Weight loss
surgery or,
what's more, properly known
as Bariatric surgery
has become increasingly common
over the years in both
the United States and worldwide.
Of all the available procedures,
the one that's being performed
the most frequently these days is
what's known as a Sleeve
Gastrectomy,
which more or less turns
your stomach into the size of a banana.
So.
In today's video,
with the help of the cadavers
here in the lab,
we're going to see exactly
what happens during this procedure.
We'll see what they cut,
how they cut it, and discuss
the repercussions
of removing
around 80% or so of your stomach.
It's going to be bananas.
Let's do this.
So
let's start off
by discussing the relevant and necessary
anatomy to understand
the procedure itself.
So what you're looking at here
is going to be the stomach
as it transitions
into the small intestine.
Now, when you first digest food, it's
obviously going to travel
into the stomach via the Esophagus.
And you can see
this right
here is the lower
most aspect of the Esophagus.
And that will transition
into the first area of the stomach,
which is known as the Cardia.
I'm just circling it with my probe here.
It's called the Cardia
because it's in close
proximity to the heart,
which would essentially
be right around this area here.
Then I'm going to use the probe
to kind of
do my best
to show you this next area
that I'm now circling,
which would be called
the Fundus Fundus translates to end.
So this is essentially
the end of the esophagus,
or at least that's
how I've always taught it.
Then the rest of the st...,
no not the rest,
but the vast majority of the stomach,
I should say,
is what's known as the body.
And I'm kind of fanning
over the entire distance in the body
is the highly expandable
portion of the stomach.
I mean, the whole stomach will expand.
But I think you can imagine
how many other structures are around here
that you just don't want
the stomach expanding into.
But in this area,
there's not much going on.
So it makes sense
that the stomach can start pushing here
as it's getting filled up.
Next, we have what's known as the Antrum.
D translates to cave
and this is essentially
where digested material
is first going to interact
with the stomach.
So as it drops from the esophagus,
it's going to land in the Antrum
and then that's going to pretty much kick
off the cascade of Digestive processes
that the whole stomach
will then engage in.
Then you have what's known as the Pyloris
,Pyloris translates to gatekeeper,
and it's called that because inside of it
is the pyloric sphincter,
which is an extraordinarily
strong sphincter
that prevents the premature
release of digested contents
into the Duodenum
or the first part of the small intestine.
Now the duodenum also
is going to have connections
from other accessory digestive organs,
the liver is going to be right
next to the stomach and actually
in front of the stomach.
And so that's actually
going to be important
because they have to retract
and lift the liver
in order to see the stomach
during the procedure.
But the liver is going to drop
along with the gallbladder bile
into the duodenum.
And then behind the stomach
is what's known as the pancreas.
And the pancreas is going to contribute
pancreatic enzymes
into the duodenum,
which is also combined
with the bile and the hydrochloric acid.
All of it's
going to contribute
to further aid in digestion.
And then the last things
I want to bring to your attention to
and then we can actually talk about
the procedure
are going to be these
two curvatures here.
This smaller curvature is
called the lesser curvature,
and this is where
you're going to have like fatty apron
that's going to help
connect the stomach
to the liver itself
as well as to the duodenum.
But this longer one is the more important
curvature called the greater curvature.
And hanging off of it
would be a large fatty
apron called
the greater omentum
that would drape over
the small intestine.
They're going to have to cut that away
during the procedure.
So just make sure to keep that in mind.
Now, in order
to receive a sleeve gastrectomy
or any bariatric surgery for that matter,
there are specific requirements
that the patient will need to abide by,
and these are given down
by the specific institutions.
But typically
what you're going to have to do
is demonstrate
that you've been unable
to lose weight
despite exercising
and making dietary changes,
as well as having a BMI or body mass
index of 40 or above.
Now they can lower that down to
35 or higher.
But then you're also going
to have to have
another comorbidity
with it, such as type two diabetes,
sleep apnea,
or maybe even high blood pressure.
