About Video

This video describes in technical detail salient points in performing an ideal sleeve gastrectomy. Operative procedure: The patient is positioned supine with both arms out. An incision is made one open hand span width from the xiphoid process and two fingerbreadths to the left off the midline. This incision is deepened and the fascia is grasped with an Adair clamp. Pneumoperitoneum is introduced through a Veress needle to a pressure of 15 mm Hg. A 12 mm trocar is introduced through this. Diagnostic laparoscopy is performed. Alternatively in extremely obese patients a visual entry is done using a 12 mm trocar in the left subcostal region at palmers point using a visiport. A 5 mm trocar is placed just below the right costal margin in the anterior axillary line to introduce the liver retractor; alternatively the liver retractor can be placed just below the xiphoid process. A 5 mm trocar is placed on the right side just below the right costal margin at the midclavicular line. A 12 mm trocar is placed one hand width below that slightly to the right side of the 5 mm trocar. Two other trocars are placed in the left side. One 12 mm trocar is placed in the left subcostal margin in the midclavicular line. Another 5 mm trocar is placed one hand width below the 12 mm trocar. The angle of His is visualized and dissected. The pylorus is identified. The greater curvature is marked 6 cm proximal to the pylorus. A spot in the greater curvature about midbody of the stomach is identified and the greater omentum is incised with an energy device and the lesser sac is entered. The dissection of the greater omentum is continued cephalad to reach the short gastric vessels and the previously dissected angle of His. The fundus is completely mobilized till the base of the left crus is visible. The greater omentum is then taken off the stomach in the caudal direction towards the mark placed 6 cm proximal to the pylorus. This completes the omental dissection. Once this is done a 38 French bougie is passed and is directed to the pylorus. Using the bougie as a guide stapling of the stomach is begun hugging the bougie and exerting even traction on the body of the stomach. Care is taken not to narrow the incisura too much. At all times anterior and posterior visualization of the stomach is done before stapling to ensure correct application of the stapler and to prevent spiraling of the sleeve. In the antral region nothing less than a thick tissue load is used to accomplish the division of the stomach. It is our practice to use a thick tissue load all the way up to the fundus. Alternatively a load one step below may be used for the fundus and the body of the stomach. Endoscopy is performed at the end of the operation to ensure that the sleeve is not narrowed and to ensure hemostasis.