Page 5 - Journal of World Association of Laparoscopic Surgeons

Specimen Extraction after Sleeve Gastrectomy

dIscussIon trocar increases the risk of postoperative pain, patient comfort, and
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Nowadays, sleeve gastrectomy is used with increasing frequency in hernia risk in the trocar site. However, for the use of staplers in the
sleeve gastrectomy, the minimum trocar diameter is 12 mm, and
the surgical treatment of morbid obesity owing to some advantages there is only one study in the literature on removal of the specimen
such as preservation of normal anatomy and absorption capacity of from a 12-mm trocar site by preserving the tissue integrity. In this
small intestines, technically easy applicability and short operation study by Nassif et al., the fascia was extended with a Kocher
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time. In this procedure, where successful results are obtained in clamp and the specimen was removed with the organ pouch. In
the resolution of weight loss and comorbid conditions, 80–90% our study, this technique has been modified. Without expanding
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of the stomach in vertical axis is resected. Removal of the the fascia and the usage of organ pouches, the specimen was
specimen outside the abdomen after this wide resection can be a extracted. Trocar-related complications such as wound site
complicated, and prolonged duration of operation. infection or trocar site hernia were not observed. According to the
In laparoscopic surgery, there are questions looked for to extraction time of the specimen, it was observed that the specimen
be answered such as from which area the specimen should be was extracted in a time similar to those of the other studies. In
removed, from how much width the specimen should be removed, three cases, it was observed that the specimen was ruptured from
how to reduce complications related to the area the specimen fundus, owing to insufficient decompression of the stomach and
removed from, and whether the integrity of the specimen should the rotation of the specimen on the reverse axis during extraction.
be preserved in benign procedures. The answer to these questions Therefore, caution should be exercised to ensure that the stomach
was not standardized also in the sleeve gastrectomy procedure. is sufficiently decompressed and not to cause any reverse rotation
The method frequently applied in laparoscopic procedures is during traction.
the extraction of the specimen by a mini laparotomy. In a study in
which the specimen was removed by a mini-laparotomy after a
sleeve gastrectomy, 5% wound site infection, 3.3% hernia, and 8.3% conclusIon
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hematoma in the site of extraction were detected. These results According to the results of our study, the specimen can be safely
show that the specimen removal by mini-laparotomy reduce the extracted from the 12-mm trocar site after the sleeve gastrectomy,
advantages of the laparoscopic surgery. without the use of additional tools and without expansion of fascia
Different techniques have been described, in which the and without prolonging the operation time.
specimen is removed after it was disintegrated. In one of these
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techniques, described by Mahmood et al., the specimen was
disintegrated by a tissue disintegrator and removed from a ethIcAl coMMIttee ApprovAl
15-mm trocar. Another technique is the technique by which Ethical committee approval was obtained from University of
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Calin et al. extract the specimen from the 12 mm trocar site, by Kocaeli (GOKAEK-2017/14.37 2017/300).
cutting and making the specimen thinner in the longitudinal axis
intraabdominally. The main disadvantage of both techniques is references
the inability of histopathological examination of the specimen 1. Lee L, Abou-Khalil M, et al. Incidence of incisional hernia
due to tissue disintegrity, and the risk of intraabdominal spread of in the specimen extraction site for laparoscopic colorectal
gastric content. As a matter of fact, it was shown in several studies surgery: systematic review and meta-analysis. Surg Endosc 2017
that in the sleeve gastrectomy specimen, there was a clinically Dec;31(12):5083–5093. DOI: 10.1007/s00464-017-5573-2.
significant histopathological finding at a rate of 3.3–5.8%, and the 2. Leung AL, Cheung HY, et al. Advances in laparoscopic colorectal
9,10
histopathological examination of the specimen was necessary. surgery: a review on NOTES and transanal extraction of specimen.
In addition, it has been shown that intraabdominal spread of gastric Asian J Endosc Surg 2014 Jan;7(1):11–16. DOI: 10.1111/ases.12070.
content may cause a localized inflammatory response, adhesion, 3. Gagner M, Hutchinson C, et al. Fifth International Consensus
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and intraabdominal abscess. Conference: current status of sleeve gastrectomy. Surg Obes Relat
Dis 2016 May;12(4):750–756. DOI: 10.1016/j.soard.2016.01.022.
The most commonly used technique for removal of specimen 4. Gastrointestinal surgery for severe obesity: National Institutes
in sleeve gastrectomy is the removal of tissue from the trocar site of Health Consensus Development Conference Statement. Am J
by preserving tissue integrity. One of the controversial points Clin Nutr 1992 Feb;55(2 Suppl):615S–619S. DOI: 10.1093/ajcn/55.
in this technique is whether the wound site is protected with 2.615s.
different auxiliary devices (wound site retractor, organ pouch) 5. Cottam D, Qureshi FG, et al. Laparoscopic sleeve gastrectomy as
when removing the specimen. Studies have reported that the an initial weight-loss procedure for high-risk patients with morbid
use of organ pouches or wound site retractors does not reduce obesity. Surg Endosc 2006;20(6):859–863. DOI: 10.1007/s00464-005-
0134-5.
infectious complications, prolonged operation time, and increased 6. Maietta P, Qureshi FG, et al. Retrieval of the gastric specimen following
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operation costs. In our technique, any auxiliary equipment was laparoscopic sleeve gastrectomy. Experience on 275 cases. Int J Surg
not used to protect the wound site and no wound site infection 2016;28(Suppl 1):S124–S127. DOI: 10.1016/j.ijsu.2015.12.057.
was seen in our series. 7. Mahmood A, Silbergleit A. The utilization of a morcellator during
In order to reduce trocar-related complications after the sleeve laparoscopic sleeve gastrectomy. Technol Health Care 2006;14(6):
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with which the specimen was extracted transgastrically has been 8. Calin ML. Specimen extraction after laparoscopic sleeve gastrectomy.
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described. However, this technique requires laparoscopic and J Laparoendosc Adv Surg Tech A 2015 Apr;25(4):330. DOI: 10.1089/
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endoscopic experience, and the risk of intraabdominal spread of 9. Safaan T, Bashah M, et al. Histopathological Changes in Laparoscopic
stomach contents is the most important disadvantage. Sleeve Gastrectomy Specimens: Prevalence, Risk Factors, and Value
In a minimally invasive surgery, the overall goal is to use a of Routine Histopathologic Examination. Obes Surg 2017 Jul;27(7):
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World Journal of Laparoscopic Surgery, Volume 12 Issue 1 (January–April 2019) 3