Surgery for Obesity and Related Diseases 12 (2016) 925–927
Video case report
Three-port sleeve gastrectomy: complete posterior approach Marius Nedelcu, M.D.a,*, Imane Eddbali, M.D.b, Patrick Noel, M.D.b a
Centre Hospitalier Universitaire Montpellier Montpellier, France b The American Surgecenter, Abu Dhabi, UAE Received December 10, 2015; accepted December 28, 2015
In 2011, laparoscopic sleeve gastrectomy (LSG) became the most commonly performed bariatric procedure in France  and 2 years later also in the United States . Its frequency has been constantly increasing worldwide. This growth can be explained by several advantages that LSG carries over more complex bariatric procedures, such as Roux-en-Y gastric bypass or duodenal switch, including the absence of most side effects of bypass procedures such as dumping syndrome, marginal ulcers, malabsorption, small bowel obstruction, and internal hernia, and a better quality of life over gastric banding . Although LSG is generally considered to be a straightforward procedure, surgical technique may be one of the major determinants of the most feared associated complication—staple line leak. Several publications have advocated the critical role of the learning curve for different bariatric procedures as it relates to diminishment of postoperative complication rates [4,5]. Even if many surgeons consider LSG to be a very simple or technically easy procedure, there are limited data  in the literature regarding the experience needed to signiﬁcantly reduce the risk of leak. Herein, we provide the technical details for a complete posterior approach and the ﬁrst didactic high-quality video of the reduced port surgery for sleeve gastrectomy.
3-port approach, with no liver retractor Complete posterior dissection of the gastric fundus Anterior eversion of the gastric fundus before the last 2 ﬁrings
The assistants stand on the right side of the patient and the surgeon stands between the legs of the patient, who has been placed in the French position. Once pneumoperitoneum is established, a 5-mm port for the camera is placed at one third of the distance between the xiphoid process and the umbilicus 3 to 5 cm lateral to the midline on the left side. Two additional ports are placed: a 15-mm port for the stapler in the umbilicus and a 5-mm port for the surgeon’s right hand in the left hypochondrium. The greater curvature of the stomach is freed, starting from the middle of the stomach, with an ultrasonic bipolar dissector (Thunderbeats, Olympus, Center Valley, PA, USA). The approach of the lesser sac at this level is easier. The standard technique for LSG includes 5 ports. A particularity of the 3-port technique is represented by the complete posterior dissection of the upper part of the stomach. The reduced port in the complete posterior approach is explained as follows:
The standard fourth trocar for the liver retractor is Personal technique The surgeon’s personal technique includes the following few particulars: * Correspondence: Marius Nedelcu, Digestive Surgery, University Hospital of Montpellier, 80, Avenue Augustin Fliche, 34295, Montpellier, France. E-mail: [email protected]
replaced by the left hand of the surgeon. The surgeon uses the posterior part of the stomach to lift up the left lobe of the liver. The dissection of the stomach is performed completely posteriorly with no anterior dissection. After complete dissection of the attachments of the posterior part of the fundus, the left crus is identiﬁed
http://dx.doi.org/10.1016/j.soard.2015.12.033 1550-7289/r 2016 American Society for Metabolic and Bariatric Surgery. All rights reserved.
M. Nedelcu et al. / Surgery for Obesity and Related Diseases 12 (2016) 925–927
and represents the main landmark of the dissection. From posterior to anterior, a tunnel is created at the level of angle of His. During dissection, the last short gastric vessels are nondivided, playing the role of the assistant exposure. The nondivided short gastric vessels replace the ﬁfth trocar from the standard technique. Another technical point of this approach is the placement of the optical port. In the standard 5-port LSG, the optical port is placed on the midline. Placing the optical port close to the left hypochondrium offers a better view of the hiatal region, facilitating in this way the exposure for the reduced port surgery. Once the stomach has been freely dissected, a 37F rigid calibration tube (MidSleeveTM, MID, Dardilly, France) is inserted by the anesthesiologist and directed through the pylorus. The stomach is then transected, respecting 2 principles. First, particular attention must be paid to the incisura angularis to avoid a stricture at this point. The left-hand stapling offers the correct direction “to respect the incisura angularis.” By the left-hand stapling, the device will be parallel with the lesser curvature and not perpendicular, which is the case when performing a right-hand stapling. Second, to perform an efﬁcient procedure, it is important to remove the whole gastric fundus. In this technique, the following occurs:
With the right hand, the surgeon grasps the posterior aspect of the gastric fundus and brings it up anteriorly.
