What to Do When It Is Technically Impossible to Perform Laparoscopic Sleeve Gastrectomy
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- Rebibo, L., Dhahri, A., Verhaeghe, P. et al. OBES SURG (2014) 24: 2069. doi:10.1007/s11695-014-1320-0
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Laparoscopic sleeve gastrectomy (LSG) is increasingly popular with surgeons because of its apparent technical ease. However, performing LSG safely is sometimes not possible during laparoscopy. The objectives of the present study were to (i) describe the context of LSG failure and (ii) suggest preoperative care options or strategies that enable secondary LSG to be performed safely.
We studied patients having undergone primary and secondary LSG between January 2008 and July 2013. The primary efficacy criterion was the LSG success rate. The secondary efficacy criteria were preoperative care procedures, the complication rate, the failure rate, and the frequency of conversion to open surgery.
During the study period, 954 patients underwent first- or second-line LSG. Laparoscopic sleeve gastrectomy was technically impossible in 12 patients (1.2 %). The cause of failure was a large left liver lobe in seven cases (58.3 %) and a lack of space in five cases. Of these 12 patients, nine underwent secondary LSG. The median preoperative BMI before the first LSG was 51.5 kg/m2. The median (range) time interval between the two LSG attempts was 6 months (3–37). Prior to secondary LSG, the preoperative weight reduction measure was a diet in seven cases (78 %), an intragastric balloon in one case, and no treatment in one case. The median preoperative excess weight loss (EWL) before the second LSG was 10 % (0–20). Five LSGs were successful, two required conversion to open surgery, and two failed again. There were two postoperative complications (22 %), both of which concerned the two patients with conversion to laparotomy.
In the event of LSG technical failure, preoperative weight loss may enable a second attempt at laparoscopic treatment. A preoperative EWL of at least 10 % appears to be required for the avoidance of conversion to laparotomy.
KeywordsLaparoscopic sleeve gastrectomyTechnical failureWeight loss
Laparoscopic sleeve gastrectomy (LSG) has become increasing popular with surgeons in view of its apparent technical ease, good weight loss results (with improvements in comorbidities ), and acceptable postoperative complication rates. It is considered that LSG has a lower complication rate than the duodenal switch (DS)  or Roux-en-Y gastric bypass (RYGBP) , due to the absence of anastomosis.
In some cases, performing LSG safely is prevented by a lack of space during laparoscopy or a large left liver lobe (LLLL) that makes exposure difficult and obliges the surgeon to stop the surgical procedure. Some series have described this type of event during gastric bypass (GB) and RYGBP but not during LSG. According to all the published series on LSG, this procedure is always possible. Nevertheless, LSG failure is a clinical reality. The objectives of the present study were to (i) describe the contexts in which LSG cannot be safely performed and (ii) suggest care options that enable secondary LSG to be performed safely.
Material and Methods
We retrospectively analyzed our prospective database for a group of patients undergoing first- or second-line LSG between January 2008 and July 2013. In all cases, the indication for bariatric surgery had been validated in a multidisciplinary staff meeting and in accordance with French national guidelines . All patients attended a surgical consultation and a nutrition/dietetics consultation and underwent respiratory, endocrine, and psychological assessments. Screening for hiatus hernia and Helicobacter pylori infection was performed gastroscopically. Respiratory function tests were used to screen for obstructive sleep apnea syndrome (OSAS).
In our institution, LSGs are performed according to the technique described by Verhaeghe et al. . The surgical technique was the same for first- and second-line LSGs. Surgery was always performed by two bariatric surgeons with experience of more than 300 LSG procedures each.
A 34-gauge French bougie was used to help staple the greater gastric curvature. The LSG transection began 6 cm above the pylorus. For patients undergoing LSG between 2004 and 2009, stapling was performed using ENDO GIA Universal XL 60 with two green staplers then four or five blue staplers (Covidien France SAS, Elancourt, France). For patients undergoing LSG from 2010 to 2012, purple staplers (tri-staple) were used. An intraoperative methylene blue test was always performed at the end of the procedure. Between 2004 and 2009, a 10-gauge French drain was always left in place.
