(Laparoscopic Sleeve Gastrectomy with Ileal Interposition)
Abdominal cavity is entered through small holes, using 5 to 7 ports. Up to 80 percent of left side of the stomach is removed using linear cutter staplers. If patient is obese, stomach tube, of approximately 60 ml, is fashioned (Sleeve Gastrectomy), over a bougie kept in the stomach. If the patient is not obese, then stomach tube of higher volume is created, so that patient can eat normally. 170 cm segment of the ileum is isolated by dividing the ileum 30 cm & 200 cm proximal to the ileocecal junction (junction of the small and large bowels). Bowel continuity is restored by joining the remaining ends of the ileum. We divide jejunum 50 cm distal to duodenojejunal flexure (from the junction of duodenum and jejunum) using linear cutter stapler. Isolated ileal segment is interposed by joining its proximal and distal ends to the corresponding jejunal ends at the site of jejunal division. All the mesenteric gaps are closed. In this operation ghrelin hormone production is reduced as fundus of the stomach is removed. Sleeve gastrectomy also results in rapid emptying of the stomach. GLP 1 hormone production is increased as food rapidly enters the interposed ileal segment. In obese diabetics because of narrow stomach tube food intake is restricted, which leads to weight loss. All these factors contribute to the resolution of diabetes. All these factors lead to resolution of type 2 diabetes. Unlike in Laparoscopic Sleeve Gastrectomy with Duodenoileal Interposition, anti incretins production is not reduced in this operation as food is not diverted from duodenum. So the results of this operation are slightly inferior. Laparoscopic Sleeve Gastrectomy with Jejunoileal Interposition – Lap SG-JII
(Laparoscopic Sleeve Gastrectomy with Ileal Interposition – Lap SG-II) (Drawn by Dr. V. Amar)
This is a very safe operation when performed on suitable candidate after obtaining fitness. Complications are rare. Described complications are bleeding, leak from staple lines (generally sleeve gastrectomy edge), vomitings due to narrowing of stomach, intestinal obstruction (block to the flow of intestinal contents), wound infections, hernias at port sites, lung infections, clots in the legs etc. As there is no diversion of food, vitamin and mineral deficiencies are very rare. We use full HD technology and advanced vessel sealing systems (Harmonic, Gyrus) to prevent bleeding. We apply additional sutures over the staple line and also check for leak at the end of operation, by filling the stomach with methylene blue solution. We fashion gastric tube over a bougie passed into the stomach before gastric division, so narrowing of the stomach is rare. To prevent internal herniation and intestinal obstruction we close all the gaps in the mesenteric layers. To prevent clots in legs we use prophylactic low molecular weight heparin and pneumatic compression stockings. We use prophylactic broad spectrum antibiotics to prevent wound infections. We close fascial defects at ports larger than 1 cm to prevent port site hernias. In this way we avoid several complications.