Laparoscopic Vertical Sleeve Gastrectomy
Overview – The vertical sleeve gastrectomy is a procedure that involves stapling the stomach in such a way as to create a tube of stomach and removing the excess stomach (about 85%). This does not involve any rerouting of the intestines, but allows for restriction of food. By removing the majority of the stomach, most of the cells that produce a hormone known as Ghrelin (a hormone linked to hunger – click here for WebMD video about ghrelin), are removed and are felt to contribute to the curbing of a patient's appetite.
Laparoscopic sleeve gastrectomy takes about 1–1½ hours. In the operating room, the patient has had Sequential Compression Devices (SCDs, also known as leg squeezers) and a preoperative dose of subcutaneous enoxaparin, as well as a dose of IV antibiotics. The surgery involves insertion of 4 to 5 working 'ports' on the abdomen. A sizing device in placed in the stomach (known as a bougie) and this calibrates the tube size to which the stomach will eventually conform.
Post-op care – The patient is brought from the recovery room to their room or to the intensive care unit (ICU) when alert. Patients with severe sleep apnea, pulmonary hypertension, or intraoperative difficulty will stay overnight in the ICU.
A Patient Controlled Anesthesia (PCA) pump will be ordered for overnight pain control, and strict nothing by mouth is observed: no ice chips, no sips of water, nothing. A swab sponge may be used to keep the mouth moistened. Typically there will not be an nasogastric (NG) tube postoperatively.
Patients should begin walking as soon as they are awake and alert enough to stand and walk with assistance. Early ambulation is an important part of Deep Venous Thrombosis/Pulmonary Embolism (DVT/PE) prevention in surgery for morbid obesity.
The following day (postop day #1), a swallow study may be performed in radiology, to check for a leak, and to be sure that there is no obstruction to liquids. First, water-soluble contrast is swallowed and observed passing through the new-formed stomach. If there is no leak seen, barium is then swallowed and observed passing. Barium is not used until a large leak is ruled out, because free leakage of barium into the peritoneal cavity can be intensely inflammatory and dangerous. If the swallow study is normal, the patient is allowed to begin a Stage 2 diet and may resume medications as written by the surgeon. All medications should be crushed or in liquid form.
Diet stages –
Hot or cold liquids should be avoided right after surgery, as this can lead to pouch irritation and PO intolerance.
Patients typically do not have a foley catheter with this procedure, but if one is placed it should be removed on postop day #1; if this is not ordered, you may ask the surgeon about removing it. Diabetic patients should have orders to check their blood glucose every 6 hours. Many patients with Type II diabetes can be discharged on no medication whatsoever; their caloric intake is so low that some will normalize their blood sugar immediately. The surgeon will decide this based on their in-house blood glucose values.
Patients are typically discharged on postoperative day #1 or #2, on a Stage 2 diet. They will stay on Stage 2 until their 2-week follow up visit with the surgeon. They are instructed to attempt to get 72-96 oz of fluid daily, in order to prevent dehydration. This may involve constant 'sipping' of water, Crystal Light, protein drinks, etc. Typically patients who are doing well with their Stage 2 diet after the first 2 weeks will be advanced to the Stage 3 diet for the next 2 weeks. Just prior to returning to the clinic for their 1 month follow up, patients will have labs drawn and if all is going well at the 1 month visit, they will be advanced to a Stage 4 diet.
It is imperative that patients follow the guidelines set forth by the program for advancing their diet. Taking in solid foods too early on can compromise the stomach pouch and lead to a leak.
Shower – Patients may shower beginning the day after surgery, with their back towards the water. They are instructed to wring out a soapy washcloth over the incision(s) and rinse using the same technique. No baths until the surgeon gives the OK, typically after two weeks.
CPAP / Oxygen – Patients on CPAP or oxygen prior to surgery will need to continue it after surgery. They are instructed to bring their CPAP machine with them on the day of surgery. They must use it at all times while sleeping, whether for naps or at night. Preoperative pressure settings are continued in the hospital.
Exercise – Patients can resume light aerobic exercise (walking, elliptical, stationary bike) when they feel able. No lifting is allowed over 10 pounds for 6 weeks. Driving is not permitted until the patient is pain-free and off all narcotic pain medications. Patients may begin weight training 6 weeks after surgery.
Pain medication – Patients are typically provided with either Lortab elixir or crushed Vicodin or Percocet. Patients with pre-existing chronic pain syndromes requiring narcotics will need to continue seeing their chronic pain specialist. Narcotic prescriptions for pre-existing conditions will not be continued or refilled by the UT Center for Bariatric and Metabolic Surgery. All postoperative medications should be crushed.
Pain medications to AVOID – NSAID use is discouraged early after surgery because it can decrease the protective coating found in your stomach. Patients should be warned against taking NSAIDs such as ibuprofen (Advil, Motrin), naproxen (Aleve), aspirin (ASA, BC Powder, Excedrin). Use of these medications can resume after the first month.
The only exception is physician-recommended ASA as a thromboembolic or cardioprotective medication. If patients are on any of these medications they must also be on an acid reducing medication such as Lanzaprazole (Prevacid).
Smoking – Smoking should be permanently discontinued after gastric bypass. We require all our patients to be smoke-free for six (6) months at the time of surgery. Smoking increases the risk of ulceration, stricture, perioperative pulmonary morbidity, and coronary events.
Vitamins – A chewable multivitamin with iron, and a chewable calcium citrate supplement should be taken daily.
Constipation – Some patients may experience occasional DIARRHEA related to certain foods or related to the new anatomic configuration of their gastrointestinal tract. Some patients may become constipated after discharge, and we recommend taking Milk of Magnesia, one to two tablespoons every six hours as needed. If constipation persists more than 1-2 days or is accompanied by bloating, nausea, vomiting, or abdominal pain, please call us at 210-450-9900. If it is outside of our regular clinic hours (8-5, Monday-Friday), please call the emergency number provided in your patient information packet.
Follow-up appointments – your 2-week and 4-week follow-up appointments are scheduled at the at your pre-op appointment office visit. Please be sure to call us at 210-450-9900 (8 am-5 pm) if you have any questions or if we need to reschedule your appointment.