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Year : 2021  |  Volume : 24  |  Issue : 11  |  Page : 1689-1693

Comparison of stapled versus stapleless sleeve gastrectomy with natural orifice specimen extraction (NOSE)

1 Department of Surgery, Yozgat City Hospital, Yozgat, Turkey
2 Department of Gastrointestinal Surgery, Inonu University, Malatya, Turkey
3 Department of Surgery, Samsun Training and Research Hospital, Samsun, Turkey
4 Department of Surgery, Istanbul Kartal Dr. Lutfi Kirdar Education andResearch Hospital, Istanbul, Turkey

Date of Submission25-Jun-2020
Date of Acceptance16-Apr-2021
Date of Web Publication15-Nov-2021

Correspondence Address:
Dr. Serdar Kirmizi
Department of Surgery, Yozgat City Hospital, Yozgat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njcp.njcp_388_20

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Background: Sleeve gastrectomy is a stapler dependent bariatric procedure. A stapleless sleeve gastrectomy can be necessary for certain circumstances. Aims: Here, we aimed to show whether laparoscopic stapleless sleeve gastrectomy with natural orifice specimen extraction (NOSE) can be an alternative procedure to stapled sleeve gastrectomy. Patients and Methods: In the stapleless group (n = 6), no staplers were used and after vertical resection of the stomach by energy devices, the stomach remnant was closed by two rows of intracorporeal sutures. The resected specimen was removed through the mouth using an endoscopic snare. In the stapler group (n = 7), sleeve gastrectomy was carried out with linear stapler under the guidance of 36 Fr bougie. The specimens were extracted from the left upper quadrant trocar site. Results: A total of 13 patients were compared (stapleless = 6 and stapled group = 7). All the sleeve gastrectomies were completed laparoscopically. The operative time was longer at 200 minutes (range 120-300) versus 120 minutes, (range 90-200) p = 0.07) and the amount of bleeding was higher at 100 ml (range 50-200) versus 30 ml (range 10-50) (p = 0.004) in the stapleless group. Leakage and gastrointestinal bleeding were seen in the stapleless group but no complications were found in the stapler group. No statistically significant difference was found between the metabolic outcomes of the two groups after the operation (p > 0.05). Decrease in BMI at similar rates was observed in 5 postoperative year (stapleless group: 35 kg/m2 (range 31-39) versus stapled group: 36.5 kg/m2 (range 31-39), p > 0.05). Conclusion: Laparoscopic stapleless sleeve gastrectomy with natural orifice specimen extraction has longer procedure time, more blood loss and complications.

Keywords: Natural orifice specimen extraction (NOSE), obesity, sleeve, stapleless, staplerless

How to cite this article:
Kirmizi S, Kayaalp C, Karagul S, Tardu A, Ertugrul I, Sumer F. Comparison of stapled versus stapleless sleeve gastrectomy with natural orifice specimen extraction (NOSE). Niger J Clin Pract 2021;24:1689-93

How to cite this URL:
Kirmizi S, Kayaalp C, Karagul S, Tardu A, Ertugrul I, Sumer F. Comparison of stapled versus stapleless sleeve gastrectomy with natural orifice specimen extraction (NOSE). Niger J Clin Pract [serial online] 2021 [cited 2022 Jan 25];24:1689-93. Available from:

   Introduction Top

Nowadays, morbid obesity is a major health problem that we face in every age group. In the treatment of morbid obesity, sleeve gastrectomy is applied more and more frequently. However, sleeve gastrectomy is a stapler dependent operation and sleeve gastrectomy without the use of staplers was very limited in the literature.[1] Stapleless sleeve gastrectomy can rarely be necessary for some special conditions such as technical defects of the staplers, patients allergies to titanium clips or sometimes when staplers were unavailable.[1],[2] As far as we know, there are no studies comparing the standard sleeve gastrectomy with stapleless sleeve gastrectomy and natural orifice specimen extraction (NOSE) so far. The purpose of this study was to search whether laparoscopic stapleless sleeve gastrectomy with NOSE can be an alternative procedure to stapled sleeve gastrectomy.