Laparoscopic surgery was always performed with an initial insufflation pressure of 13–14 mmHg. If required, the insufflation pressure was increased to 16 mmHg (but not above this value, in order to avoid gas embolism, lung atelectasis, and other related complications). All patients underwent an oral contrast (Gastrografin®) study of the upper gastrointestinal tract on postoperative day 1, in order to check for the absence of complications and enable the resumption of oral feeding.
Inclusion and Noninclusion Criteria
Patients were included in the study if they had undergone secondary LSG after technical failure of the primary LSG. Patients having undergone other bariatric surgical procedures (e.g., GB, DS, and RYGBP) or patients not having undergone LSG because of anaphylactic shock during the induction of anesthesia were excluded from the study.
Study Efficacy Criteria
The study’s primary efficacy criterion was the success rate for secondary LSG after primary LSG failure. The secondary efficacy criteria were the complication rate, operating time, the rate of conversion to laparotomy, the length of hospitalization, and weight loss after the second surgical procedure.
Preoperative data: age, gender, body mass index (BMI), and comorbidities (diabetes mellitus, hypertension, dyslipidemia, metabolic syndrome (as defined by the National Cholesterol Education Program (Adult Treatment Panel III) guidelines (NCEP-ATP III), and OSAS).
Preoperative management: type of diet, BMI, excess weight loss (EWL), percentage weight loss, and the time interval between primary and secondary LSG
Peroperative data: operating time, conversion rate, causes of conversion, and the peroperative complication rate
Short-term follow-up data: postoperative complications (according to the Clavien classification ), length of hospital stay, and the revisional surgery rate in the 3 months following surgery
Mid- and long-term follow-up data: mean follow-up time, BMI, EWL, percentage weight loss (according to current guidelines ), and correction of preoperative comorbidities
All statistical analyses were performed with SAS software (version 4.3, SAS Institute Inc., Cary, NC, USA). The results are presented as the median (range) or the number (percentage).
During the study period, 954 patients (192 males, 20.1 %) underwent first- or second-line LSG. Forty-five patients underwent LG after previous GB removal, 54 underwent GB removal and LSG in the same procedure, and 26 underwent repeat LSG. Eight hundred and twenty-nine patients underwent first-line LSG.
During the study period, LSG was found to be technically impossible in 12 patients (1.2 %). This group consisted of nine men and three women (25 %), with a median (range) age of 39 (25–62). The median preoperative BMI was 49.5 kg/m2 (41.5–61.3). Five patients had a BMI ≥50 kg/m2 (41.6 %). The comorbidities comprised diabetes mellitus (41.6 %; n = 5), hypertension (16.6 %; n = 2), dyslipidemia (16.6 %; n = 2), OSAS (25 %; n = 3), and metabolic syndrome (16.6 %; n = 2). The cause of LSG failure was LLLL in seven cases (58.3 %) and lack of space in five cases (41.7 %). The LSG failed in nine men (4.6 %) and three women (0.4 %) (odds ratio for failure and male gender—11.5).
The median operating time was 60 min (40–100). The greater curvature of the stomach was released in three cases (25 %) and an additional trocar was used in one case (8.3 %). After release of the greater curvature of the stomach, the surgical procedure had to be stopped because a lack of good visibility prevented safe transection of the stomach. The median (range) length of hospital stay was 2 days (1–3). There were no postoperative complications after first-line LSG.
Preoperative Care for Secondary LSG
Of the 12 patients with failed front-line LSG, nine underwent secondary LSG. The three others did not undergo preoperative weight loss procedures (because of cancer in one case, refusal in one case, and missing data for the third). The group of nine patients consisted of five men and four women (44.4 %), with a median age of 43 (25–62). None of the nine had a history of bariatric surgery. The median preoperative BMI before first-line LSG was 51.5 kg/m2 (41.5–61.3). Five patients had a BMI ≥50 kg/m2 (55.5 %). Eleven preoperative comorbidities affected eight patients in all: diabetes mellitus (44.4 %; n = 4), hypertension (11.1 %; n = 1), dyslipidemia (11.1 %; n = 1), OSAS (33.3 %; n = 3), and metabolic syndrome (22.2 %; n = 2).
