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249]  ||  Click here to download free Android application for this journal

Original article  125

Technical tips associated with reduction in leak rate after

laparoscopic sleeve gastrectomy: lessons to learn from a
nested case–control study
Mohamed Bekheita,b,c, Khaled Katrid, Wael Abdel-Salamd, Tamer Nabil
Abdelbakia, Bruno Sgromoe, Jean-Marc Cathelinef, Galal Abou ElNagahd,
El Said El Kayald
a
Department of Surgery, Alexandria main Background
University Hospital, Faculty of Medicine,
Laparoscopic sleeve gastrectomy (LSG) is one of the common bariatric procedures for the
University of Alexandria, bMinimal Invasive
Surgery Unit, Department of Surgery, treatment of morbid obesity. One of the most drastic complications of this procedure is leak.
El Kabbary General Hospital, El Kabbary, Objective
Alexandria, Egypt, cCentre Hepatobiliare, The aim of the study was to discuss the possible technical factors that might contribute to the
Paul Brousse Hospital, Villejuif, France, occurrence of postoperative leak and how to avoid it through analyzing our series.
d
Associate Professor of Surgery, Department
of Surgery, Alexandria main University Hospital,
Materials and methods
Faculty of Medicine, University of Alexandria, Analysis of the influence of technical adaptations on the outcome of LSG was performed in a
Egypt, eConsultant Upper GI and Bariatric nested case–control group of patients. The main modification adapted was performing invaginating
Surgeon, Oxford University Hospitals, sutures over the staple line. The primary outcome was the occurrence of leak. The secondary
Oxford, United Kingdom, fAssociate Professor
outcomes were bleeding, operative time, prolonged hospital stay, back pain, and mortality.
of Surgery, Chief of Gastrointestinal Surgery
Unit, Department of Surgery, Delafontaine Results
Hospital, Paris, France The group who had invaginating sutures (group 2) had a significantly lower frequency of leak
(0%) than those without invaginating sutures (7.3%; group 1) (PF = 0.016). There was no
Correspondence to Mohamed Bekheit, MSc,
MRCS, MRCPS, Minimal Invasive Surgery Unit, significant difference in the occurrence of postoperative bleeding or mortality between the
Department of Surgery, El Kabbary General groups (PF = 0.162 and 0.250, respectively). The frequencies of a hospital stay longer than
Hospital, El Kabbary, Alexandria 31241, Egypt 48 h and back pain were significantly higher in group 1 (PF = 0.004, PF < 0.001, respectively).
Tel: +2(0)3-5570891 There were no significant differences between groups in the preoperative BMI (Student’s
e-mail: [email protected]
t = −0.763, P = 0.45) or the age (Student’s t = −0.5, P = 0.61). The operative time was longer
Received 24 December 2013 in group 1 (Student’s t = 3.56, P < 0.001). There was also a significantly lower intraoperative
Accepted 11 February 2014 blood loss in group 2 (Student’s t = 1.99, P = 0.048).
The Egyptian Journal of Surgery Conclusion
2014, 33:125–130 From our experience, leak after LSG could be minimized by invaginating sutures of the staple
line and by adapting the ergonomic trocar positioning described herein.

Keywords:
bariatric surgery, obesity, sleeve gastrectomy, staple line enforcement, suturing

Egyptian J Surgery 33:125–130

© 2014 The Egyptian Journal of Surgery
1110-1121

Despite the efforts to minimize leaks after LSG

Introduction
[10], they still occur [11]. The reported leak rate
Obesity is a well-known health risk [1] that is
in the literature is up to 3% [10] and is associated
associated with several comorbidities [2]. Bariatric
surgery has proven to provide a sustainable with significant morbidity and mortality  [12].
weight loss with improvement in the related The learning curve of the procedure could be an
comorbidities [3,4]. One of the more recently important factor determining the outcome [13].
introduced interventions is laparoscopic sleeve Mentorship programs could effectively reduce the
gastrectomy (LSG), which is proved to induce a complications during the learning curve of LSG
significant excess weight reduction [5]. Despite the [14]. Mentorship programs, despite available, might
successful outcomes reported, LSG, as any other not be achievable for every surgeon who wishes to
bariatric surgery, is not without complications treat his patients with LSG. The alternative solution
[6]. Leak is considered one of the most drastic is to have a clear description of the technique that
complications after LSG  [7]. Several strategies to explains the subtle differences and their influence on
prevent leak were utilized in many clinical studies. the course of the procedure.
Staple line enforcement is one of the most tried
protective methods against the leak [8]. Buttressing, The objective of this study was to describe the technical
oversewing, and roofing with fibrin glue of the staple factors that might reduce the leak during the learning
line were used to address the prevention of leak [9]. curve of LSG.
1110-1121 © 2014 The Egyptian Journal of Surgery DOI: 10.4103/1110-1121.131682
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126  The Egyptian Journal of Surgery

