Background

This Video demonstrates a case where accidental stapling of the temperature probe occurred during performance of a Laparoscopic Sleeve gastrectomy. The temp robe was released after sharp dissection and we closed the resulting gastrotomy in two layers and secured omentum over the repair. The patient has done well in the psotoperative period. While our institution and OR team has a long-standing policy of no placement of esophageal temperature probes, or naso- or orogastric tubes during any bariatric or foregut case that will require stapling. In this particular case, the anesthesia resident was a CA-1, and this happened to be his first GI surgery case. Since this case we have instituted an education program for anesthesia residents and nurse anesthetists, and have started an intraoperative “time out” prior to stapling that ensures there is nothing in the esophagus that we are not aware of.