Abstract
Background:
Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure in the world, with 75% of the primary procedures performed in the United States. It is a safe and effective primary bariatric procedure with good weight loss. When comparing with other procedures, LSG is limited to the stomach, avoiding the presence of internal hernias, preserving the pyloric anatomy, with normal gastric emptying, and conveying less severe rebound hypoglycemia.
Materials and Methods:
We describe the technique, step-by-step, we use to perform a sleeve gastrectomy (SG) and analyze why we think it is a good surgery.
Results:
The highlights of a safer SG systematization are based on minimum 36F bougie calibration, starting 4–5 cm from the pylorus, keeping ∼1 cm distance from esophagus. We routinely use staple line reinforcement by continuous suture. Comparing with Roux-en-Y gastric bypass, less bowel obstruction, less dumping syndromes, less hypoglycemia, and also less ulcers are described.
Conclusion:
LSG is a safe and effective primary bariatric procedure with durable weight loss. And when comparing with others with intestinal anastomosis, we found fewer complications such as less internal hernias, access to the bile duct after surgery, and has the great advantage that it can be revised when it fails.
Introduction and History
Laparoscopic sleeve gastrectomy (LSG) is currently the most frequent primary bariatric procedure performed worldwide. 1 In the United States, 75% of all primary bariatric procedures are sleeve gastrectomies (SGs).
It has evolved from an open vertical gastrectomy in duodenal switch procedure to a laparoscopic duodenal switch in July 2nd, 1999, at Mount Sinai School of Medicine, which included the first LSG in humans by M.G., and has evolved by serendipity to a two-stage approach for higher risk patients at Mount Sinai School of Medicine in 2000, using the LSG alone as an interim procedure.
As M.G. describes in his publication (the perfect SG), the isolated open SG was performed by Dr. Gary Anthone, and reported in 2004. Marceau's team in Quebec City has had cases in open “parietal cell gastrectomy” manner from 2001, and laparoscopic in 2006, so this is much later after the development of LSG as a stand-alone procedure.1–3
When comparing LSG with Roux-en-Y gastric bypass (RYGB), it is limited to the stomach, avoiding the presence of internal hernias in the postoperative follow-up, this being an important advantage.1,4,5 Other advantage is preserving the pyloric anatomy, with normal gastric emptying, conveying less severe rebound hypoglycemia.
Surgical “Step-by-Step” Technique
In the following section we describe the technical aspects on how we perform an LSG.
We place the patient supine in a French technique using in a split leg position.
At the umbilicus, a Veress needle (or open technique) is placed and CO2 is insufflated up to 15 mmHg.6,7
A first 10 mm trocar is placed in a line equidistant between the umbilicus and the epigastrium. Four more trocars are placed as shown in Figure 1. Additional trocars can be added for retraction of the omentum or enhanced fatty hepatic left lobe to make a superior exposure of the left crus.2,3,8,9
Trocar position: 2 of 13 mm, 2 of 5 mm, and 1 of 10 mm for the camera.
Once the left crus is dissected, an optimal exposure of the hiatus is mandatory to find incidental hiatal hernias, and if found, we repair it by posterior cruroplasty using absorbable sutures, because the evidence demonstrated that repair of hiatal hernias improves the outcomes regarding postoperative gastroesophageal reflux (Fig. 2).3,6,7
Dissection of the left crus. Exposure of the hiatus to find incidental hiatal hernias. Also this dissection is important to avoid retained fundus.
Then the next step is to open the greater omentum, close to the stomach wall, inside and away from the gastroepiploic arcade, and to completely free it from the His angle, all along the greater curvature to 3–4 cm to the pylorus.7,10–14 Posterior adhesions are then carefully divided, but avoiding injury to the lesser curve (Fig. 3).2,3,8,15.
Omental attachments to the greater curvature are divided beginning 3–4 cm proximal to the pylorus.