through a 12-mm trocar, inserted a hand breadth

Materials and methods
(13–14 cm) beneath the xiphoid process and minimally
We started LSG in 2009. Because of the high
deviated to the left of the midline. A second 12-mm
initial leak rate in our series, we considered some
optical trocar is inserted two fingers breadth beneath
technical modifications to minimize the leak rate.
the costal margin just at the left midclavicular line.
We retrospectively reviewed the clinical data of the
Three 5-mm trocars are inserted: One subxiphoid for
whole cohort of patients who underwent LSG in our
prospectively maintained bariatric registry. The leak liver retraction and manipulation of the gastric fundus
rate was the primary outcome of evaluation in both when needed, another one at the left midaxillary
the initial (the control group; group 1) and the current line for the assistant, and the third one in the right
series (the intervention group; group 2). The secondary pararectal line, two fingers breadth below the costal
outcomes compared were the occurrence of bleeding, margin (Fig. 1). The last one may transfix the falciform
the operative time, the frequencies of prolonged ligament if found broad and long.
hospital stay and back pain, and the mortality rate.
Dissection was pursued using ultrasonic dissector
Informed consent was taken from all patients included
(Harmonic Ace; Ethicon Endo-Surgery, USA)
in this study. The ethical committee of human research
through accessing the lesser sac, then the whole greater
(IRB), Faculty of Medicine, Alexandria University,
curvature of the stomach is dissected. Afterwards,
Alexandria, Egypt, approval was obtained before
complete liberation of the posterior gastric attachments
adapting the LSG.
except for the unique left gastric vessel bundle is
performed. All the remaining fat, peritoneal bands,
Statistical analysis and posterior fundic vessels are freed from their gastric
The independent t-test was used to estimate the attachment (Fig. 2a and b). Complete exposure of the
significance of difference of the quantitative data of left crus is gained and mobilization of the angle of His
both groups and the c2-test was used for the qualitative is completed through dissection of the phrenogastric
data using portable SPSS V20. The significance level membrane from the left side until the gastroesophageal
was set for a P value less than 0.05. junction is mobilized (Fig. 3).

The resection is started 2–3 cm from the pylorus

through the paramedian trocar with gold loads (closed
The surgical technique (group 2) staples height is 1.8 mm) mounted on a 60-mm stapler
Patients were positioned in a steep anti-Trendelenburg (Echelon Endopath; Ethicon Endo-Surgery) and is
position with the pneumoperitoneum established performed with a 38-Fr calibrating tube inside the
pouch. The resection is continued until the angle of
Figure 1 His through the same port. During resection, traction

Figure 2

(a) 12 mm port site (paramedian trocar) is inserted at 13–15 cm

(green interrupted line) from the xiphoid process and is used initially b
for scope until the dissection is complete then used for stapling. (b)
12 mm port site is used initially for right working hand of the surgeon (a) Posterior attachment of the gastric fundus before dissection. The
then for the scope. (c) 5 mm port site for the left working hand. (d) 5 blue line shows the division line for the posterior fundic attachments.
mm port site for liver retraction and assisting in fundus manipulation (b) Dissection of the posterior fundic vessel cuff if encountered. C,
for dissection. (e) 5 mm port site for assistant and is the site for drain crus; GF, gastric fundus; LGV, left gastric vessels; P, pancreas; PFV,
left after completion of intervention. posterior fundic vessel; S, spleen.
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Minimizing the leak after LSG Bekheit et al  127

Figure 3 below the xiphoid process. The dissection of the greater

curve of the stomach at the region of the antrum was
limited to 4–6 from the pylorus. The resection phase
started with the first firing from the paramedian trocar,
then the rest of the firings are continued through the
left midclavicular trocar. Sutures were not taken except
for control of bleeding points from the staple line in
the form of figure-of-eight absorbable stitches.

