Three-dimensional laparoscopic sleeve gastrectomy: improved patient safety and surgeon convenience

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 Downloaded om h p://me idian.allenp ess.com/in e na ional-su ge y/a icle-pd /100/6/1134/2210015/in su g-d-14-00287_1.pd by Uni e sidad de Za agoza. Biblio eca use on 16 Feb ua y 2021 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 In Su g 2015;100 1135 Downloaded om h p://me idian.allenp ess.com/in e na ional-su ge y/a icle-pd /100/6/1134/2210015/in su g-d-14-00287_1.pd by Uni e sidad de Za agoza. Biblio eca use on 16 Feb ua y 2021 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 1136 In Su g 2015;100 Downloaded om h p://me idian.allenp ess.com/in e na ional-su ge y/a icle-pd /100/6/1134/2210015/in su g-d-14-00287_1.pd by Uni e sidad de Za agoza. Biblio eca use on 16 Feb ua y 2021 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. Re e ences 1. Kong SH, Oh BM, Yoon H, Ahn HS, Lee HJ, Chung SG. Compa ison o wo- and h ee-dimensional came a sys ems in lapa oscopic pe o mance: a no el 3D sys em wi h one came a. Su g Endosc 2010;24(5):1132–1143 2. S o z P, Buess GF, Kune W, Ki schniak A. 3D HD e sus 2D HD: su gical ask e iciency in s anda dized phan om asks. Su g Endosc 2012;26(5):1454–1460 3. Wagne OJ, Hagen M, Ku mann A, Ho gan S, Candinas D, Vo bu ge SA. Th ee-dimensional ision enhances ask pe o - mance independen ly o he su gical me hod. Su g Endosc 2012; 26(10):2961–2968 4. Honeck P, Wend -No dahl G, Rassweile J, Knoll T. Th ee- dimensional lapa oscopic imaging imp o es su gical pe o - mance on s anda dized ex- i o lapa oscopic asks. J Endou ol 2012;26(8):1085–1088 5. Tanagho YS, And iole GL, Pa adis AG, Madison KM, Sandhu GS, Va ela JE. 2D e sus 3D isualiza ion: impac on lapa o- scopic p o iciency using he undamen als o lapa oscopic su ge y skill se . J Lapa oendosc Ad Su g Tech A 2012;22(9):865– 870 6. Kune W, S o z P, Ki schniak A. Fo 3D lapa oscopy: a s ep owa d ad anced su gical na iga ion: how o ge maximum bene i om 3D ision. Su g Endosc 2013;27(2):696–699 THREE-DIMENSIONAL LAPAROSCOPIC SLEEVE GASTRECTOMY MARTI ´NEZ-UBIETO In Su g 2015;100 1137 Downloaded om h p://me idian.allenp ess.com/in e na ional-su ge y/a icle-pd /100/6/1134/2210015/in su g-d-14-00287_1.pd by Uni e sidad de Za agoza. Biblio eca use on 16 Feb ua y 2021