Data on patients undergoing secondary LSG
Patient no. 1
Patient no. 2
Patient no. 3
Patient no. 4
Patient no. 5
Patient no. 6
Patient no. 7
Patient no. 8
Patient no. 9
Reason for failure
Weight loss (%)
Weight loss (%)
The technical success rate for secondary LSG was 55.5 % (n = 5). In two patients, the LSG failed again because of LLLL (n = 1) and lack of space (n = 1). Two other patients underwent conversion to open sleeve gastrectomy because of lack of space (n = 1) and LLLL (n = 1). The median operating time was 100 min (50–110).
Short-Term Follow-Up Data
There were no postoperative deaths. The median length of hospital stay was 2 days (2–35). There were two postoperative complications (14.3 %): a postoperative lung infection (Clavien grade 2) treated with antibiotics and a postoperative evisceration resulting from a gastric fistula (Clavien grade 3b). One patient underwent further revisional surgery for gastric fistula.
Mid- and Long-Term Follow-Up Data
The median follow-up time was 7 months (6–35). One patient was lost to follow-up. For the seven patients that ultimately underwent open sleeve gastrectomy or LSG, the median BMI was 31.5 (24.6–52), the median EWL was 65 % (20–101), and the median percentage weight loss was 37.6 % (10.2–49). During follow-up, only one patient was found to have persistent OSAS (16.6 %). The postoperative gastric fistula (n = 1) had healed 56 days after its discovery.
In modern societies, the prevalence of obesity is increasing. Although dietary and pharmacological treatment options have been suggested, surgery is still the only efficient treatment for morbid obesity . Surgery obtains the best results in terms of weight loss  and the correction of comorbidities (such as diabetes mellitus , hypertension , or OSAS ). Bariatric surgery reduces certain cardiovascular risk factors, the risk of cancer, and thus the relative risk of death by 89 % .
Laparoscopic sleeve gastrectomy is an efficient surgical treatment for long-term weight loss, with a EWL at 5 years of 57 % . In some cases, however, the bariatric procedure is complicated by a LLLL or a lack of space—making the procedure longer and, therefore, more dangerous, with a greater risk of postoperative complications.
None of the literature series describe LSG failure. Here, it was not possible to safely perform LSG in 12 cases (1.2 % of all LSGs performed in our institution). The surgical team has a considerable experience as shown by our publications in performing LSG [15–17]. This suggests that these cases of failure to achieve LSG may also affect other surgical teams. In our series, the most important cause of failure was the presence of LLLL in 63.6 % maybe due to the presence of nonalcoholic steatohepatitis (NASH) in our population as found in many cases of obese patients with a rate of NASH in obese population near 70 % . In a recent study in our institution, liver biopsy was performed in 198 out of 750 LSG patients . Of these 198 patients, 47 had signs of NASH. Additionally, 13 of the 47 had signs of cirrhosis.
A variety of risk factors for conversion to open RYGBP  have been described: steatohepatitis, male gender, diabetes mellitus, adhesions with various causes, high BMI, and large waist size. The likelihood of adhesions due to previous abdominal surgery should be reviewed prior to the bariatric procedure (e.g., in patients with a history of laparotomy). In the series reported by Schwartz et al. , one of the most frequent causes for conversion to an open procedure was LLLL (accounting for 29.2 % of conversions). Unfortunately, an LLLL may only be discovered during surgery. First-line conversion to open surgery during LSG exposes the patient to a higher risk of postoperative complications (particularly those related to the abdominal wall, with an elevated risk of wound infection and abdominal eventration). Our management of patients undergoing LSG changed over the study period. Initially, there were no specific preoperative management procedures (particularly concerning diet). When faced with possible LSG failure and in view of our better knowledge of risk factors for difficult surgery, we now suggest a preoperative diet to patients with very high BMI or signs of steatohepatitis (e.g., elevated preoperative serum transaminase)—particularly among male patients. Also, patients with primary LSG failure are informed of the risk of conversion to laparotomy and are then asked whether they prefer to undergo laparotomy sleeve gastrectomy (with the associated increase in the risk of complications). Indeed, patient no. 8 refused laparotomy and so sleeve gastrectomy was not performed.
