Page 4 - World Journal of Laparoscopic Surgery

Shailesh Kumar et al
obviously negative implications on exercise and energy Preoperative Preparation
expenditure at the biological level. Apart from that All routine investigations including upper gastrointes-
medical care, food habits, educational status, and family tinal endoscopy, echocardiography, and psychological
income have dramatically improved, which, along with
easy access to city and television watching, result in assessment for conducting LSG were done on every
unwanted changes in lifestyle. These have eventually patient. All patients were instructed to start chest phys-
led to significant increase in BMI. iotherapy using incentive spirometry and liver shrinkage
Obesity is one of the major risk factors for diabetes, diet 1 week prior to surgery. Deep venous thrombosis
yet there has been little research focusing on this risk (DVT) prophylaxis with DVT pump during surgery and
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factor across India. Therapeutic interventions for the subcutaneous low-molecular-weight heparin were given
treatment of obesity range from lifestyle and diet modi- to all patients 12 hours before and continued for 7 to
12
fications to pharmacologic and surgical therapy. Studies 10 days after the surgery.
showed that the nonoperative interventions for sustained
weight loss usually fail to provide real benefits and are SURGICAL METHOD
usually insufficient and not sustainable. 13,14 Bariatric A procedure of LSG was performed using classical five
surgery is an evidence-based treatment of morbid obesity ports under general anesthesia. The patients were in
with proven, sustained weight loss and improvement in antitrendelenburg position with legs apart to facilitate
comorbidities. 15-17 the small intestine to remain out of field of surgery. The
The limited and nonsustainable success of behavioral, surgeon stood between the legs. Pneumoperitoneum was
lifestyle modification and drug therapies in morbidly achieved using a closed technique with a Veress needle,
obese patients has led to a increase interest in bariatric placed in supraumbilical area just left to the midline. The
6
surgery in Canada. A variety of surgical procedures xiphisternum was taken as the reference point. Three
are available, and currently it is difficult to identify the ports of size 12 mm were placed from the reference point
most effective option based on patient characteristics at 15 to 18 cm at right mid-clavicular line (left working
and comorbidities. Furthermore, little is known regard- port), 2 to 3 left to mid-line (optical port), and left mid-
ing the effect of the various surgical procedures on gly- clavicular line (right working port) respectively. The
cemic control and on Type 2 diabetes mellitus (T2DM) 4th port of 5 mm (assistant port) were inserted at left
remission. 18-21 anterior axillary line below the costal margin. The epi-
Laparoscopic sleeve gastrectomy (LSG), a single-stage gastric port of 5 mm was inserted to retract the left lobe
procedure, is a relatively new and effective surgical of liver. All surgeries were done by the same surgeon to
22
option for morbid obesity. Although LSG functions as minimize the biasness (Figs 1 to 3).
a restrictive procedure, it may also cause early satiety by
removing the ghrelin-producing portion of the stomach. 23 The stomach was decompressed by placing an oro-
gastric tube. The operating surgeon stood in between
MATERIALS AND METHODS the legs of the patient with the first and second assistant
standing to the patient’s right and left side respectively.
The prospective cohort study was conducted at the Omentolysis was started about 3 to 5 cm proximal to the
Dr. Ram Manohar Lohia Hospital and Post Graduate Insti-
tute of Medical Education and Research, New Delhi, India,
between January 2015 and March 2016. Patients included
were of either sex of age 18 to 60 years who had tried for
weight loss for at least 6 months by dietary restriction and
lifestyle modification, but failed to maintain sustained
2
weight loss. The criteria for selection were BMI ≥ 40 kg/m
2
or BMI ≥ 35 kg/m with comorbidity. All the patients
were screened by a multidisciplinary team consisted of a
surgeon, a nutritionist, a cardiologist, an endocrinologist,
a chest physician, and a psychologist. All the patients
were thoroughly evaluated and an informed consent in
detail was taken.
The percentage of excess weight loss (EWL) was
measured on each follow-up visit. The BMI up to 25 was
taken as the normal, and weight beyond that were taken
as the excess weight. Fig. 1: Port placement
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