Results
A total of 119 consecutive patients were operated
following our modifications (group 2). Their mean
preoperative BMI was 48.4 ± 10.2 kg/m2 and their
mean age was 39 ± 5 years. In this group, 80 patients
Complete dissection of the angle of His. C, crus; PEM,
phrenoesophageal membrane. (67.2%) were women and 39 (32.8%) were men. The
mean operative time was 116 ± 13 min. The mean
operative blood loss as measured from the suction cup
is applied at the greater gastric curvature that is slightly was 50 ± 10 ml.
pulled toward the anterior abdominal wall to remove
All patients of this group except one remained in hospital
the relatively larger surface of the posterior wall of
the gastric fundus. Care was always taken during the for 48 h after surgery with a standard postoperative
stapling not to crumble the stomach inside the stapler care, and all contrast studies were negative for leakage.
by avoiding caudal traction of the stomach. This was The NGT was removed on the first postoperative day
particularly important at the region of the fundus of in all patients. The tube drain was removed before
the stomach. discharge in all patients except one in whom there
was a continuous blood efflux of 500 ml/day during
It is also of importance to avoid the crossing over of the the first and the second day. Laparoscopic exploration
staples, which could cause the stapler’s knife disturbing was performed on the second postoperative day, but no
the junction between the consecutive firings. This could active source of bleeding could be found. Nonetheless,
be achieved by applying the stapler to the middle of a large intraperitoneal hematoma was irrigated and
preceding end of the staple line. a large caliber drain was reinserted. Despite that, the
patient continued to have a bloody effluent of about
Invaginating sutures were adapted in December 2010. 150 to 50 ml per day for 7 consecutive days without
Sutures were taken into the superficial seromuscular manifestations of systemic decompensation. After
layer, 2–3 mm lateral to the staple line, in a continuous discharge, all patients were attended at 1 week and
manner. The sutures covered the staple line from the at 4 weeks’ follow-up visits, where no clinical signs of
gastroesophageal junction until approximately the leakage was demonstrated.
level of the gastric incisura, using polypropylene 3/0,
26–30-mm round needle (Ethicon Sutures, Cincinnati, Five patients in this group (4.2%) had significant
Ohaio, USA) in a continuous manner. low back pain during the early postoperative period,
which significantly decreased before discharge in four
A leak test with diluted methylene blue is performed patients. One patient required facet joint injection for
and a tube drain is left with respect to the gastric pain relief, which was partially successful.
pouch. We routinely keep the nasogastric tube (NGT)
until the first postoperative night, and the tube drain Forty-one patients, 10 (24.4%) men and 31 (76.6%)
is removed before discharge at 48 h unless otherwise women, were operated before these adaptations
indicated. (group  1). Their mean preoperative BMI was 47.2 ±
8.1 kg/m2 and their mean age was 38.2 ± 9.7 years.
The mean operative time of this group was 130 ±
The differences from our initial technique
24 min. The estimated mean operative blood loss was
This group of patients was operated from November
150 ± 45 ml. Five patients (12.1%) remained in hospital
2009 to December 2010. The port sites, in this group
for more than 48 h; this included two readmissions.
of patients, were generally the same except for the
Two patients remained in hospital under conservative
paramedian trocar, which was inserted about 18 cm
management of a drain effluent of 250 and 300 ml of
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128  The Egyptian Journal of Surgery

fresh blood per 24 h. The effluent amount decreased differences in the occurrence of postoperative bleeding
to less than 50 ml before discharge on the fourth and
or mortality between the groups (PF = 0.162 and 0.250,
fifth postoperative day. The drain was removed on the
respectively). The frequencies of a hospital stay longer
seventh postoperative day in one patient and on the
than 48 h and back pain were significantly higher in
10th postoperative day in the other. None of them
required blood transfusion. group 1 (PF = 0.004, PF < 0.001, respectively).