In cases of LLLL, there are many preoperative care options. For example, a low-energy liquid diet (as described by Fris ) can reduce the size of the liver by 5 %. Furthermore, Iannelli et al.  showed that 4 weeks of preoperative supplementation with omega-3 polyunsaturated fatty acids reduced the left liver lobe’s volume by 20 % (as judged by ultrasound measurements before and after the treatment). However, Iannelli et al. were limited by the small sample size (20 patients) and the absence of preoperative risk factors for conversion to open surgery (90 % of the patients were female and the mean (range) BMI was relatively low at 42 kg/m2 (37–51)). In fact, this type of preoperative management should be evaluated in patients with preoperative risk factors for conversion to open procedures. Transversus abdominis plane (TAP) block (described for the first time in 2001 ) might be a solution when laparoscopic surgery is problematic; it provides analgesia of the ipsilateral hemi-abdominal wall and is associated with a reduction in opioid requirements, pain levels, and sedation and promotes early ambulation . It would be interesting to evaluate this anesthetic technique in bariatric surgery in general and for increasing abdominal space during laparoscopic surgery in particular.
In our series, eight patients underwent repeat surgery with good outcomes. There was only one case of secondary LSG failure in a patient who did not undergo preoperative weight loss. The ability to perform successful secondary LSG means that we do no longer perform first-line conversion to open surgery when exposure during laparoscopy is difficult. In fact, conversion to open surgery exposes the patient to an elevated risk of postoperative complications (e.g., 18.7 % for open RYGBP vs. 12.3 % for laparoscopic RYGBP ).
In the present series, the preoperative management corresponded to a diet in six cases and the implementation of intragastric balloon in another case. The use of an intragastric balloon prior to LSG has already produced good results in the literature. This technique enables preoperative weight loss in the super-super-obese and allows LSG to be performed under good conditions and with a low postoperative gastric fistula rate . According to Mohamed et al., the implementation of an intragastric balloon was associated with a mean preoperative EWL of 22 % . However, some patients in our present series achieved similar EWL by dieting. Indeed, Leeman et al.  found that the use of an intragastric balloon did not confer additional preoperative weight loss, when compared with structured weight management. The latter researchers concluded that the continued use of intragastric balloons in this way cannot be justified .
As an alternative to LSG, gastric banding during laparoscopy was considered. However, poor visibility of the gastric fundus prevented gastric banding via a pars flaccida approach. Although suboptimal LSG was also considered, only three of the 12 patients had partial release of gastric curvature. Further, suboptimal LSG would not always have been possible in patients with very high BMIs. The last option is gastric bypass, which was not considered because LSG is acknowledged to be an easier surgical procedure with a shorter operating time  (particularly on super-obese patients) and is sometimes performed as a first step in a RYGBP or a duodenal switch.
On the present series, five patients successfully underwent secondary LSG after a median EWL of 10 %. The two patients who required conversion to open surgery during laparoscopy (patient nos. 7 and 8) had the lowest preoperative EWL values (7 and 2 %, respectively). This finding suggests that a minimum preoperative weight loss is required for the safe performance of secondary LSG. Indeed, patient nos. 7 and 8 developed a lung infection and patient no. 8 had evisceration caused by a gastric fistula, requiring longer hospital stays (5 and 35 days, respectively). The postoperative weight loss in our series confirms the benefits of performing LSG, with a median EWL of 65 % after 7 months of follow-up and the correction of preoperative comorbidities in 88.8 % of cases.
In the event of LSG technical failure (due to LLLL or a lack of space), preoperative weight loss may enable a second attempt at laparoscopic treatment. In our experience, a preoperative EWL of at least 10 % appears to be required for the avoidance of conversion to laparotomy. During primary LSG, conversion to open sleeve gastrectomy should not be performed.
Conflict of Interest
None of the authors have any conflicts of interest to declare.