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Bikini Line LSG

Improving aesthetic outcomes with the Bikini Line LSG

The suturing phase was more demanding because of the relatively longer distance to the esophagogastric junction, but this became more comfortable as the operations advanced towards the antrum

Researchers from Egypt have revealed a new approach to improve the aesthetic outcome following laparoscopic sleeve gastrectomy (LSG) – the bikini line sleeve gastrectomy (BLSG). Lead by Dr Tamer N Abdelbaki from Alexandria University Faculty of Medicine, Alexandria, Egypt, the team’s method is to place conventional ports placed at the lower abdomen and carry out a standard LSG.

The approach, described in the paper, ‘Bikini Line Sleeve Gastrectomy: Initial Report’, published in Obesity Surgery, was performed on 28 patients (22 females, six males) who had not had previous upper abdominal surgery, presented with long distances between the xiphoid process and the sites for ports placement and did not have a large hiatal hernia that required repair. In addition, patients with xiphoid-umbilicus, xiphoid-symphysis pubis and xiphoid-anterior superior iliac spine (ASIS) distances of more than 25, 36 and 33cm were excluded due to limitations of working with standard size bariatric instruments and camera telescopes (length).

Tamer Abdelbaki

To assess the outcomes, the researchers collected the baseline characteristics, operative time, intra-operative and postoperative complications, painscore (visual analogue scale), percentage excess weight loss and patient’s scar satisfaction. Patient’s scar satisfaction was assessed by using scar assessment questionnaire (PSAQ), which has four validated subscales which include as follows: appearance, consciousness, satisfaction with appearance, and satisfaction with symptoms (each scoring 1 to 4 points. Patients were also asked to grade their overall satisfaction with scar appearance as very satisfied, satisfied, dissatisfied or very dissatisfied and followed up for a minimum of six months post-surgery.

The mean age was 34.6± 3.7 years (22– 40) and the mean pre-operative BMI and weight were 42.46±3 (37–50) and 110.5±42 (90–140), respectively. Four (14.3%) patients presented with hypertension, three (10.7%) with T2D, one (3.6%) with sleep apnoea and seven (25%) with arthritis patients.

The mean distances between the xiphoid process to the umbilicus, symphisis pubis and ASIS were 20.9±2.3c (18–25), 33.1±2.4cm (29–36), and 30.6±2.3cm (27–33), respectively, and were compatible with all instruments and provided acceptable ergonomics.

Technique

The researchers stated that they made some little modifications to the procedure – for example,  the degree of leg splitting was slightly modified, by making the angle a little smaller, and specifically, the left leg was more straight compared to the right leg to allow for more space during the suturing phase of the procedure. Furthermore, patients were strapped to the table at a lower level, where the strap was placed at the level of the upper one third of the thigh, therefore completely exposing the lower abdomen.

The Bikini line was defined as a curved line just above the symphisis pubis. All four trocars were placed while the table is in the flat position, then the table was tilted 45° in the reverse Trendelenburg position. All reusable laparoscopic instruments were bariatric instruments (length = 43cm); on average the researchers used a 30° average length camera telescope (31cm), while endoscopic stapler and bipolar energy source length were 34 and 37cm, respectively.

Outcomes

All patients completed follow-up at three and six months (five patients completed 12 months after the operation but only four attended the follow-up clinic at 12 months). The researchers reported that patients stated that their post-operative pain was minimal (visual analogue scale 2.9±0.9, 2–4) at 24hrs postoperatively. All patients had a length of stay of one day and there was one minor wound infection.

Five patients had a lower abdominal scar (Pfannenstiel incision), four patients had a Caesarean section and one patient for chocolate cyst evacuation. These scars did not present any difficulty during port placement. The mean operative time was 64.5 ± 12.1min (range 50– 80). There were no major intra- or post-operative complications.

Patient’s satisfaction with port site scars, measured using PSAQ at ten days, three and six months, showed a mean of 43.36±4.46, 31.80±4.50 and 29.30±4.70, respectively. Grading the overall satisfaction with the scar appearance, 26 patients were very satisfied and two patients were just satisfied with the scar appearance.

The mean postoperative BMI and weight at six months were 28.5±1 (26–38) and 79.8kg±2 (54–114), respectively. The mean percentage excess weight loss at three and six months were 39.5±4.6 and 64.5±5%, respectively. The mean percentage excess weight loss at one year (four patients) was 69.8±6%. All patients with diabetes and hypertension were off medications and the patient with sleep apnoea had improved symptoms.

Regarding the operation, the researchers noted that the lower placement of the ports in the suprapubic region did not compromise a complete gastric mobilisation with good exposure of the upper most and posterior short gastric vessels together with a clear visualisation of the left crus. However, the suturing phase was more demanding because of the relatively longer distance to the esophagogastric junction, but this became more comfortable as the operations advanced towards the antrum.

“BLSG was found to be potentially safe, feasible, and effective with a favourable aesthetic outcome; it could possibly be offered to a selected group of patients that are conscious about their scar appearance,” the paper concluded. “However, this was rather a descriptive and a pilot study of a small number of patients over a short period without a control group, and in order to make any conclusions, we need long-term prospective controlled studies with larger number of patients to assess its widespread applicability and safety.”

This research was conducted in 2016 and was presented at the IFSO World Congress in London, 2017.

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