Bleeding After Laparoscopic Sleeve Gastrectomy

We present a case of complicated laparoscopic sleeve gastrectomy performed by a surgical trainee.
The aim of our video was to show, how easily can complication occur and how hard it is to manage that problem. We found this topic to be very didactic, especially for young surgeons.
During laparoscopic sleeve gastrectomy, we use harmonic scalpel, which is a very good surgical instrument, but very sensitive to tissue traction. Harmonic scalpel must be used very gently with good tissue feeling. In this case excessive traction led to bleeding in the postoperative period.
Ligation of the short gastric vessels is one of the most difficult parts of sleeve gastrectomy, because the procedure is carried out in immediate proximity to the spleen and if the injury of the short vessels occurs, it can be very difficult to obtain hemostatis. In this patient, excessive traction during the use of harmonic scalpel by a junior surgeon caused bleeding from short gastric vessels. The bleeding cut ends of the short gastrics were coagulated with harmonic scalpel. As you can see in this case, the surgeons thought that the bleeding was adequately controlled and sleeve gastrectomy was continued. The leak test was negative and at the completion of initial operation no bleeding was observed.
Unfortunately on the first postoperative day the patient showed signs and symptoms of active bleeding, so that the decision was made to perform re-operation.
A big hematoma was found as soon as the camera was inserted into the abdomen. The suction-irrigation device was used to remove it.
Progressing with re-laparoscopy, the bleeder was localized. A delta-shape liver retractor was used to retract fatty tissue obscuring the view near the spleen.
Blood was coming from the cut short gastric vessels between the cardia and the superior pole of the spleen.
In this case bipolar forceps were used to provide proper hemostasis. Suction, irrigation, and bipolar devices were repeatedly used to ensure that bleeding stopped. At the end hemostatic material was applied near the spleen and the drain was left in place. Postoperative period was uneventful.