   Material and Methods Top

In June 2013, we launched a natural orifice surgery program including several procedures. In this context, we planned natural orifice specimen extraction of sleeve gastrectomy specimens. Patients who were eligible and agree with participation in the stapleless sleeve gastrectomy combined with transoral specimen extraction study were accepted into two groups (Registered at Inonu University Human Ethical Committee as a Research. The registration ID is 2014/33). This study was registered with (NCT03982823). A total of six morbidly obese patients (body mass index more than 40 kg/m2) who had undergone stapleless sleeve gastrectomy between May 2014 and December 2014 were retrospectively reviewed from a prospectively maintained database. In the same period, seven other morbidly obese patients included in the control group were treated with stapled sleeve gastrectomies. The grouping was done by the acceptance of the patients. The stapleless sleeve gastrectomy group combined with natural orifice surgery. Patients who did not participate in the stapleless group were treated by the stapled sleeve gastrectomy and the specimens were extracted through the trocar site. Informed consent was obtained from all patients. All the operations were carried out by two surgical instructors and two assistants in a single-center. In both groups, patients'age, gender, height, weight, body mass index, comorbidity, and lifestyle properties were recorded. Intraoperative blood loss, operating time, length of hospital stay, postoperative complications, and the metabolic/bariatric results of the two groups were evaluated after five years

The statistical analyses of the data were used SPSS 22.0 (IBM Corp., Armonk, NY, USA). Statistical comparisons were performed with nonparametric statistical tests (Mann-Whitney U-test and Wilcoxon Signed Rank Test). Numerical data expressed as median and range. P < 0.05 was considered significant.

Surgical technique

In the stapleless group, following pneumoperitoneum with a Veres needle, the first 5 mm trocar was entered 14 cm down and 4 cm left from the xiphoid process. The other two 5 mm trocars were applied to the left and right upper quadrant. The last two 5 mm trocars were placed just below the xiphoid process for automatic liver retractor and through the epigastrium as a working port. A 5 mm 30° optic camera was used and the intraabdominal pressure was set to 14 mmHg. Gastrocolic and gastrosplenic ligaments were divided by 5 mm Ligasure (Force Triad, Covidien, Boulder, CO, USA) starting from 4-6 cm to pylorus till the angle of His. The greater curvature was freed up to the left crus of the diaphragm. The anterior and posterior walls of the stomach were transected with a 5 mm Ligasure device under the guidance of a 36 Fr bougie, starting 4-6 cm away from the pylorus and division of both gastric leaves headed vertically in the direction of the angle of His. After completion of the gastric division, the resected specimen was removed through the mouth with the help of an intraoperative peroral endoscopy using an endoscopic snare. The remaining open anterior and posterior walls of the stomach were continuously sutured to each other with 3/0 polypropylene sutures. The suture length was 20 cm. All the trocars were 5 mm in size in the stapleless group.

The surgical technique of the stapled group has been defined in detail before.[3] In short, vertical gastrectomy was applied with a 60 mm linear stapler (Endo GIATM Ultra, Covidien) under the guidance of 36 Fr bougie. These procedures were done through three 12 mm and two 5 mm trocars, that were placed in the same locations with the stapleless group. The specimens in the stapler group were extracted from the left upper quadrant trocar site. No supportive material or suture was applied to the staple lines. The intraoperative leak test was routinely performed with methylene blue. A drain was placed in all of the cases.

After 6-8 hours postoperatively, the patients were mobilized, thromboembolic stockings were kept for five days. Prophylaxis of deep vein thrombosis was continued for 15 days. A liquid diet was started on day one.

