Laparoscopic Procedures for Morbid Obesity

Creating a safe pneumo-peritoneum in a morbidly obese patient is simple. The same safety rules apply. A Standard or Long (120cm) is used to create the pneumo-peritoneum. We favor the sub-umbilical position.

The trocars are inserted as shown. The intra-abdominal cavity is explored.

The surgeon will check the omentum is free of adhesions ( pelvis).  The omentum is then retracted toward the upper portion of the intra-abdominal cavity as the operating table is tilted in Trendelenbourg Position (Head down).

A  Mediflex® 5 mm Retractor is inserted and locked in place (using the MEDFLEX® Retractor or the ENDORETRACT®) retracting the omentum cephalad while simultaneously exposing the ligament of Trietz.

 

The Gastro-esophageal junction should be exposed as described in the laparoscopic antireflux procedures. The inferior aspect of the liver is retracted upward with an ENDORETRACT* instrument. The Gastro-esophageal junction is identified. The anterior aspect of the gastric fundus is pulled inferiorly using an ENDO BABCOCK* instrument. The medial aspect of the lesser curvature is then bluntly dissected using an ULTRASHEARS* instrument.

An ENDO RETRACT* Maxi instrument is used to create a GE Window. Although in some cases, this technical step can be omitted, we have found it very useful in mobilizing the entire upper portion of the gastric fundus.

An ENDO GRASPER* instrument is used to stabilize the stomach. A Bougie Size #38 French is inserted into the stomach (Oral insertion). Using the ENDO BABCOCK* instrument, the bougie is pushed against the lesser curvature.

One of the lateral VERSAPORT* trocar or the most cephalad trocar is removed and plugged with a finger. The insertion site is enlarged/dilated (successively using  empty syringes up to 20 cc)  to fit a CEEA* 25 or 28 Stapler. The anvil is removed and inserted into the abdomen via the most lateral trocar site manually. A CEEA* Stapler is inserted without the Anvil (the white trocar in retracted position) via the lateral trocar site. The white trocar is then advanced in full extended position. It is poked ( 5 cm below the GE junction) through both anterior and posterior gastric walls as close as possible to the bougie. The white trocar is removed. The anvil is grasped with an ENDO GRASPER* instrument and attached to the CEEA* Stapler. The CEEA* Stapler is closed, fired, reopened and withdrawn from the intra-abdominal cavity

The integrity of the CEEA* doughnuts is checked.

The VERSAPORT* trocar is reinserted in its original position. The insertion site is approximated closed with a suture or with a "Towel clip". An ENDOTA II  (with 60 mm cartridge) is inserted and opened. The upper jaw of the instrument is inserted into the gastric "bullet hole" and directed toward the GE junction, parallel to the bougie. It is fired and withdrawn (this stapling device staples but does not transect).

The gastric pouch ( 15 to 25 cc) has been formed.

 

A 5 x 1 inch SURGIPRO* Mesh is created, it is inserted into the intra-abdominal cavity via a trocar using a grasper. The SURGIPRO* Mesh is now passed through the bullet hole and both ends (at the tips) are grasped with an ENDO GRASPER* (in locked position). The ENDOGIA II (with a 30 cm cartridge) is inserted. The grasper will position the two ends of the mesh flat between the jaws of the grasper. At this point, the operator will assess if he is indeed creating a collar or band of 5 cm in diameter. If feasible, a portion of the omentum is brought between the jaws of the stapler to be stapled at the same time. The ENDOGIA II  is fired, stapling the two ends of the mesh together. The ENDOGIA II   is withdrawn and the collar is covered with omentum.

The procedure is completed.