LAUSR

Gastric leakage after sleeve gastrectomy (SG) is the “major” complication occurring in approximately 2% of cases [1–5]. After 4 months of unsuccessful medical treatment [6], a fistula becomes chronic [4, 7–9] and the treatment is surgery with 2 main options: total/subtotal gastrectomy when required [9] or Roux limb placement (RLP) when feasible [4, 8, 10]. These techniques are technically challenging in classic laparoscopy, especially laparoscopic RLP. Is there a place for a robotic approach in such surgeries? A 26-year-old female was treated for a chronic gastrocutaneous fistula after laparoscopic SG in our department. After more than 6 months of initial conservative endoscopic management failure (pig-tails, enteral nutrition), robotic Roux limb placement was performed (DaVinci XiTM system, Intuitive Surgical Inc®, Sunnyvale, CA) to treat the chronic fistula. Although difficult, the sleeve tube was entirely dissected. The left hepatic lobe was adhered to the parietal wound and was unmobilized. The lower omentum was opened to dissect the right pillar of the diaphragm to lower the right part of the esophagus. Concerning the left part of the gastric tube, straight adhesions of the greater omentum and pancreas were carefully dissected from the inferior part to the top of the gastric tube. At the level of the esogastric junction (cardial region), the fistula was opened via meticulous dissection of the spleen and of the left pillar of the diaphragm (Fig. 1a). Scar tissue was resected to prepare the fistula orifice. Then, the left part of the esophagus was mobilized to lower the esophagus into the abdomen. A Roux-en-Y reconstruction was then performed using a short biliary limb 20–30 cm in size and an alimentary limb 60–70 cm in size: