen, care should be taken not to avulse the short gastric vessels with excess traction force. Additionally, when transecting short gastric vessels near the tip of the
spleen, the stomach can be rotated medially over the Bougie to obtain a more favorable angle for the vessel sealer. Dissection is complete once a clear view of the base
of the left crus is obtained and insuring the entirety of the fundus can be retracted
laterally.
At this point, the stomach is free from its lateral attachments. Occasionally, posterior lmy adhesions are present in the retro-gastric area which need to be taken
down if they impede the trajectory of the stapler. Next, a 60mm long tri-staple
3.5mm (Blue load) stapler is introduced via the 12 mm port (port # 1) and a site
5–6cm away from the pylorus is selected. This stapler ring is positioned parallel
to the incisura and 2cm off of the VisiGi® tube to prevent narrowing at the incisura
leading to obstruction (Fig.2). Typically, subsequent stapler res can be performed
using a 2.5m (White Load) stapler, and the stapler is brought close to the VisiGi® to
create a tight sleeve. After each staple ring, the staple line should be examined for
any deformed or loose staples prior to ring the next load as to avoid stapler misres. Port #4 can be a useful instrument to retract the stomach laterally as to avoid
inadvertent twists/folds developing on the posterior aspect of the stomach (Fig.3).
While progressing towards the fundus of the stomach, the fundus must be retracted
laterally along the cut edge of the short gastric vessels, as to avoid leaving excess
posterior fundus behind. The nal staple ring should emerge lateral to the left crus
at least 2 cm lateral to the esophagus to avoid narrowing the gastroesophageal
junction.
After the entire stomach is transected, the staple line should be examined for any
obvious defects or bleeding (Fig.4). It is the preference of this author to over-sew
the staple line with suture. Once this is done, a leak test is performed. The prepyloric region is grasped with an instrument (Fig.5), and 60cc of saline mixed with
methylene blue dye is injected into the VisiGi® to distend the stomach. Alternatively,
Fig. 2 Sleeve gastrectomy
division, rst stapler re
leaving a 2cm gap as to
not narrow the incisura
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Fig. 3 Sleeve gastrectomy,
stapler snug along the
bougie, most lateral arm
(4th arm) retracts the
fundus laterally as to avoid
inadvertent folds posterior
to the stapler and avoid
leaving excess fundus
Fig. 4 Examining the
staple line for bleeding or
abnormalities
G. Basishvili and C. Holcomb
Fig. 5 Leak test.
Pre-pyloric region grasped
to prevent air/dye from
escaping
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some surgeons choose to remove the ViSiGi® or bougie, instill saline in the left
upper quadrant, and perform an endoscopy to perform a leak test and look for intraluminal bleeding at the same time. Once the leak test is conrmed negative, the
VisiGi® is taken off suction and withdrawn. The liver retractor is removed. The
robot is undocked and the transected stomach is removed from the 12mm port site.
The extraction site is closed with a gure of eight suture and irrigated to prevent
infection. 8mm port sites are closed at the skin.
6 Roux-en-Y Gastric Bypass
6.1 Port Placement andAbdominal Entry
The Xiphoid process and costal margins are marked. Additional markings for port
placement include: 1 port at 20–22cm below the Xiphoid process and 2cm to the
left of midline, and 2 ports in the left mid abdomen, and 1 port in the right mid abdomen separated by at least 8cm (approximately width of a palm) from one another.
A 36 French ViSiGi® is introduced into the stomach and placed to suction.
Laparoscopic entry is obtained into the abdomen via the Veress needle at Palmer’s
point, and the abdomen is insufated. A Laparoscopic TAP block can be performed
to decrease postoperative pain and narcotic requirements. Ports are placed as
depicted in Fig.6.
Fig. 6 Port placement for robotic gastric bypass
12mm
20–22cm
5mm - Liver
Rectractor
8mm
12mm
8mm
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G. Basishvili and C. Holcomb
6.2 Description ofProcedure
The patient is placed in 15–20° of reverse Trendelenburg. The liver retractor is
placed to the left of the ssure of the liver and directed to the tip of the hiatal opening, revealing the angle of his and any undiagnosed hiatal hernia. The robot is
docked. The camera is placed in the periumbilical port #2 and targeted to the upper
stomach. Instruments are placed in the remaining ports; it is the preference of this
author to place graspers in port # 1 and # 4 and a vessel sealer in #3. The ViSiGi® is
taken off suction, advanced to proximal stomach, and placed back to suction. The
authors typically begin by dissecting the GE junction fat pad and clearing the Angle
of His using the vessel sealer device. This allows for easier passage of the stapler
when forming the gastric pouch.
The gastrohepatic ligament (pars accida) is opened and the lesser sac examined
for any major posterior adhesions. A retro-gastric window is created starting 5–6cm
distal to the gastro-esophageal junction. An additional landmark that surgeons can
use to determine length of gastric pouch is to transect between the 2nd and 3rd gastric veins. Once a plane posterior to the stomach is created, a 2.5mm white load of
the stapler is introduced in Port #1 and positioned transversely across the stomach.
The length of this re determines the width of the pouch; the stapler is inserted up
to the 35–40mm mark (Fig.7). The 36 Fr VisiGi® tube is then advanced to the distal
end of the pouch. Additional longitudinal staple res are performed using the
2.5mm (white) staple loads loosely along the VisiGi® tube, with the last re vertically across the angle of His (Fig.8).
Once the gastric pouch is created, the greater omentum is reected upwards and
to the right side over the transverse colon. Often in obese patients, the omentum is
thick and can create tension on the ante-colic roux limb. It is usually necessary to
Fig. 7 Transverse division
of the gastric pouch
Laparoscopic Assisted Robotic Sleeve Gastrectomy, Laparoscopic Assisted Robotic…
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Fig. 8 Longitudinal
division of the gastric
pouch over bougie
Fig. 9 “Omega” Loop.
Biliopancreatic (BP) limb
on the left side, Alimentary
(roux) limb on the
right side
203
divide it in half to allow the roux limb to travel towards the pouch without tension.
Next, the transverse colon is gently retracted towards the head and the ligament of
Treitz (LOT) is identied. The inferior mesenteric vein can also be used to identify
the LOT as it is consistently found just lateral to fourth portion of the duodenum as
it passes through the colonic mesentery. The bowel is run 50–60cm distal to the
LOT, ensuring that the biliopancreatic (BP) limb is on the left side of the body and
the alimentary (roux) limb is on the right side of the body. The location can be
marked with a vicryl suture and gently retracted cephalad toward the gastric pouch
as an “Omega” loop (Fig.9).
After positioning the omega loop and the gastric pouch parallel to each other,
enterotomies are made in the gastric pouch and the omega loop using “Cut” with the
robotic hook (Fig.10). A 2.5mm (white) load of the stapler is then inserted 30mm
into each limb and red. The ViSiGi® tube is brought through the gastrostomy and
guided into the roux limb. The common enterotomy is closed in two layers over the
tube using a running absorbable 3-0V-loc suture. Once, the common enterotomy is
closed, the omega loop is transected on the left side of the suture line to disconnect
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Fig. 10 Enterotomies on
gastric pouch and omega
loop using “cut”
electrocautery
Fig. 11 Transection of the
omega Loop on the left
side of the gastrojejunostomy to separate the
biliopancreatic (BP) limb
G. Basishvili and C. Holcomb
the biliopancreatic limb (Fig.11). Next, a leak test is performed using either blue
dye or insufation via endoscopy.
After a negative leak test, the ViSiGi® tube is removed. The alimentary limb is
run distally for 125–150cm and positioned in a side-to-side, anti-peristaltic fashion with the biliopancreatic limb. An enterotomy is made in each limb using the
“cut” on robotic hook, and the 60mm 2.5 mm (White) staple load is inserted in
into each limb and red to create the jejuno-jejunostomy (Fig.12). The common
enterotomy is sutured in one layer using a 3-0 running absorbable, barbed suture.
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