In Su g 2015;100:1134–1137
DOI: 10.9738/INTSURG-D-14-00287.1
Th ee-Dimensional Lapa oscopic Slee e
Gas ec omy: Imp o ed Pa ien Sa e y and
Su geon Con enience
Fe nando Ma ı
´nez-Ubie o, Te esa Jim´
enez-Be nad´
o, Ja ie Ma ı
´nez-Ubie o, An onio
Cab e izo, Ana Pascual-Bellos a, Luis Mu˜
noz-Rod iguez, Al edo Jim´
enez-Be nad´
o
Se ice o Gene al Su ge y, Uni o Ba ia ic and Me abolic Su ge y, Viamed Mon ecanal Hospi al,
Za agoza, Spain
One o he aims o lapa oscopic su ge y is o imp o e upon he esul s ob ained by open
su ge y. This clea ly appea s o ha e been achie ed in ba ia ic su ge y. Two-
dimensional (2-D) sys ems ha e been used o da e, hough new 3-dimensional (3-D)
echnologies ha e been in oduced in an a emp o imp o e su geon ision and hus
inc ease he sa e y o he su gical echniques. Six y obese pa ien s unde wen slee e
gas ec omy using a de ice equipped wi h 3-D op ics allowing su ge y o be iewed by
he su geon in 3 dimensions by using a speci ic moni o and wea ing app op ia e glasses.
The mean pa ien age was 48.1 yea s. The mean weigh was 114 kg ( ange, 92–172), wi h a
mean body mass index (BMI) o 44 65.21 kg/m
2
. All su ge ies we e pe o med using he
3-D sys em, wi h a mean su gical ime o 71 649.6 minu es and a mean hospi al s ay o
3.0 61.2 days. Only 1 in aope a i e complica ion was eco ded: e ope i oneal bleeding
on inse ion o he op ical oca . O e a mean ollow-up pe iod o 12 mon hs, he mean
body weigh o he pa ien s was 88 kg ( ange, 71–121), wi h a BMI o 30.56 63.98 kg/m
2
and a pe cen age excess weigh loss o 68.14% 67.89%. The e was clea imp o emen o
bo h he blood p essu e and glucose le els. Th ee-dimensional slee e gas ec omy is
sa e, iable, and ully ep oducible compa ed wi h 2-D su ge y, imp o ing isualiza ion
o he su gical ield, sa e y, and su geon con enience. Randomized s udies in ol ing
la ge pa ien samples a e needed o he compa ison o esul s.
Key wo ds: 3-D lapa oscopy – Ba ia ic su ge y – Me abolic su ge y
Co esponding au ho : Fe nando Ma ı
´nez-Ubie o, MD, PhD, Jose Ma ia Laca a 37, Za agoza, Spain.
Tel.: þ34 649 85 40 04; Fax: þ34 976 22 94 88; E-mail: [email p o ec ed]
1134 In Su g 2015;100
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In ecen yea s, lapa oscopic su ge y has become
clea ly indica ed in ba ia ic and me abolic su -
ge y. This su gical echnique has made i possible o
educe mo bidi y and mo ali y in compa ison wi h
con en ional open su ge y, and o sho en hospi al
s ay. In addi ion o he usual 5- oca echnique,
lapa oscopic su ge y has also p oduced sa is ac o y
esul s wi h he single-po app oach, which is
ega ded as less in asi e and a o ds equi alen
ou comes and imp o ed aes he ic esul s.
Mo e ecen ly, he possibili y o using h ee-
dimensional (3-D) su ge y has been conside ed.
The ilm A a a (James Came on, 2006) ep esen ed
a s a ing poin o a numbe o mul ina ional
medical enginee ing companies who launched
p ojec s ha now allow us o use 3-D lapa oscopic
sys ems. This new echnology o e s he pe cep ion
o dep h, which was no p e iously a ailable.
Slee e gas ec omy is one o he su gical ech-
niques p esen ly used o ea obesi y. I was ini ially
ega ded as i s -s ep su ge y in pa ien s wi h a high
body mass index (BMI), be o e pe o ming bilio-
panc ea ic di e sion. Slee e gas ec omy is cu en ly
conside ed o be a es ic i e echnique ha can be
used as a sole op ion in mo bid obesi y, e en when
accompanied by diabe es melli us, as con empla ed
by he In e na ional Slee e Gas ec omy Expe
Panel Consensus o 2011.