   Results Top

All the procedures were completed laparoscopically and no additional port placement was required. The operation time for stapleless group was 80 minutes longer than stapled ones 200 minutes (range 120-300) versus 120 minutes (range 90-200) (p=0.07). The total amount of bleeding was significantly higher in the stapleless group 100 ml (range 50-200), 30 ml (range 10-50) (p=0.004). Demographic characteristics and comorbidities of the two groups are presented in [Table 1]a and [Table 1]b. Intraoperative complications were seen in two of the stapleless cases. In the first case, a mucosal injury was observed in the esophagus during the insertion of the 36 Fr bougie into the stomach. The intact esophagus wall was confirmed by intraoperative endoscopy and postoperative contrast radiography. This complication was not related to the selected sleeve gastrectomy technique. No complications were observed in this case during the follow-up. In the second case, the remnant posterior gastric wall was narrower than the anterior wall. However, after suturing both walls of the stomach to each other, no stenosis was seen. In the early postoperative period, there were no complications in both groups, and patients were discharged uneventfully. However, there were two re-admission and both were in the stapleless group. According to the Clavien-Dindo classification, they were Grade 2 and Grade 4b.[4] One was due to upper gastrointestinal bleeding and was treated successfully by conservative methods for five days. Another one had peritonitis 3 days after discharge. She required a laparotomy and a suture line leak was found out. The leak point was repaired by sutures again. The postoperative course was uneventful and she was discharged without any other complications 13 days after the second hospitalization. There was no mortality in this study.

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The mean follow-up periods of laboratory investigations and body mass index were 59 months (range 56-62) in both groups. Decrease in BMI at similar rates was observed in 5 postoperative year (stapleless group: 35 kg/m2 (range 31-39) versus stapled group: 36.5 kg/m2 (range 31-39), (p > 0.05) [Table 2]. No statistically significant differences was found between the metabolic outcomes of the two groups five years after the operation. Excess of body mass index loss (EBMIL) of stapleless group and stapler group (51.1% and 48%, respectively) were similar in the 5th follow-up year. In the stapleless group, there was only one patient with glucose intolerance and her glucose intolerance was completely relieved. In the stapled group, three patients were diabetic and one patient had glucose intolerance. Two of them completely stopped using oral antidiabetics, and one of them continued to use an oral tablet at the same dose. Sleep apnea in both groups was resolved completely. Preoperative and postoperative levels of low-density lipoprotein (LDL), highdensity-lipoprotein (HDL), triglycerides, cholesterol, and HgA1c levels were similar in both groups [Table 2].
Table 2: Preoperative and postoperative values of both groups

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   Discussion Top

The popularity of sleeve gastrectomy is increasing among patients and surgeons. The operation constitutes more than one-third of bariatric processes now performed all over the world and more than half in the United States.[5] Sleeve gastrectomy is a stapler dependent procedure like Roux-en-Y gastric bypass, biliopancreatic diversion and duodenal switch and a limited number of data is available in the literature for sleeve gastrectomy operations without the use of staplers. Himpens et al.[6] had reported two cases of the sleeve gastrectomies without using staplers, but they did not mention the details of these cases. In case of technical problems of the staplers, sometimes, stapleless suturing can be inevitable during sleeve gastrectomies. For example, El Geidie et al.[7] reported that the stapler was locked in laparoscopic sleeve gastrectomy after the third firing of the stapler. In such cases, stapleless surgery is inevitable. In 2013, Rezvani, et al.[2] described a robotic sleeve gastrectomy without staplers in a patient who was allergic to metallic materials. The researchers concluded that stapleless sleeve gastrectomy with the robot had advantages in term of ease of suturing, but also stated that the cost of surgery increased. Despite the limited number of patients, there are recent publications on sleeve gastrectomy with stapleless in the form of small series. In none of these studies was gastric specimen transorally removed.[8],[9]

Cost-effectiveness sometimes becomes important in laparoscopic surgery in developing countries. Stapleless gastrectomy will significantly reduce the cost of the procedure for countries that have difficulty in purchasing materials for economic reasons.[8]