The other three patients with prolonged hospital stay There were no significant differences between groups
had staple line leaks. Leak was diagnosed clinically in the preoperative BMI (Student’s t = −0.763, P =
in one patient on the first postoperative day, who was 0.45) or the age (Student’s t = −0.5, P = 0.61). The
brought back to the operating theater for laparoscopic operative time was longer in group 1 (Student’s t =
exploration. The leak site was located by a diluted 3.56, P < 0.001). There was also a significantly lower
methylene blue administration through the NGT. It intraoperative blood loss in group 2 (Student’s t = 1.99,
was at the most proximal part of the pouch for which P = 0.048). Table 1 summarizes the main findings of
a single figure-of-eight stitch was taken. Peritoneal this study.
lavage was performed and a drain was left nearby the
pouch. The patient’s drain continued to have leakage
efflux for 45 days during which the patient was on
regular enteral feeding, with nearly normal daily activity. Discussion
In a second patient with a BMI 64 kg/m2, leak was Leak after LSG is ubiquitously reported in the
diagnosed on the third postoperative day. Computed literature and its incidence varies from 0 to 5% [15,16].
tomography (CT)-guided drainage of intraperitoneal Devascularization and increased intraluminal pressure
collection was attempted and an endoscopic stent was were widely accepted predisposing factors for leaks [17].
placed, which failed to contain the leak. The patient We believe that preservation of the left gastric bundle
developed pulmonary embolism during the course of adequately supplies the pouch by its branches along
treatment, despite the antithrombotic measures, on the lesser curvature – that is, the extensive posterior
the 16th postoperative day, which led to consumption dissection and the dissection of the whole greater curve
of the patient reserve, and the patient died on the is less likely to jeopardize the pouch vascularity.
34th postoperative day. The leak in the third patient
was diagnosed on the seventh postoperative day. The Leak is most common at the proximal part of the
patient had CT-guided drainage and was successfully stomach [10]. This could be attributed to the difficulty
managed conservatively for 3 weeks. The diagnosis of to manipulate the proximal gastric area from the
leak in the last two patients was achieved by CT scan, earlier trocar sites, and the temptation to reduce the
which was requested upon clinical suspicion. pouch volume lead to stapling over the relatively
more vulnerable bare area of the stomach or even the
The postoperative back pain was significant in three
patients in this group. All of them showed considerable stretched lower esophageal end, if excessive traction
improvement at discharge. is posed during stapling. We had one patient in the
first group with stapling over a small part of the lower
Statistical analysis showed that group 2 had a esophagus, which passed without complications. The
significantly lower incidence of leaks than group  1 stapling in this patient was conducted through the left
(PF  = 0.016) (Fig. 1). There were no significant midclavicular trocar.

Table 1 Summary of the outcome data and the comparison of both groups
Complication No suture group (n = 41) With suture group (n = 119) Estimated significance of the difference
Frequency Frequency Significance
Leakage 3 0 pF = .016
Post operative bleeding 2 1 pF = .162
Mortality 1 0 pF = .250
Back pain 3 5 pF < .001
Prolonged hospital stay 5 1 pF = .004
Mean ± SD Mean ± SD Significance
Age 38.2 ± 9.7 year-old 39 ± 5 year-old Student t = −.5, p = 0.61
Operative time 130 ± 24 minutes 116 ± 13 minutes Student t = 3.56, p < .001
Pre-operative BMI 47.2 ± 8.1 kg/m2 48.4 ± 10.2 kg/m2 Student t = −.763, p = 0.45
Intra-operative bleeding 150 ± 45 ml 50 ± 10 ml Student t = 1.99, p = 0.048
pF, Fisher exact significance.
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Minimizing the leak after LSG Bekheit et al  129