Th ee-dimensional lapa oscopic slee e gas ec o-
my equi es 5 po s, like he wo-dimensional (2-D)
lapa oscopic echnique, and one o hem mus be
enla ged o ex ac he sec ioned s omach. Howe e ,
3-D isualiza ion is e y use ul in all he su gical
s eps, as i imp o es spa ial o ien a ion and can
inc ease he sa e y o he su gical echnique.
The p esen s udy analyzes he esul s o 3-D
lapa oscopic slee e gas ec omy a e a sho 1-yea
ollow-up pe iod, wi h a iew o e alua ing i s
sa e y and easibili y in pa ien s wi h se e e o
mo bid obesi y and ype 2 diabe es.
Ma e ials and Me hods
Be ween Janua y and Sep embe 2013, we pe -
o med 3-D lapa oscopic slee e gas ec omy in 60
pa ien s wi h se e e o mo bid obesi y and como -
bidi ies. The inclusion c i e ia we e based on he
Na ional Ins i u es Consensus De elopmen Panel
epo (1991). Acco dingly, we included pa ien s
wi h BMI 35 kg/m
2
associa ed wi h como bid
condi ions o pa ien s wi h BMI .40 kg/m
2
wi h o
wi hou como bidi ies.
Su gical P ocedu e
Su ge y was pe o med unde s anda d gene al
anes hesia wi h o o acheal in uba ion and no
cen al enous ca he e iza ion. Rocu onium was
used as muscle elaxan . Neu omuscula moni o ing
was pe o med wi h TOF-Wa ch SX (O ganon L d,
Dublin, I eland). The ime o ex uba ion was de ined
by a ime o ligh (TOF) a io o o e 0.9, wi h he
adminis a ion o sugammadex (2 mg/kg) i lowe
han his alue a he end o he ope a ion. The
pa ien was placed in supine decubi us and in he
an i-T endelenbu g posi ion, wi h he su geon be-
ween he legs and an assis an on each side.
We used an Olympus 3-D lapa oscopic sys em
(Olympus L d, Hambu g, Ge many) equipped wi h
op ics (Endoeye Flex 3D, Olympus) using 2 high-
esolu ion came as encapsula ed a he dis al ip o
he de ice and wi h high-densi y imaging senso s in
he ideo-endoscope. The ip allows angula ions o
1008in 4 di ec ions and o e s e y use ul isuali-
za ion o he su gical ield, pa icula ly in less-
accessiblezones.A any ime,andbysimply
p essing a bu on, we can swi ch om 3-D o 2-D
isualiza ion and ice e sa. No ocusing o he
endoscope is needed.
The su gical echnique in ol ed a con en ional 5-
po app oach, accessing he abdominal ca i y
h ough an op ical oca . The pylo us was i s
iden i ied, and a a dis ance o 4 cm, we s a ed o
mobilize he g ea e cu a u e o he s omach,
sec ioning i s essels wi h Caiman (Aesculap,
Tu lingen, Ge many) o he angle o His, whe e
we isualized he le c us o he diaph agm. Any
adhe ences be ween he pos e io su ace o he
s omach and he panc ea ic capsule we e emo ed,
and he anes he is hen ad anced a 36-F ench
bougie o he gas ic an um. Resec ion o he
an um was s a ed wi h Echelon 60 Endo lex
(E hicon Endo-Su ge y, Cincinna i, Ohio) and gold
load (3.8 mm), lea ing a leas wice he wid h o he
bougie a he le el o he incisu a angula is. This
was ollowed by esec ion o he gas ic co pus and
undus, using he bougie wi h blue loads (3.5 mm).
On g asping wi h he endos aple and be o e
igge ing he de ice, he anes he is checked ha
he ube was mobile, in o de o a oid apping i by
acciden . We wai ed a leas 15 seconds be o e each
igge o he endos aple , and usually equi ed a
o al o 5 o 6 igge s o ully sec ion he s omach.