So when it comes to the actual procedure,
the patient is going to be given an I.V.
and then they're going to go underneath
general anesthesia,
which probably makes
a ton of sense to you.
This is not something
you want to be awake
or coherent for in any capacity.
But once that's happened, they-
the surgeons will then perform
five laparoscopic incisions.
So laparoscopic
incisions are small incisions that allow
for very precise surgical technique.
And it makes it
so you don't have to create this
gigantic injury,
open up the body
just so you can see
what you're looking at right
through these tiny incisions.
ress can insert cameras
and other surgical equipment.
It's just makes things a lot easier
in terms of recovery and lowering
risk for the patient.
In one of those laparoscopic incisions,
they'll insert a port,
which is essentially just a tube.
Then they will insert
what's known as a veress needle.
A veress needle will then deliver carbon
dioxide gas into the abdominal cavity,
creating a purposeful pneumoperitoneum.
What this means is
you just have gas going
inside of there
and separating the tissues.
Now you can have a non
purposeful pneumoperitoneum
and that is a very serious condition.
But in this case
you're just lifting
the tissues away from one another
so you can actually see what you are
looking at
in order to perform the surgery.
Now they'll initially increase
that pressure to quite a high amount
and then they're going to draw it back
once they know
they've got everything in place.
Now, in another one of those
laparoscopic incisions, they will
then insert
a retractor that can lift the liver
out of the way
so they can see the stomach at all.
Another one of those incisions
will be
where they will pull out the stomach
or the portion of the stomach
that they have dissected away.
And then those last two
are going to be where they can insert
surgical instrumentation
to perform the surgery itself.
Now, once they've
kind of expanded everything in there,
they will then insert a nasogastric tube,
and that is a
tube that will go in the nose
through the nasal cavity
and then down the throat,
down the esophagus,
and then enter into the stomach itself.
And what they'll do
is they'll use that to decompress
the stomach
you don't want in the air or gas
or anything inside of here.
You want the stomach completely collapsed
from there.
They're then going to have to cut away
that greater omentum, that fatty apron
we talked about.
Now,
the greater omentum
has many blood vessels
that will actually be provide
in blood supply
to this greater curvature.
So what they'll do
is when they're cutting it away,
they're doing something called ligation,
where they're actually
sealing off the blood
vessels, preventing blood loss.
So they're not only just
it's not like
they're just snipping in a way,
because then you'd have blood
going everywhere.
They're preventing blood loss
and litigating the blood vessels.
Once they've done that,
this is where they'll insert
what's known as a calibrating bougie,
a calibrating bougie
is essentially
just a cylinder that they will insert
that will go through the esophagus
and go into the stomach,
and it will actually trace
that lesser curvature
and go down towards the pyloris.
Now there's different sizes of bougie's
and it just kind of depends
on the institution,
but just understand
there's going to be a cylinder
that is going to be traveling here
and this is going to be necessary
for the surgeons to understand
just how narrow of a sleeve
they're going to create. Right.
So I've got my trusty banana here.
And if you think of the bougie, I mean,
the banana is going to be larger
than the bougie would be,
but you can kind of understand that
we want to create this shape
on the stomach.
So by inserting the bougie
into the stomach,
that gives them an area to trace.
So once they have that in there,
they're then going to take a really cool
surgical instrument
called a powered stapler.
And what this does
is it simultaneously cuts through tissue
and then delivers staples on either
side of what it's cutting.
So what they can do
is they're going to come in at the antrum
when they come in,
and they cut the antrum
and start stapling
there, then going to; if i
put the banana back.
They're coming in an angle here.
They want to create like a flap.
You don't want to just like, come in
because then it's too narrow here
and that can create some complications
We'll talk about in a moment.
So they'll come in
kind of like
at this angle,
creating this flap at the Antrum
and towards the Pyloris.
And then they're going to go right
alongside that bougie.
