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Laparoscopic Sleeve Gastrectomy with Duodenoileal Interposition (Lap SG-DII)

Procedure –

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. First part of the duodenum is disconnected, 4 cm distal to the stomach, using linear cutter stapler. 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. This ileal segment is joined above to the proximal divided end of the duodenum and below to the jejunum 50 cm distal to the duodenojejunal flexure (from the junction of the duodenum and jejunum). 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 directly enters ileal segment. Food is diverted from the duodenum (excluding the first 4 cm), so production of anti incretins is reduced. 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 in more than 95 percent of type 2 diabetic patients. Laparoscopic Sleeve Gastrectomy with Duodenoileal Interposition – Lap SG-DII

(Laparoscopic Diverted Sleeve Gastrectomy with Ileal Interposition – Lap DSG-II)    (Drawn by Dr. V. Amar)


Complications –

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. There is a slight risk of vitamin and mineral deficiencies, as food doesn’t enter most of the duodenum and proximal jejunum. So we prescribe lifelong vitamin and mineral replacement for these patients. Calcium and iron deficiencies generally do not occur, as first 4 cm of the duodenum is not bypassed. 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.