With the left hand, the stapler is placed close to the endoluminal tube and partially closed.
The stapler is then gently opened, while the right hand of the surgeon pulls the anterior stomach laterally.
When the anterior part is completely aligned with the
posterior part previously pulled up, the stapler is ﬁnally closed and then ﬁred. This maneuver is repeated for the last 2 ﬁrings to keep the staple line straight, avoiding an oblique sectioning of the gastric fundus. The operative specimen is placed in a bag and extracted by the 15mm port.
Discussion As LSG becomes adopted by more bariatric surgeons, the need for standardization of the procedure has grown in an effort to achieve similar results across different practices and safety proﬁles. With increasing use of LSG, its technical details become better understood and the mechanisms of leak pathology will be better studied. LSG is not a simple procedure, and because the procedure is irreversible, surgeons should strive to minimize the risk of complications. Even if multiple techniques are described for LSG, the majority of reports regarding leak involve the same 2
factors: stricture at the incisura angularis and stapling near the esophagus at the angle of His. Our previous publication illustrates the association between these 2 main causes . In our technique, these 2 risk factors are best managed by stapling the stomach with the left hand, when the surgeon is placed between the legs of the patient. For the ﬁrst stapler, the tip of the instrument will be further from the incisura angularis compared with the techniques in which the stapler is maneuvered by the surgeon’s right hand. In general, the right hand of the surgeon is the most important arm for the dissection and the stapling during LSG. In this particular 3-port approach, compared with the standard 5-port approach, the job of the right hand is not particularly different during dissection. But the task of the left hand is completely different in the 3-port approach. During the initial part of the dissection, the left hand is progressively lifting up and to the right the anterior part of the greater curvature of the stomach. Once the dissection is progressing to the short vessels, the left hand is grasping the posterior part of the fundus close to the greater curvature. In the standard 5-port approach, in case of a huge left lobe liver with steatohepatitis, the liver retractor can cause a partial section of the liver parenchyma. In the 3-port approach, the shaft of the left arm grasp is always passing under the dissected stomach. The stomach is playing the role of a uniform biological liver retractor and the risk of injury of the left liver is considerably diminished. In the presence of hiatal hernia, we consider the risk of intrathoracic migration for the sleeve too important as the diameter of a correct sleeve is narrower than the crural repair. In our experience, Roux-en-Y gastric bypass is considered for this particular situation, especially when it is associated with grade C or D esophagitis or Barrett’s esophagus. In 3 cases the hiatal hernia has not been diagnosed during the preoperative workup (upper endoscopy and Gastrograﬁn swallow) and an additional 5-mm port was placed in the epigastrium for the crural repair. Disclosures M. Nedelcu and I. Eddbali have no conﬂicts of interest or ﬁnancial ties to disclose. P. Noel has honorarium for speaking engagements for Olympus and Gore. Appendix Supplementary data Supplementary data cited in this article is available online at http://dx.doi.org/10.1016/j.soard.2015.12.033. References  Lazzati A, Guy-Lachuer R, Delaunay V, Szwarcensztein K, Azoulay D. Bariatric surgery trends in France: 2005-2011. Surg Obes Relat Dis 2014;10(2):328–34.
Three-Port Sleeve Gastrectomy / Surgery for Obesity and Related Diseases 12 (2016) 925–927  Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg 2013;23(4):427–36.  Fezzi M, Kolotkin RL, Nedelcu M, et al. Improvement in quality of life after laparoscopic sleeve gastrectomy. Obes Surg 2011;21(8):1161–7.  Ali MR, Tichansky DS, Kothari SN, et al. Validation that a 1-year fellowship in minimally invasive and bariatric surgery can eliminate the learning curve for laparoscopic gastric bypass. Surg Endosc 2010;24(1):138–44.  Geubbels N, de Brauw LM, Acherman YI, van de Laar AW, Wouters MW, Bruin SC. The preceding surgeon factor in bariatric
surgery: a positive inﬂuence on the learning curve of subsequent surgeons. Obes Surg 2015;25(8):1417–24.  Bellanger DE, Greenway FL. Laparoscopic sleeve gastrectomy, 529 cases without a leak: short-term results and technical considerations. Obes Surg 2011;21(2):146–50.  Nedelcu M, Manos T, Cotirlet A, Noel P, Gagner M. Outcome of leaks after sleeve gastrectomy based on a new algorithm adressing leak size and gastric stenosis. Obes Surg 2015;25(3):559–63.