Laparoscopic Sleeve Gastrectomy After Orthotopic Liver Transplantation, Video Reported.

INTRODUCTION: The immunosuppressive therapy for life after liver transplantation (LT) is considered as a risk factor for obesity. Seven percent of the transplanted patients develop severe or morbid obesity. The obesity induces non-alcoholic steatohepatitis (NASH), which is a major risk factor for liver cirrhosis and hepatocellular carcinoma, without forgetting the cardiovascular risk and the devastating impact of obesity on quality of life of the transplanted patients. Consequently, obesity exposes these patients to future transplant loss. Bariatric surgery has been proposed for transplant patients to reduce the obesity-related comorbidities and to improve survival. We report in this video the surgical technique of laparoscopic sleeve gastrectomy (LSG) after LT. METHODS: We have performed between 2008 and 2017 the sleeve gastrectomy (SG) after LT in nine patients. Six procedures (66%) were performed totally by laparoscopy and three by upfront laparotomy. All the patients had a standard preoperative evaluation for obesity. All the procedures were assisted by a hepatic surgeon. Postoperatively patients were transferred to the liver ICU for 24 h then to the liver unit ward. RESULT: The median BMI was 41.9 kg/m2 (range 38-46.1 kg/m2). Median operative time was 120 min (range, 90-240 min). No intra-operative complications occurred. The median length of hospital stay was 7 days (range, 4-81 days). The postoperative course of the majority of the patients was uneventful except for one patient who develops a staple line leak. CONCLUSION: LSG after LT is technically feasible. Larger series are needed to improve the safety of the procedure in this high-risk population.

Total Gastrectomy with Roux-En-Y esophagojejunostomy for Chronic Complicated Post-Sleeve Gastric Fistula-Video Report.

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) has become one of the most popular bariatric surgeries worldwide. However, complications related to the stapler line can be very serious. Among several challenging post-LSG complications, fistula is the most feared. Its management can be very challenging and chronic. In case of chronic fistula and failure of surgical, endoscopic, and radiological treatment, total gastrectomy with esojejunal anastomosis (RYOJ) can be considered as an effective solution. We describe in this video the steps of our laparoscopic technique. METHODS: We have performed a total gastrectomy with RYOJ in a particular patient with chronic and persisting gastric fistula 9 months after LSG. The body mass index (BMI) was initially 50 kg/m2 at the time of the LSG against 31 kg/m2 on the day of the RYOJ. RESULTS: The postoperative course was uneventful. An upper GI series was done at 1 week and 1 month postoperatively without any abnormality. The patient was evaluated clinically and biologically at 1, 3, and 6 months later on with no evidence of dysphasia or biological abnormality. CONCLUSION: RYOJ in our particular case was efficient. However, longer series and longer follow-up are needed to confirm the effectiveness of this rescue procedure.

Single-incision robotic cholecystectomy is associated with a high rate of trocar-site infection.

BACKGROUND: Single-incision robotic cholecystectomy has been developed to decrease post-operative pain and improve cosmetic results. METHODS: Thirty-seven patients underwent single-site robotic cholecystectomy between 2014 and 2015. Postoperative outcomes and costs were compared to reported outcomes for laparoscopic cholecystectomy using the configuration of suprapubic trocars. RESULTS: The median age was comparable between the two groups (46 years in the robotic group vs. 47 years in the laparoscopic group). The operative time was longer in the robotic group (132 minutes) than in the laparoscopic group (53 minutes). The average length of stay was 1 day in the robotic group and 1.7 days in the laparoscopic group. Costs were higher in the robotic group (2229.46 €) than in the laparoscopic group (1141 €). In the robotic group, the trocar-site infection rate was 13.5%. CONCLUSION: The robotic approach does not seem to offer additional benefit in terms of surgical outcomes.

"Hand-Over-Hand Grasping Technique": A Fast and Safe Procedure for Specimen Extraction in Laparoscopic Sleeve Gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has become one of the most popular bariatric surgeries worldwide, given good result concerning weight loss and long-term morbidity. While surgical technique is well standardized, specimen extraction is still a matter of controversy between surgeons. In this video, we present a simple, fast, safe, and reproducible technique of specimen extraction after laparoscopic sleeve gastrectomy. METHODS: After the sleeve gastrectomy is completed with hemostasis, the specimen is introduced in a retrieval bag. Stomach specimen orientation is very important, such as the largest specimen part is removed firstly. The 2 cm of the held fundus is introduced under direct vision in the 12-mm trocar. Traction is applied to simultaneously remove the trocar, the cord of the bag, and the grasper. The stomach is held by a Kocher once it is outside the peritoneal cavity. The bag is opened and everted to protect the wound. The pneumoperitoneum is deflated to relax the abdominal wall. The specimen is removed from the abdominal cavity by traction hand-over-hand grasping with gauze. RESULTS: We have applied this technique in 200 consecutive patients with an average body mass index of 42.5. At the first postoperative visit (1 month), none of the patients experienced wound infection. Clinical incisional hernia was detected in one patient (0.5%). CONCLUSIONS: This hand-over-hand grasping with gauze technique is simple, safe, reproducible, and time saving.

Prebiliary right hepatic artery resulting in common hepatic duct compression and subsequent intrahepatic stone formation: myth or reality?

The vascular anatomy of the liver is subjected to many variations. Aberrant hepatic artery is not an uncommon finding during visceral surgery; however, topographic variations are less reported in the literature. Prebiliary artery crossing anteriorly to the common hepatic duct was firstly reported in 1984. We present here a case of a 52-year-old lady who presented with obstructive jaundice and right upper quadrant pain. Paraclinical investigations were consistent with intrahepatic stones and a benign stricture on the CBD. During surgery, a prebiliary right hepatic artery compressing the CHD was noted. The liver pedicle was dissected and a hepaticojejunostomy was performed that resulted in a good outcome after 24 months of followup.