A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional
Issue link: https://bariatrictimes.epubxp.com/i/69664
CHECKLIST IN LAPAROSCOPIC SLEEVE GASTRECTOMY Part 1: SURGICAL TECHNIQUE continued LAST FIRING AND WHERE TO END THE TRANSECTION Stay away from GE junction on last firing EXPERT COMMENTARY Ninh T. Nguyen, MD University of California Irvine Medical Center, Irvine, California I n my experience, the last firing during construction of the sleeve gastrectomy should be oriented vertically toward the angle of His, slightly staying away from the bougie to avoid stapling onto the GE junction (as recommended by the SG panel of experts). This staple line of the last firing (i.e., the most proximal aspect of the sleeve or the proximal one- third of stomach) is particularly prone to developing leaks. The consensus panel experts agreed that the use of staple line reinforcement (buttress or over sewing) will reduce staple-line bleeding. In my opinion, bleeding may weaken the integrity of the staple line leading to dehiscence. Traction on the fundus and transection of the stomach against the bougie, lateral to the fat pad at the GE junction. Confidence Through Compression. Performance Demonstrated in Thick Tissue* *Superior is defined as fewest malformed staples. Thick tissue defined as 3mm to 5mm as measured with an 8g/mm2 thickness measuring device. Study conducted by Ethicon Endo-Surgery in a porcine model. Data on file. ECHELON FLEX™ 60mm with Green Cartridge (88 staples per cartridge) vs. ENDO GIA® Universal with 60mm Green Roticulator™ (90 staples per cartridge) (not compared with EGIA60AMT/EGIA60AXT). Please read and follow the Instructions for Use for important information, including indications, contraindications and complete steps for use. STAPLE LINE REINFORCEMENT Use staple line reinforcement to reduce bleeding along staple line EXPERT COMMENTARY Gregg H. Jossart, MD, FACS California Pacific Medical Center, San Francisco, California T B4 he current generation of staplers have a reinforced anvil and higher compressive forces than prior generations. In my opinion, surgeons should select the correct size staple cartridge and should not add thick buttress material without considering how much the staple line will be compromised. I believe that early leaks and segmental staple line disruptions will occur from these types of errors. On sleeve gastrectomies made with Bougie size 32–40F and antrectomies, made within 2–3 cm of pylorus, no smaller than green cartridges should be used. I recommend avoiding buttress material on the antrum, as I have observed that 10 to 20 percent of staple lines will disrupt the seromuscular layers and additional sutures are required. I think that buttress materials along the mid-body (above incisura) are reasonable, but keep in mind that overlapping buttress material at the staple line junctions may occupy up to 40 percent of staple line height and could be a potential site for disruption. It is well known that the cardia is where the majority of leaks occur, even with buttress material. Therefore, I hypothesize that suture inversion of the cardia with 1 to 2 Lembert type sutures is probably the most effective way to manage this high-risk area. Bovine pericardium being used for staple line reinforcement [Bariatric Times JUNE 2012, SUPPLEMENT B]