Wi h he las igge , we kep away om he
esophagus, espec ing he a pad in his a ea, and
igge ed he de ice a a dis ance o a leas 1 cm
THREE-DIMENSIONAL LAPAROSCOPIC SLEEVE GASTRECTOMY MARTI
´NEZ-UBIETO
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ou side he angle o His. We did no use bu ess
ma e ial a all o ein o ce he s aple line. O e -
sewing was pe o med wi h polyp opylene along
he en i e sec ioned gas ic ma gin. A me hylene
blue–leak es was pe o med a he end o he
ope a ion, in oducing he solu ion h ough he
bougie and p e iously p essing upon he gas ic
an um. An aspi a ion d ain was placed along he
sec ion ma gins o 5 o 7 days. The oca on he le
side a midcla icula le el was enla ged o ex ac
he esec ed s omach.
Resul s
The s udy was ca ied ou be ween Janua y and
Sep embe 2013 and included 60 pa ien s (34 men
and 26 women). The mean body weigh o he
pa ien s was 114 kg ( ange, 92–172), wi h a mean
p eope a i e BMI o 44 65.21 kg/m
2
. The mean
pa ien age was 42.6 yea s.
The main como bidi ies we e ype 2 diabe es (16
pa ien s), a e ial hype ension (8 pa ien s), and
obs uc i e sleep apnea (10 pa ien s). A cholecys-
ec omy was also pe o med in 3 cases owing o he
p esence o galls ones.
Su ge y p o ed une en ul in all cases, and he
con e sion a e o open su ge y was 0%. The mean
du a ion o he p ocedu e was 71 649.6 minu es.
The 3-D sys em was used in all cases, and swi ching
o 2-D was only pe o med on an isola ed basis o
compa e ision be ween he 2 sys ems.
As in aope a i e complica ions, we eco ded a
single case o e ope i oneal bleeding on inse ing
he op ical oca . Comp ession was applied o
se e al minu es, wi hou he need o su ge y o
ans usions. Hemos asis a he end o su ge y was
sa is ac o y.
The mean hospi al s ay was 3.0 61.2 days. The e
was no mo bidi y–mo ali y in ou se ies, and he
pa ien s emained on a liquid die o 20 days,
ollowed by a mashed die un il 1 mon h a e
su ge y, when ood o no mal consis ency was
allowed. Vomi ing was eco ded du ing he i s
mon h in 12 pa ien s, g adually dec easing in
quan i y un il ull esolu ion 1 mon h a e he
ope a ion, wi hou he need o complemen a y
ea men measu es. We only insis ed on he
equen inges ion o ood in small amoun s,
wi hou mixing solids and liquids. The pa ien s
ecei ed omep azole 40 mg ia he o al ou e
h oughou he ollow-up pe iod.
O e he 12 mon hs o ollow-up, he mean body
weigh o he pa ien s was 88 kg ( ange, 71–121),
wi h a pe cen age excess weigh loss o 68.14% 6
7.89%. The BMI 1 yea a e su ge y was 30.56 6
3.98 kg/m
2
. In ou uni , slee e gas ec omy is he
mos used echnique o ba ia ic su ge y, and i is
used as he p ima y p ocedu e, including supe -
obese pa ien s in ou p o ocol. None o ou pa ien s
was subjec ed o u he p ocedu es.
Twel e o he diabe ic pa ien s equi ed no
medica ion, and 4 achie ed diabe es con ol wi h
o al an idiabe ic d ugs alone, wi hou he need o
insulin as be o e su ge y. O impo ance, in hose
pa ien s who had had mo e han 10 yea s diabe es
p og ession and who had needed ea men wi h
insulin (4 pa ien s), imp o emen was achie ed;
hey no longe needed insulin and con inued
ea men wi h only o al an idiabe ic medica ion.
In hose pa ien s wi h less han 10 yea s diabe es
p og ession and who had no been ea ed wi h
insulin, con ol o hei diabe es was achie ed wi h
die and wi hou need o medica ion.
O he pa ien s wi h a e ial hype ension, 4 we e
able o suspend medica ion, and 4 equi ed a lowe
d ug dosage. Fu he mo e, obs uc i e sleep apnea
was esol ed in all cases.