Removal of the gastrectomy specimen by an expansion of the entrance of the trocar is a routine process. We were able to find only three studies that removed sleeve gastrectomy specimens transorally. In these studies, it was aimed to reduce post-operative pain, the length of hospital stay and trocar wound-related complications. In these studies consisting of small patient series, they have argued that this method is safe and easy to apply.[10],[11],[12] Stapleless sleeve gastrectomy publications in the literature were schematized in [Table 3].
Table 3: Overview of included studies

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In our cases that we did not use staplers, the opening of the stomach allowed us the access to extract the specimen through the esophagus and mouth by endoscopy. We did not need an extension of skin incision to remove the specimens and no complications were observed related to the oral specimen extraction.

Laparoscopic stapleless sleeve gastrectomy with natural orifice specimen extraction (NOSE) is a challenging process that requires experience and patience. Longer procedure time, more blood loss, and complications were associated with the stapleless group. The effectiveness of this technique should be investigated with high volume and prospective studies.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

The authors declared that this study has received no financial support.

Conflict of interest

The authors declare no conflict of interest.

   References Top

De Menezes JEMT, Ramos AC, Azaro E, Galvao-Neto MP, Mello CA, Galvao MS, et al. Staplerless laparoscopic gastric bypass: A new option in bariatric surgery. Obes Surg 2006;16:638-45.  Back to cited text no. 1
Rezvani M, Sucandy I, Antanavicius G. Totally robotic stapleless vertical sleeve gastrectomy. Surg Obes Relat Dis 2013;9:79-81.  Back to cited text no. 2
Sansal M, Saglam K, Gokler C, Sümer F, Kayaalp C. Laparoscopic sleeve gastrectomy technique; How we do it? Laparosc Endosc Surg Sci (LESS) 2018;25:76-80.  Back to cited text no. 3
Clavien PA, Barkun J, De Oliveira ML, Vauthey JN, Dindo D, Schulick RD, et al. The Clavien-Dindo classification of surgical complications: Five-year experience. Ann Surg 2009;250:187-96.  Back to cited text no. 4
Angrisani L, Santonicola A, Iovino P, Formisano G, Buchwald H, Scopinaro N. Bariatric surgery worldwide 2013. Obes Surg 2015;25:1822-32.  Back to cited text no. 5
Himpens J, Leman G, Sonneville T. Laparoscopic Roux-en-Y gastric bypass performed without staples. Surg Endosc 2005;19:1003.  Back to cited text no. 6
El Geidie A, Gadel Hak N, Abdulla T. Stapler's malfunction during laparoscopic sleeve gastrectomy: An unusual but correctable complication. Surg Obes Relat Dis 2013;9:144-6.  Back to cited text no. 7
Leyba JL, Llopis SN, Aulestia SN, Ochoa R, Azuaje E. Stapleless laparoscopic sleeve gastrectomy. Preliminary report. Surg Obes Relat Dis 2017;13:701-4.  Back to cited text no. 8
Catanzano M, Grundy L, Bekheit M. Stapleless laparoscopic sleeve gastrectomy: Reasoning and technical insights. Obes Surg 2018;28:854-61.  Back to cited text no. 9
Dotai T, Coker AM, Antozzi L, Acosta G, Michelotti M, Bildzukewicz N, et al. Transgastric large-organ extraction: The initial human experience. Surg Endosc 2013;27:394-9.  Back to cited text no. 10
Gunkova P, Gunka I, Zonca P, Dostalik J, Ihnat P. Laparoscopic sleeve gastrectomy for morbid obesity with natural orifice specimen extraction (NOSE). Bratisl Lek Listy 2014;116:422-5.  Back to cited text no. 11
Lirici MM, Romeo V, Simonelli L, Tierno S, Vitelli CE. Minimizing the access trauma of laparoscopic sleeve gastrectomy: The transoral specimen extraction technique. Obes Surg 2016;26:229-33.  Back to cited text no. 12


  [Table 1], [Table 2], [Table 3]


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