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Issue link: http://bariatrictimes.epubxp.com/i/492631
A8 Bariatric Times • April 2015 • Supplement A 5 th INTERNATIONAL CONSENSUS SUMMIT FOR SLEEVE GASTRECTOMY port for the stapler in the umbilicus and a 5-mm port for the surgeon's right hand in the right hypocondrium. The greater curvature of the stomach is freed, starting from the middle of the stomach, as the entry into the lesser sac is easier at this point. A particularity of this technique is represented in the complete posterior dissection of the upper part of the stomach. Care is taken to divide all the posterior attachments of the gastric fundus with the identification of the left crus of the diaphragm before cutting the short gastric vessels. By this manner, the fourth trocar for liver retractor is replaced by the left hand of the surgeon who is using the stomach to lift up the left liver. The non-divided short gastric vessels replace the fifth trocar from the standard technique, playing an important role in the exposure, as illustrated in Figure 1. Once the stomach has been dissected free, a 37-Fr rigid calibration tube (Midsleeve ™ , Medical Innovation Developpement [MID], Dardilly, France) is inserted by the anesthesiologist and directed through the pylorus. The stomach is then transected with two key points. First, particular attention must be paid to incisura angularis in order to avoid any stricture at this point. The left-hand stapling offers the ideal direction "to respect the incisura angularis." Second, in order to perform an efficient procedure, it is important to remove the whole fundus of the stomach. Other particularities of Dr. Noel's personal technique are as follows: • The right hand of the surgeon grasps and brings anteriorly the posterior aspect of the gastric fundus. • The stapler is placed by left hand close to the endoluminal tube and partially closed. • The stapler is then gently opened while the surgeon's right hand pulls the anterior stomach laterally. • When the anterior part is completely aligned with the posterior (previously pulled up), the stapler is finally closed and then fired. This maneuver is repeated for the last two 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. RESULTS A total of 1,800 LSGs were performed in La Casamance Private Hospital, Aubagne, France, between September 2005 and March 2014. Twenty cases (1.12%) of gastric fistula were recorded. Of these, 18 patients were women (90%) with a mean age of 39.4 years (range 22–61) and mean body mass index (BMI) of 41.2kg/m 2 (range 34.8–57.1kg/m 2 ). The yearly distribution and the frequency of leak after LSG are summarized in Table 1. In order to evaluate the role of surgeon's experience on leak occurrence rate, we divided the entire experience in two equal groups of patients as shown in Table 2. In Group A (the first 900 cases), there were 18 recorded cases of gastric leak and in Group B (the last 900 cases) two cases of gastric leak. In Group B, the last 600 cases were performed with reinforcement of the Figure 1. Complete posterior dissection of the gastric f undus Figure 2. Anterior eversion of the gastric fundus before the last two firings: A) The posterior wall of the stomach is gently grasped and pulled anteriorly. B) The stapler is placed against the endoluminal bougie and partially closed. C) After exposure of the anterior part, the stapler is ready to be fired.