Specimen Extraction After Laparoscopic Sleeve Gastrectomy

Dear Editor:

The way in which authors present their methodology for extracting the gastric specimen after laparoscopic sleeve gastrectomy may have a positive impact on the patient's postoperative outcome in terms of trocar-site pain and esthetic appearance. From the enlargement of the trocar-site port to natural orifice translumenal endoscopic surgery (NOTES^®; American Society for Gastrointestinal Endoscopy [Oak Brook, IL] and Society of American Gastrointestinal and Endoscopic Surgeons [Los Angeles, CA]), ¹ all of the various ways to “skin the cat” demonstrate the surgeons' interest in minimizing the surgical access site and increasing patients' satisfaction. This letter provides comments on the article by Gorecki et al. ² published in this journal.

Since 2010, in our practice, we have extracted the gastric specimen via the 12-mm port without removing the trocar. At the end of the procedure, before extraction, the stomach remnant is transected with shears intraabdominally until it becomes a long thin “noodle” that fits into the trocar lumen. We have published our results of an observational study that included 49 patients who underwent this technique, compared with 133 patients in whom we used the conventional extraction. ³ The conclusions of Gorecki et al. ² reinforce our previous finding that the stomach can be safely extracted after intraabdominal partitioning without increasing postoperative complications and without a significant increase in operative time. After the stomach is partitioned, not only can it be extracted through a 15-mm trocar as the case report ² suggests, it can also be easily extracted via the 12-mm trocar as we demonstrated in our published study. ³ The majority of surgeons believe that a 15-mm trocar still requires fascia closure, which can lead to significant postoperative discomfort. We do not close the fascia for the 12-mm port site, resulting in less postoperative discomfort.

In our opinion this technique is easy, feasible, and reproducible, and patient satisfaction is considerably improved as the trocar-site closure pain is decreased and the cosmetic appearance is less impacted.

An important aspect that has to be carefully considered is the theoretical risk of tumor seeding from a potentially undetected gastrointestinal stromal tumor that could exist in the resected specimen. This risk can be successfully mitigated by careful preoperative, intraoperative, and postoperative evaluation of the stomach. We routinely perform upper gastrointestinal endoscopy preoperatively for all our patients, and we take the time to examine the serosa of the stomach before proceeding to opening it intraabdominally. If any suspicion of a lesion arises, we perform the extraction in the classic approach. These precautions, along with postoperative surveillance of the pathology specimen, should minimize this potentially adverse event.