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Stapleless LSG

Concept study finds stapleless LSG safe and cost-effective

The researchers analysed a stapleless technique for LSG where a pouch is created via energy-based resection, and the stomach is closed with sutures alone

Stapleless laparoscopic sleeve gastrectomy (LSG) has the potential to be an affordable alternative to the standard LSG techniques, both in terms of financial costs and complication rate, according to a proof of concept study by researchers from El kabbary General Hospital, Alexandria, Egypt, the University of Aberdeen, Aberdeen, UK, the Centre Hépato-Biliaire and Inserm Unité, Villejuif, and the Universite Pais-Sud, Cedex, France. Their preliminary study in three females reported no post-operative leaks and median excess weight loss of 39% of initial weight loss at six months and 57.7% at 12 months. However, they noted that additional high-powered studies and formal cost analyses will be required looking specifically at the stapleless method versus the standard LSG to ascertain whether the procedure is safety, efficacious and cost-effective.

In the paper, ‘Stapleless Laparoscopic Sleeve Gastrectomy: Reasoning and Technical Insights’, published in Obesity Surgery, the authors state that although LSG has become the procedure of choice in many countries concerns remain about the complications raising from staple closure such as haemorrhage and gastric leak. Although several staple line reinforcement (SLR) techniques and materials have been developed, this merely adds to the cost of procedures.

Therefore, in this study the researchers analysed a stapleless technique for LSG where a pouch is created via energy-based resection, and the stomach is closed with sutures alone. They carried out their technique on three middle-aged women (median age 42 years old), and the primary outcome was the incidence of post-operative, with operative time and hospital stay as the secondary outcomes.


All patients were positioned in a steep anti-Trendelenburg position with the pneumoperitoneum established through a 12mm trocar, inserted a handbreadth (13–14cm) beneath the xiphoid process, and minimally deviated to the left of the midline. A second 12mm optical trocar was then inserted two fingers breadth beneath the costal margin just at the left midclavicular line and three 5mm trocars inserted: one subxiphoid for liver retraction and manipulation of the gastric fundus when needed, a second at the left midaxillary line for the assistant, and a third in the right pararectal line, two fingers breadth below the costal margin. The last one may also transfix the falciform ligament if found broad and long.

Dissection was performed with an ultrasonic dissector (Harmonic Ace; Ethicon Endo-Surgery) through accessing the lesser sac and the whole greater curvature of the stomach was dissected, and the liberation of the posterior gastric attachments except for the single left gastric vessel bundle was performed. All the remaining fat (peritoneal bands and posterior fundic vessels) were freed from their gastric attachment. Complete exposure of the left crus is gained and mobilisation of the angle of His was completed through dissection of the phrenogastric membrane from the left side until the gastroesophageal junction was mobilised.

The pouch was designed drawing a line 0.5cm lateral to the angle of His, running parallel to the lesser curvature to 3–4cm from the pyloru, depending on how far the pylorus is shifted to the right side. A lateral extra 0.5cm was allowed, to give space for the second layer of sutures. The pouch size was calibrated over a 38Fr size calibrating bougie. Initial marking of the resection line was done with a low-powered Hook monopolar electrosurgery. The distance between the full thickness and the imbricating suture layers was designed to prevent excess tissue invagination which would otherwise produce internal inhomogeneity in the tube.

The resection was started 3–4 cm from the pylorus through the paramedian trocar with ultrasonic dissector (Harmonic Ace; Ethicon Endo-Surgery,) and was performed with a 38Fr calibrating tube inside the pouch. The resection was continued until the operators reached the angle of His through the same port. During resection, traction was applied at the greater gastric curvature and was slightly pulled toward the anterior abdominal wall to remove the relatively larger surface of the posterior wall of the gastric fundus.

A few permanent, full thickness, sutures, using Vicryl 3/0 mounted on a 26–30mm round needle, were taken 2–3 mm lateral to the resection line (Figure 1a), every 4–6 strokes of the harmonic, to act as stations for the continuous suture, as well as to better control the resection and design the pouch throughout (Ethicon Sutures).

Full thickness sutures, stationed at the interrupted sutures, were taken full thickness at 2–3mm lateral to the resection line, in a continuous manner (Figures 1b–d). The sutures covered the entire resection line, using Vicryl 3/0, 26–30mm mounted on a round needle (Ethicon Sutures). Invaginating sutures were taken into the superficial seromuscular layer, 2–3 mm lateral to the first layer, in a continuous manner. (Figures 1e–g) The sutures covered the entire resection line, using polypropylene 3/0, 26–30 mm round needle (Ethicon Sutures).

Figure 1: a) The first stay suture made 4–5cm after cutting through the stomach with the harmonic scalpel. b) Start of the full thickness first layer just above the cut angle at the angle of His. c) and d) Stationed (tie between the running full thickness and any one of the stay). e) and f) Second continuous invaginating seromuscular layer of sutures being taken

A leak test with diluted methylene blue was performed and a tube drain was left adjacent to the gastric pouch. Post-operative computed tomography with oral contrast was routinely adopted in this series (30–48 hrs post-op), to verify the absence of leak and demonstrate the appropriate size of the pouch.


The outcomes revealed that the median operative time was 132 min (range 120–195 min) and all patients stayed for two days in the hospital and there was no leakage on the routine post-operative CT (30–48 hrs). Median excess weight loss (EWL) at six months was 39% (range 32–43%) and at one year 57.7% (range 50.4–63%).  All patients had some form of post-operative anorexia, experienced nausea secondary to food odour and reported vomiting at least once post-operatively.

“In this proof of concept study, there was neither leak nor bleeding from surgery. However, a powered study is required to fully investigate the merits of this procedure. Stapleless LSG seems to have the potential to be an affordable alternative to the standard LSG techniques, both regarding financial costs and complications rate,” the authors conclude. “High-powered studies and formal cost analyses will be required looking specifically at the stapleless method versus the standard LSG.”

To access this paper, please click here

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