Discussion
The new 3-D lapa oscopic sys ems allow imp o ed
isualiza ion, wi h he sensa ion o dep h, and
he e o e be e spa ial o ien a ion. The aim o his
new echnology is o make su ge y mo e con enien
and as e , wi h inc eased sa e y and consequen ly
less mo bidi y and mo ali y. Imp o ed ision,
ounded upon 3-D isualiza ion, is he goal o bo h
hese mode n de ices and o obo ic su ge y—
hough he la e is mo e expensi e and in ol es a
longe lea ning cu e. The 3-D sys ems a e a li le
mo e expensi e han he con en ional 2-D sys ems,
hough handling is simila in bo h.
In ou expe ience, and om he s a o 3-D
su ge y, he lea ning cu e was e y sho , as we
quickly became used o he new o m o isualiza-
ion. In he i s cases, he du a ion o su ge y was
simila o ha o p e ious ope a ions using 2-D
sys ems and was seen o sho en as ou expe ience
wi h 3-D lapa oscopy inc eased. This imp o emen
in lapa oscopic skills is also e idenced when expe
and no el su geons pe o m a se ies o pel i aine
asks—be e esul s a e ob ained wi h he 3-D
sys ems han wi h he adi ional 2-D sys ems.
1–5
In his espec , he 3-D echniques may sho en he
lea ning cu e, he eby allowing su geons o gain
expe ise in a b ie pe iod o ime.
1,2
MARTI
´NEZ-UBIETO THREE-DIMENSIONAL LAPAROSCOPIC SLEEVE GASTRECTOMY
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Men ion mus also be made o he possible
nega i e e ec s o hese new 3-D sys ems. The i s
epo s desc ibed su geon dizziness and nausea,
hough his is no longe a p oblem wi h he new
sys ems. A pending issue is possible eye a igue
wi h his new echnology. As e idenced by ou own
expe ience, a numbe o ules should be ollowed
when pe o ming su ge y o his kind:
1. The mode n 3-D sys ems use 2 high- esolu ion
came as a he dis al ip o he de ice. We mus
es ablish an adequa e dis ance be ween ou eyes
and he moni o , seeking s e eopsis com o
zones o op imum isualiza ion, and a oiding
he limi a ions o he human eye.
6
In ou sys em,
he dis ance be ween he eyes o he su geon and
he moni o should be 2.5 imes he diagonal
leng h o he moni o .
2. The cu en 3-D moni o s a e less b igh han he
2-D moni o s; i he e o e may be use ul o
da ken he ope a ing oom.
6
3. B usque mo emen s o he op ics a e o be a oided
as he esul ing discom o is g ea e han in he
case o b usque mo emen s wi h 2-D sys ems.
4. I is ad isable o occasionally and al e na ely
close one eye and hen he o he in o de o
disce n whe he he op ics a e di y, as his is
ha de o de e mine han wi h he 2-D sys ems.
5. The op ical oca mus ha e gene ous space
wi h espec o he o he oca s in o de o a oid
con ac ha can mo e he lens o ins umen s
loca ed e y close o he came a, he eby al e ing
he iew.
Ou esul s indica e ha hese sys ems may
become e y use ul in he nea u u e. Fo a ew
seconds, we compa ed 2-D e sus 3-D isioning in
pe o ming common asks such as su u ing o
examining he angle o His, swi ching be ween he
2 modes by simply p essing a bu on on he op ics.
All eam membe s ag eed ha isualiza ion was
be e in 3-D, and ha consequen ly he su gical
s eps we e sa e — his being he undamen al
ad an age sough by 3-D lapa oscopic su ge y.
In conclusion, u he p ospec i e s udies a e
needed compa ing 2-D and 3-D lapa oscopic su -
ge y, wi h he e alua ion o su ge y imes, sa e y,
and mo bidi y and mo ali y. Pe haps, in he nea
u u e, imp o emen in he 2-D sys ems should be
swi ched o 3-D.
Acknowledgmen s
The au ho s ha e no con lic s o in e es o inancial
ies o disclose.
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THREE-DIMENSIONAL LAPAROSCOPIC SLEEVE GASTRECTOMY MARTI
´NEZ-UBIETO
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