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SITU is a feasible alternative to standard laparoscopic SG

SITU laparoscopic SG is safe and feasible

Single-incision transumbilical (SITU) laparoscopic sleeve gastrectomy is safe and feasible, and can be performed without changing the existing principles of the procedure, according to a study published in the Journal of Minimally Access Surgery.

The paper’s authors from the Department of Surgery, Medical University Innsbruck, Innsbruck, Austria, write that at the moment single-incision laparoscopic surgery (SILS) is “considered to be a bridging technique to natural orifice transluminal endoscopic surgery (NOTES)”.

They added that although the SITU approach beneficial, particularly for cosmetic reasons, short-term evidence regarding its application in morbid obesity is limited.


To assess the validity of SITU sleeve gastrectomy, they examined the short term results and technical consideration in ten consecutive female morbidly obese patients (mean preoperative BMI 40.4 range, 35.1-44.9) who underwent SITU-SG as a primary, and potentially definitive, bariatric procedure between June 2010 and June 2011.

During the procedure, patients were placed in the supine position and a 3-4cm transumbilical skin incision was made down to the linea alba, where a 4cm fascial incision was made.  After the peritoneum was incised, the surgeons deployed the GelPOINT advanced access platform (Applied Medical) and three 5mm GelPOINT trocars were inserted.

The operators used a 5mm LigaSure (Covidien) and a 5mm flexible grasper, to mobilise the greater curvature of the stomach starting from a point 6cm proximal to the pylorus. The mobilsed portion of the greater curvature of the stomach was then taken by a 5mm flexible grasper and pulled to the left side in the direction of the underside of the left hepatic lobe, explained the authors.

Once the stomach was been completely mobilised, they inserted a 36Fr orogastric tube orally into the pylorus and placed against the lesser curvature.

“This will calibrate the size of the gastric sleeve, prevent constriction at the gastroesophageal junction, and provide a uniform shape to the entire stomach,” they write. “Then, we changed one 5mm trocar into a 12mm trocar.”

The gastric transection was started at a point 6cm proximal to the pylorus, leaving the antrum and preserving gastric emptying. They then inserted a  long laparoscopic reticulating 60mm XL Endo-GIA stapler with a golden cartridge (Echelon Flex, Ethicon-Endosurgery) through a 12mm trocar. The stapler was fired consecutively along the length of the orogastric tube until the angle of His was reached.

One day post-surgery, an upper gastrointestinal contrast study was performed to rule out leaks and obstruction. Patients were discharged six days day after surgery.


The results revealed a mean operative time of 98 minutes (range, 77-137) and a mean hospital stay of 6.3 days (range, 5-7). Interestingly, the authors noted that the long stay was caused by the Austrian insurance and clearing system, although most patients could be discharged home day two.

They reported no mortality, peri- or post-operative complications, and the mean .post-operative BMI was 30.8 (range, 25.9-38.7). After a mean follow-up period of 5.2 months (range, 1-12), the patients were losing a mean of 26.2kg excess weight (range, 15-60kg) from their initial assessment.

“Patient selection is important for the single-incision bariatric surgery, and some patients are not well-suited for these procedures,” the authors write. “We have found that in a select group of obese patients, for example with a BMI 35-45, this procedure can be performed entirely through the umbilicus without the need for any extraumbilical incisions.”

They also reported that in this series, all patients were “very satisfied” with the cosmetic outcomes and excess weight loss.

“Single-incision transumbilical laparoscopic sleeve gastrectomy is safe, technically feasible, and reproducible, and it is a feasible alternative to standard laparoscopic SG,” conclude the authors. “We are satisfied with our initial experience, and we plan to continue using this approach whenever possible. However, this approach should be tailored according to the patient's body habitus and liver size.”

The complete article can be accessed here.

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