Operative Note

Position: Supine.

Findings: Laparoscopic sleeve gastrectomy performed over a 40 F bougie with staple line reinforcements.

Description of Procedure: The patient was brought to the operating room and was placed in supine position.  After the induction of general anesthesia, a Foley catheter was inserted and the abdomen was prepped and draped in the usual sterile fashion.

A left subcostal 5 mm incision was made.  A Veress needle was inserted.  The abdomen was insufflated with carbon dioxide to a pressure of 15 mmHg.  A 5 mm trocar was inserted, followed by a 5 mm laparoscope.  Additional ports were placed under laparoscopic visualization:  12 mm in the left paramedian area above the umbilicus, 5 mm rlght subcostal in the midclavicular line, 15 mm right upper quadrant paramedian, and 5 mm right subcostal midaxillary ports. The 5 mm laparoscope was replaced with a 45 degree, 10 mm laparoscope.  The left lobe of the liver was retracted anteriorly with a 5 mm liver retractor inserted in the lateral right upper quadrant 5 mm port.  A 10 mm 45 degree laparoscope was used.

The gastrocolic ligament was divided close to the greater curvature with an Enseal device starting at the antrum about 5 cm proximal to the pylorus.  We proceeded along the greater curvature to the angle of His.  There was no hiatal hernia.   The orogastric tube was removed.  A 40 F bougie was passed into the stomach and directed toward the pylorus.  A 45 mm black GIA stapler cartridge loaded with Seamguard was placed approximately 5 cm proximal to the pylorus and fired parallel to the lesser curvature.   The sleeve was created using one additional 60 mm black GIA stapler cartridge loaded with Seamguard followed by three 60 mm purple GIA stapler cartridges loaded with Seamguard.  The bougie was removed.  The sleeve gastrectomy specimen was extracted from the 15 mm trocar site.   

The 12 and 15 mm trocar sites were closed with 0 Polysorb suture using a Carter Thompson device.  The trocars were removed under laparoscopic visualization.  There were no injuries identified from trocar insertion.  The abdomen was deflated and the skin was closed with 4-0 subcuticular Polysorb sutures.