And as they're doing that,
it's delivering staples
to the side that they're cutting away,
which is going to be all of this
portion of the stomach.
And they're stapling this side
that has the bougie.
And this is going to probably
make a ton of sense to you
that you don't want
to just cut the stomach
and then suture afterwards,
because the stomach,
even though it's been decompressed,
even though they put the nasogastric
tube in there,
there can still be
hydrochloric acid as well as blood.
I mean, you're cutting into an organ.
There's going to be blood
that's going places.
So by stapling,
as you're cutting it all
at the same time,
you're preventing blood
loss and gastric juices from emptying in
to that abdominal cavity.
It's a really cool thing.
So what they'll do is
then they trace
and go alongside that bougie
until they get up top towards the fundus.
And again,
what they don't want to do
is create two narrow of an area here.
Otherwise
you run the risk of creating
what's called a stricture.
A stricture is just when it's too narrow
and something can't pass.
I mean,
if you cut away
the majority of the stomach
and you have too narrow of a space,
well now it's nonfunctional
and nothing can get through.
You have a serious problem on your hands.
It's not like you can regrow
stomach here.
So what they'll do
is when they get to the funding,
they will actually create
another flap up here,
which they call a dog ear.
So again,
bringing the banana back,
they come in, they trace long
and then when they get here,
they create a little dog ear
that will provide
just a little more space.
Then once they've done that,
they then have a fully separated area.
At this point, they've cut away
80% of the stomach.
They've essentially cut off
the body of the stomach.
They came in at the antrum
and then they left a good portion
of the fundus.
Not all of it,
but a good portion of the fundus
the majority of the stomach
That has been removed
is going to be the body.
What they will
then do is take that body and remove it
from one of the ports
in one of those laparoscopic incisions
that we discussed.
Now, what they also can do
is remember that
that greater omentum
was attached to the stomach.
And what you don't want
is this newly sleeved out stomach.
And if I hadn't made this
clear, I'll make it clear.
Now, the reason
why it's called a sleeve gastrectomy
is that the sleeve portion,
this is the sleeve, right?
We've created this gastric sleeve here.
What you don't want it to do
is rotate and turn on itself.
So one option
they have
is to actually take that greater omentum
and they will actually suture it
to this new, greater curvature
to prevent the stomach
from flipping on itself.
Some surgeons will elect
to just leave it there.
So it's just going to kind of hang out.
But that is something
that is is an option.
But they will
then take that portion
of the stomach, remove it,
and then that's when they can
then decompress.
They can remove all the carbon
dioxide from the abdominal cavity,
getting rid of that pneumoperitoneum,
and they can then
put the liver back in place,
they can suture everything up.
And the procedure is essentially done.
Now, the reason
why this procedure is
so effective really comes down
primarily to two things.
And the first
is going to be
a reduction in the amount of a hormone
called ghrelin.
Ghrelin is a hormone
that's involved in hunger
as well as satiation or feeling full.
And just the overall breakdown
and processing of energy in the body.
Now, ghrelin is going to be produced
by the cells of the stomach.
So if you remove 80% of the stomach,
I mean, I don't want to say
you get rid of 80% of the ghrelin,
but you are going to be removing
a significant amount of it, which is why
patients who've had a sleeve
gastrectomy will even say, you know,
I just don't really feel hunger
like I did.
The second reason is,
I mean, if you've removed
80% of the stomach
and you have this narrow
sleeve,
then obviously it's going to fill up
faster, meaning
you're going to
physically feel full, quicker,
and that means you're going
to consume less calories.
And if the end of the day,
that's really how weight loss occurs.
I mean, it's
just the laws of physics, right?
y you consume
less calories
than you're actually burning,
then you are going to lose weight.
It's not as though,
you know, we're in this procedure.
You're getting liposuction
or lipo plasty.
In the end of the day,
what really comes down to is
just you're not going to
want to eat as many calories
and then you can't physically
eat as many calories,
at least in the early stages.
