Mestrado em Biotecnologia, Universidade Positivo, Rua Angelo Bom 315, casa 1, Curitiba, Paraná, 81210340, Brazil.
Université Montpellier 1, Montpellier, France.
Surg Endosc. 2017 Oct;31(10):4256-4257. doi: 10.1007/s00464-017-5419-y. Epub 2017 Feb 24.
Laparoscopic sleeve gastrectomy (LSG) is the most common bariatric surgery performed worldwide. Improvements in LSG have been suggested to achieve better weight loss or to lessen the complications rates. We propose a change in the standard technique to privilege the use of thinner instruments, the needlescopic sleeve gastrectomy (NSG).
A 40-year-old female, BMI 40, with no previous abdominal surgery was selected for a NSG. She was placed in a semi-sitting position with the surgeon standing between the legs. Pneumoperitoneum was created through open laparoscopy; 5 trocars were inserted in standard position for laparoscopic gastric surgery. We have used one 12 mm trocar in the navel for a 5 mm scope and for stapling the stomach; one 5 mm trocar for impedance coagulator and also for the scope during the stapling process, and three 3 mm trocars for liver retraction, left hand manipulation, and greater curve exposition. Surgical techniques are basically the same as for a standard LSG until the moment of stapling the stomach, when the 5 mm scope is changed to the right hand trocar. Stapling can be done trough the umbilical port, parallel to the lesser curvature, in contact with the calibration tube. After stapling, hemostasis was achieved by bipolar coagulation, application of titanium clips, and absorbable suture. The 12 mm umbilical orifice is closed after extraction of the resected stomach.
Operative time was 76 min. There was no per-operative complication. Recovery was uneventful and patient was discharged at post operative day 2. Pain was considered minor by the patient. One month after surgery, cosmetic results were very convincing.
There are several proposed technical modifications in LSG. They can influence complication rates or weight loss like the length of antrum resection, the size of Fouchet tube, or the reinforcement of staple line [1-4]. Besides that other concepts regarding reduction of size or number of trocars have also been applied. LSG has been performed with fewer trocars, using for example special designed internal retractors or even the posterior part of the dissected stomach to replace the liver retractor and its trocar [5, 6]. Single port is another well-known possibility [7, 8], but mini-laparoscopy or needlescopic SG is still not well explored in our opinion. We believe that this technical alternative proposed in this video keeps the standards of care and safety of conventional LSG. There is no change in the position of the surgeon, not even the trocars. Specially designed needlescopic instruments show enough strength to be used in bariatrics and allow the surgeon to perform all the routine maneuvers from dissection to suturing. LSG can be done by mini-laparoscopy with a short adaptation period, previewing a short learning curve with no increase in the complications rate.
NSG is feasible in selected patients and with few modifications in the standard technique. There might be a benefit in terms of pain. Further studies with large series are necessary to observe these potential benefits.
腹腔镜袖状胃切除术（LSG）是全球最常见的减重手术。有人提出改进 LSG 以实现更好的减重效果或降低并发症发生率。我们建议改变标准技术，优先使用更细的器械，即针式袖状胃切除术（NSG）。
选择一位 40 岁、BMI 为 40、无既往腹部手术史的女性进行 NSG。她被置于半坐卧位，医生站在两腿之间。通过开放式腹腔镜创建气腹；在标准位置插入 5 个 trocar 进行腹腔镜胃手术。我们在肚脐处使用一个 12mm 的 trocar 插入 5mm 的内窥镜和进行胃钉合；一个 5mm 的 trocar 用于阻抗凝固器，也用于钉合过程中的内窥镜，以及三个 3mm 的 trocar 用于肝脏牵引、左手操作和大曲率暴露。手术技术基本与标准 LSG 相同，直到胃钉合时，才将 5mm 的内窥镜更换到右手 trocar。可以通过脐部端口，沿小弯侧平行于校准管进行钉合。钉合后，通过双极电凝、钛夹和可吸收缝线进行止血。切除胃后，关闭 12mm 的脐部切口。
手术时间为 76 分钟。无术中并发症。恢复顺利，患者术后第 2 天出院。患者认为疼痛轻微。术后 1 个月，美容效果非常令人信服。
LSG 有几种提出的技术改进。它们可以影响并发症发生率或减重效果，如胃窦切除长度、Fouchet 管大小或钉合线加固[1-4]。此外，还有其他关于减少 trocar 数量或大小的概念。LSG 已经使用更少的 trocar 完成，例如使用特殊设计的内置牵开器，甚至使用分离的胃后壁代替肝脏牵开器及其 trocar[5,6]。单端口也是另一种众所周知的可能性[7,8]，但我们认为，在我们看来，这种在视频中提出的技术替代方案保持了常规 LSG 的护理标准和安全性。医生的位置没有改变，甚至 trocar 也没有改变。专门设计的针式器械具有足够的强度，可用于减重手术，并允许医生进行从解剖到缝合的所有常规操作。LSG 可以通过迷你腹腔镜进行，只需很短的适应期，预计并发症发生率不会增加，学习曲线也会很短。
NSG 适用于选定的患者，并对标准技术进行了一些修改。在疼痛方面可能会有一些好处。需要进一步的大系列研究来观察这些潜在的好处。
