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How I do it - Sleeve Gastrectomy Uncut BMI 50 _ Surgery at its Best
Sleeve gastrectomy is the most popular, elegant and simple bariatric surgery today. However, heartburn and weight regain are the most common problems. Operating on large patients is also not very easy. In my desire for perfection, to reduce problems and achieve best results, with my technique I pursue three main goals – 1. Dissection of the hiatus and posterior crural proximation as most of hiatal hernias in obese patients are difficult to diagnose; 2 Uniform and narrow gastrectomy on the entire length of the stomach – less than 5-6 x 60mm cartridges is inadequate in my hands, and 3. Most important, accurate re-attachment of the omentum to restore the “C-shape” outlook of the stomach preventing obstructive complications from kinking or torsion.
Full length video of re-do gastric sleeve after gastric band conversion to sleeve gastrectomy
The patient underwent gastric band surgery revised once seven years prior. The gastric band surgery was converted elsewhere to a sleeve gastrectomy in two consecutive operations eight years ago. The patient failed to lose any weight after the band or the sleeve but continued to complain of reflux; a moderate size hiatus hernia was demonstrated on radiological studies and endoscopy. The surgery is revised and the hiatus hernia is repaired in this video, with view to a second stage gastric by-pass. The patient recovered well, with minimal discomfort and was discharged day one after surgery.
Previous sleeve gastrectomy with poor weight loss results and worsening GERD. The residual antrum is large and although an attempt was made to repair the hiatus hernia by anterior crural proximation alone, there is a still a large hiatus hernia and the unresected gastric fundus is in the posterior mediastinum.
Surgery at its best – revision sleeve to sleeve in a young lady with a 500ml gastric sleeve and a large hiatus hernia (uncut video at double speed; video starts with the 3D CT reconstruction image of the existing sleeve).
Finally, after nearly three months of Covid-related restrictions I got to do today what I do best – revisional surgery; after evaluating the patient, I decided that I could give the sleeve another chance if I can reduce the volume under 200ml and repair the hiatus hernia.
Conversion from sleeve gastrectomy to Roux-Y-Gastric Bypass
Gastric Leak treatment with oeso-gastric stent in my practice
The video below (with patient permission) shows a patient day one after stenting when she presented with a leak at the COJ and a subphrenic collections on day seven after re-do sleeve gastrectomy. The collection was drained percutaneously and the patient was discharged on day seven without need of surgery or intensive care. She tolerated the stent well at home and, three weeks later was readmitted overnight for stent removal.
Several of my patients had leaks managed with stents following revisional surgery, primary gastric sleeve or band erosion with closure of the leak in 2-4 weeks and no added morbidity from the stent. The patients were managed exclusively by myself.
The picture on the left shows the placement of the stent, rapid normalisation of the vitals and the subphrenic collections drained two days later percutaneously.