SLEEVE FIXATION IN LAPAROSCOPIC SLEEVE GASTRECTOMY FOR MORBID OBESITY-TECHNIQUE AND BENEFITS

Sleeve gastrectomy is one of the most commonly performed procedure for treatment of morbid obesity. The surgery evolved from two step procedure of biliopancreatic bypass/duodenal switch. The procedure is safe and associated with symptoms of gastroesophageal reflux, food intolerance and vomiting. These symptoms are attributed to the improper sleeve position and deformity, due to the loss of natural attachments of the stomach. We here by present a case with morbid obesity in which we did sleeve gastrectomy with sleeve fixation. Post operatively patient had benefit from complications which are previously attributed due to sleeve rotation .Our patient was 51 year old male with the history of morbid obesity since 10 years with the BMI of 44.20 . Patient has the history of Smoking, hypertension, Obstructive sleep apnea, Diabetes Mellitus with renal failure. After preoperative workup and anaesthetic check up patient was taken up for surgery and sleeve gastrectomy procedure with sleeve fixation was done. Gastrograffin study done on post op day 1 was normal and Patient was started orally liquids on day 1 and discharged on day 2. On follow up patient was doing fine, lost 36 kg weight in 8 months. There was no problem of gastroesophageal reflux, heart burn, food intolerance and vomiting. Aim To devise the gastric sleeve fixation for the laparoscopic sleeve gastrectomy. Technique The gastric tube is fixed along the new greater curvature with the gastrocolic omentum using the PDS 3-0 in continuous fashion. The interrupted suture is used to fix at the lower part of the tube with the transverse mesocolon near the lower edge of pancreas. Conclusion the gastric fixation stratergy is safe and easy. It can reduce the problems arising from the improper gastric tube position, reducing the incidence of food intolerance and gastroesophageal disease.


INTRODUCTION
Laparoscopic Sleeve gastrectomy has become the first option in treating the morbid obesity world wide. The first open sleeve gastrectomy was done as a part of more complex operation known as duodenal switch, was done by Doug Hess in Bowling Green Ohio, in the year 1988. Lawrance L Tretbar described the weight loss associated with fundoplication of reflux surgery. He suggested the fundoplication causing the creation of stomach tube can cause weight loss. Dr Hess used the concept of tubularised stomach, from extended plication to the actual longitudinal or vertical gastrectomy. In the year 1997 Almogy G, et al operated on a13 year girl with CBD calculi but as the calculi could not be cleared, he did the open sleeve gastrectomy so that later on ERCP can be done on patient. After this surgery he performed on 21 morbidly obese patient and found upto 50 % of excess weight loss (EWL) in these patient before a definitive procedure. Gagner et al. did the first laparoscopic sleeve gastrectomy in patient with very high BMI of 50-71 kg/m2. This procedure was the first part in reducing the weight and was followed by definitive procedure later on.
From the year 2001-03 seven cases with high BMI was done. The results of Mills and Magenstrasse. Procedure was published by Johnson et al. There were 100 patient with the 5 year follow up and 60% effective weight loss. First the sleeve gastrectomy was done followed by the definitive ROUX -En -Y surgery was done. This sleeve gastrectomy has evolved form the duodenal switch to open sleeve gastrectomy to the laparoscopic sleeve gastrectomy. The procedure is simple but is associated with the early complication of bleeding and leak are point of concern. (Trelles N G et al 2008, Campanile  In view of the current studies this technique helps in the fixation of the stomach tube and prevents the improper position and twist of the stomach tube. Also the procedure provides the better anatomic and physiologic fixation of the stomach bringing it to the natural habitat.

Technique
The newly created greater curvature is utilized for the fixation of the gastric tube with gastrocolic omentum. The suturing is started near the gastroesophageal junction invaginating the gastric suture line at the level of gastroesophageal junction and the proceeding distally as continuous suture .We use absorbable suture PDS 3-0. On the gastrocolic omentum side the suture must contain enough of the omentum t through by suture. The lower part of the gastric tube is fixed to transverse mesocolon at the inferior part of pancreas using interrupted suture with PDS 2-0. Care is taken that it does not involve the vessels. In view of the current studies this technique helps in the fixation of the stomach tube and prevents the improper position and twist of the stomach tube. Also the procedure provides the and physiologic fixation of the stomach The newly created greater curvature is utilized for the fixation of the gastric tube with gastrocolic omentum. The suturing is phageal junction invaginating the gastric suture line at the level of gastroesophageal junction and the proceeding distally as continuous suture .We use 0. On the gastrocolic omentum side ntum to prevent cut . The lower part of the gastric tube is fixed to transverse mesocolon at the inferior part of pancreas using 0. Care is taken that it does not Invaginating of the gastroesophageal junction with PDS 3-0.
0 on the new greater curvature with the gastrocolic omentum.   The fixation to the gastric tube has been proposed, aimed to er position of the gastric tube, symptoms of food intolerance and gastro esophageal reflux. The procedure more functional and anatomical position. The correct mechanism is still under the study, the symptoms may emerge in the postoperative cases which may cause t and may require the The proposed causes de loss of gastric complacency, hiatal hernia, impairment of the lower sphincter function, and mechanical and functional obstruction along the gastric tube. The stomach is normally fixed to gastrosplenic, and gastrocolic ligaments. These are na attachment of the stomach. distention caused by presence of food in the stomach causes rotation of the stomach tube due to loss of the natural attachment. (

CONCLUSION
The stomach fixation strategy is safe and seem to provide suitable and reliable refixation. This may reduce the occurrence of reflux and intolerance related to improper positioning of the gastric tube. The stomach fixation strategy is safe and seem to provide suitable and reliable refixation. This may reduce the occurrence olerance related to improper positioning of the Trelles NG, Michel. Updated Review of Sleeve The Open Gastroenterology Journal.