Oversewing and buttressing of the staple line have enforcement in reducing either leak or bleeding from
received great attention as prophylactic measures staple line [8,15,19]. We emphasize that bleeding
against leaks. Buttressing of the staple line was found detected during the postoperative period could be
to be effective in reducing the incidence of leak in some from sources other than the staple line. Therefore,
studies [18], which, nevertheless, has a higher cost than unless a definitive source of bleeding is identified
sutures [15]. during laparoscopic exploration, no bleeding in the
postoperative stage could be linked to the staple line.
This study demonstrates that invaginating the staple Perhaps, this is one reason why it is difficult to link
line could help in reducing the leak rate after LSG. staple line enforcement to postoperative bleeding [9].
This finding is supported by a recent meta-analysis [19] One other value of staple line invagination, in our
that has, nevertheless, included only two randomized opinion, is to decrease the postoperative adhesions
studies with over 1000 patients. between the pouch and the liver, thus reducing the
difficulty of a second intervention if needed.
We previously reported our leak rates after various
bariatric procedures [20]. In that series, there were three The mean operative time was shorter in the second
cases of leak (7.3%) after LSG. Our initial experience group, despite the additional time incurred because of
involved only reinforcement of the crossing points sutures. This could be ascribed to the learning curve
of the consecutive firings of the staple line in some of the procedure. Besides, in the first group, we had to
patients or hemostatic sutures for bleeding points, but it take multiple figure-of-eight sutures for the purpose
neither involved the adapted higher trocar positioning of hemostasis or at the crossings of consecutive firings,
nor the invagination of the upper two-third of the which could have consumed a significant time. We
staple line. Besides, in our earlier experience, we used could not estimate the suturing time in group 1 as there
to perform only the first firing through the paramedian was no dedicated step for sutures and many of them
port and the rest of the firings were performed through were taken before completion of stapling. The mean
the left midclavicular port. The recently adapted firing suturing time in group 2 was 23 ± 4 min. It might not
direction facilitated easier gastric manipulation and be possible, in this study, to demonstrate that sutures
more consistent pouch calibration. will not significantly increase the operative time. It is
yet unimpeachable that, if the reduction in the leak rate
The above described extensive gastric mobilization is not is true, invagination of the staple line could save much
only valuable for reducing the gastric pouch volume, but more time than it would take.
also necessary for safe stapling. This was assisted with the
adapted more ergonomic positions of the ports, which The lower frequency of back pain in the second group
facilitated the manipulation at the proximal gastric area, could be due to the modification of the patient positioning.
particularly when only regular length staplers are available. We used to support the arch of the lordosis early in our
experience. This was modified to support also the thoracic
Recent recommendations support the use of a relatively region rather than the lumbar alone. The philosophy of
large calibrating tube (≥40 Fr), as it is thought to be this modification comes from the hypothesis that pain
associated with a lower incidence of leak [10]. The use originates from the overstretch of the spinal ligaments as
of a calibrating tube of 38 Fr seems to be safe in our a result of the exaggerated lordosis, particularly in patients
experience as long as there is no much traction applied with full buttocks. This is also accentuated by the leg
to the stomach during stapling. Excessive traction would abduction that could lead to more strain on the ligaments
lead to overstretch of the pouch wall, which could lead as a result of the internal rotation of the hips that is
to stricture or narrowing of the gastric pouch. reflected on the sacroiliac joints with more stretch. With
thoracic support, the lordosis angle is reduced; hence, the
Caudal traction is equally unfavorable as this would tension over the ligaments could also be reduced.
crumple the stomach inside the stapler, leading to
higher tension on the fired staples. Besides, the struggle The beforehand study results should be cautiously
with the abdominal wall to overcome the shortage in interpreted as the study was conducted retrospectively
instrument length would also render the stapling process and without a priori power analysis. Moreover, the control
difficult, subsequently contributing to its failure. Indeed, group (first or historical) contained a relatively small
one of our known bariatric surgeons had gastric slippage number of patients, which could have inflated the type
from the stapler during firing as a consequence of this II error in this study; this was also the reason why the
struggle; this led to staple misfire that he had to sew. percentage of leaks in this group was 7%. It is, nonetheless,
evident that the leak rate after LSG has been minimized
Noteworthy, the current evidence has controversial to zero, in the subsequent consecutive patients, after the
statements regarding the value of staple line technical modifications described herein.
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130  The Egyptian Journal of Surgery

 7 Sakran N, Goitein D, Raziel A, Keidar A, Beglaibter N, Grinbaum R, et al.

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 8 Parikh M, Issa R, McCrillis A, Saunders JK, Ude-Welcome A, Gagner M.
to have good dissection that would ensure gentle tissue Surgical strategies that may decrease leak after laparoscopic sleeve
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 9 Gentileschi P, Camperchioli I, D’Ugo S, Benavoli D, Gaspari AL. Staple-
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Acknowledgements 11 Berende CA, de Zoete JP, Smulders JF, Nienhuijs SW. Laparoscopic
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Aboushady for her assistance in the linguistic editing of this 2012; 22:330–334.
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Conflicts of interest
13 Daskalakis M, Berdan Y, Theodoridou S, Weigand G, Weiner RA.
There are no conflicts of interest.
Impact of surgeon experience and buttress material on postoperative
complications after laparoscopic sleeve gastrectomy. Surg Endosc 2011;
25:88–97.

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