Now,
I don't want to make it seem
as though someone still can't overeat.
The stomach
once it's
healed, is still going to be capable
of increasing in size.
I mean, it's not as though
if we've created the sleeve,
the stomach
grow back to its normal size
if you continually
overeat and overindulge.
But it still can increase in size,
which means
it's going to be super important
after this procedure to then
continue making lifestyle changes.
Right.
In terms of exercise
and those dietary changes. Right.
And you're going
to have to control your portions
and things of that nature
because while this can lower, obviously,
the amount of calories
that you're consuming, I mean, over time,
you can start building up,
especially if you're eating
more calorically dense foods.
Now, in terms of recovery,
the patient can expect
to spend around 2 to 4 days
inside of the hospital.
And during that time,
they're going to be testing for leakages
because obviously
if they were leaking anywhere
along where the staples are,
that's a bad thing.
You don't want stomach acid
or any of the digestible contents
you've been consuming to leak out
into the abdominal cavity.
Assuming there are no leakages,
they'll then be given the patient water,
tea, soups
and then they can leave the hospital
and then move to eating more juicy
type foods for the next two weeks.
Then after that
they can start eating more soft
like foods,
but they'll be eating pretty much
only juicy,
soft, liquidy diet
for pretty much an entire month.
And then after that,
they can start moving
to more of solid foods.
As with any surgery, there's
going to be potential complications
and risks.
Now, we've already spoken about leakages
being one of those,
but another one
is going to be acid reflux.
So if we think about it again,
you have this narrow sleeve now
there's less space for the stomach acid.
It's possible
for that to more easily
and readily go into the esophagus
and create the
oh so fun feeling of heartburn
like we already mentioned too,
It's possible
for the stomach to move now
and because it's now
less anchored to the body
and potentially move into an area
you don't want to creating
a type of hernia.
We also already mentioned stricture
being a possibility, Right.
You don't want
if it's too narrow as possible,
it could get blocked
and that could create a significant issue
as well.
Blood clots are also a possibility
with any surgery.
I mean, when you're cutting through blood
vessels, you're creating injuries.
So, again,
the surgeons are planning for this
and they're doing and they're educated,
they're doing whatever they can
to limit this as much as possible.
But it is still definitely possible.
But despite all of this,
from my understanding,
a sleeve gastrectomy is still considered,
at least at this point in time,
to be
not only the safest
but the most effective
form of bariatric or weight loss surgery.
Generally speaking.
And the reason
why I say, generally
speaking, is because each
individual is different.
And this is only one
of many different types
of bariatric surgeries
that can be performed.
And each of them
have their own set of pros and cons.
Some of them will actually be more
or rather say better
for certain comorbidities.
So for instance,
if your goal is not only weight loss
but also to combat type two diabetes,
a sleeve gastrectomy
might not be the best option for you,
which is why you'll want to speak
with your bariatric specialist
to ensure that you're going to be
if you're going to go under the knife,
that you're going to be going at it
in a way that's going to be, you know,
just give you
the best set of possibilities.
But generally speaking, this one is
the least invasive,
the least amount of complications,
the least amount of risk.
And it has pretty good outcomes.
I mean, at the end of the day, again,
you're just limiting those calories
by a tremendous amount.
So I still feel like it's probably
okay to say that this is indeed,
generally speaking,
the safest
and most effective
bariatric surgery out there.
It is mind blowing to me
that we as humans
have come up with a procedure
such as this one.
I mean, the powered stapler alone
is ridiculously cool.
I mean, simultaneously
cutting and stapling both.
How cool is that?
It takes
a special mind to come up with solutions
and tech tactics and tools
for complex problems like that.
And it's something that I personally
am always striving to do so myself.
I mean,
I mean not come up
with new surgical techniques,
but finding new tools and tactics
for complex problems
is something I'm constantly striving for,
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Thanks for watching everybody.
I really hope you enjoyed today's lesson
and I will see you in the next video.