Special care has to be taken during the division of the short gastric vessels, because they could be covered with a large amount of fat that is difficult to identify2,3,9 and can cause severe bleeding during the procedure or in the postoperative period.3,8,9 A complete visualization of the hiatus and fundus has to be performed, as misdiagnosis of a hiatal hernia or unresected fundus could cause severe postoperative reflux.2,3,9
We routinely use a 36F bougie to calibrate the sleeve.2,3,5,11 The stapler should never be placed abutting the bougie, it should be used solely for guidance of the resection of the stomach, to avoid a stricture at the incisura. The stomach is placed in its anatomical position and the bougie is inserted (Fig. 4).
The stomach is placed in anatomical position to insert the 36F bougie.
Regarding the initiation point from the pylorus to begin gastrectomy, we mostly fire the stapler 5 cm away from the pylorus. For the most part, surgeons begin division 2–5 cm from the pylorus to avoid leaving large antrum.3,6,11
We then perform SG, choosing the tallest stapler cartridges (green) at the antrum level, and while going proximal in the stomach, shorter (golden, blue, and purple) staplers are used.2,8,12,15 Based on the use of Ethicon Echelon stapler™, we should start with black or green cartridge and continue with golden and finish with blue cartridge. 3 But with Medtronic Tri-stapler™, we should start with one or two black cartridges and finish with purple cartridge.3–5 The posterior aspect of the stomach has to be verified before firing. The last fire has to be done 1-cm lateral to the His angle to avoid inclusion of esophageal tissue and avoid the risk of fistulas (Figs. 5 and 6).2,3,11,12
Gastric resection is performed using 60 mm loads. Tallest cartridges are used at the antrum and gradually shorter cartridges proximally. But when using buttressing, we use the tallest cartridges.
Gastric resection is performed using 60 mm loads. Tallest cartridges are used at the antrum and gradually shorter cartridges proximally. But when using buttressing, we use the tallest cartridges.
We always perform staple line reinforcement by using oversewing with absorbable suture or absorbable buttressing material (Fig. 7). Methylene blue test is performed routinely to check for strictures, kinks, twists, and rarely leaks.2,3,9 It is optional to place a drain.
Image after last fire to complete the sleeve.
Why We Think SG Is a Good Operation?
When we analyze the published level I evidence (RCT JAMA Jan 2018), it has similar weight loss when comparing with RYGB, and major complications are lower, as reported by reports from the MBSQIP database. When weight regain and recurrence of type-2 diabetes are observed, the LSG can be revised and converted to another procedure, such as single anastomosis duodenoileostomy.2,3
Also more patients can be treated in a short interval time, due to it is a shorter procedure at time and in some centers can also be performed as outpatient procedure. 2 We also have extended indications such as high-risk patients, very young to very old, very high body mass indexes, transplant candidates or donors, and cirrhosis.
Concerning biliary access issues, after an LSG, for common bile duct exploration or pancreatic diseases, it can be achieved by endoscopic retrograde cholangiopancreatography. 2
When comparing LSG with RYGB, the first one has less dumping syndromes, less hypoglycemia and also less ulcers being this an important advantage for smokers and arthritic patients. LSG also has less bowel obstruction or re-interventions due to fewer adhesions. 2
In the Swedish Obese Subjects study, RYGB has more falls with pathological fractures, also more ethanol abuse plus substance abuse when comparing with LSG.
Downside, LSG has increase of gastroesophageal reflux, requiring and endoscopic follow-up in order to diagnose and treat a Barrett's esophagus, if it appears. 3
Conclusions
LSG is a safe and effective primary procedure with adequate weight loss. The highlights of a safer LSG systematization are based on minimum 36F bougie calibration, starting 4–5 cm from the pylorus, keeping 1 cm distance from esophagus, and reinforcing the staple line routinely. And when comparing this procedure with others with intestinal anastomosis, we found fewer complications such as less internal hernias, access to the bile duct after surgery, can be performed safely in extreme patients, and has the great advantage that it can be revised when it fails.
Footnotes
Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.