To the editor,

I read with interest the letter by Serra et al.

I concur with the authors that suture reinforcement of the staple line in gastric sleeve surgery can help prevent leaks related to ischemia and staple line failure and can assist in hemostasis. Oversewing of the staple line has other advantages not mentioned in the letter, such as correction of irregularities in the shape of the sleeve to reduce areas of dilatation, which is one of our strategies to reduce gastroesophageal reflux after sleeve surgery [1], and prevention of adhesion formation in cases of revision. I cannot agree more with Serra et al. that the self-locking first stitch facilitates oversewing. The placement of the first stitch at the top of the sleeve in a very obese patient can be cumbersome, especially for the inexperienced surgeon. The uppermost portion of the staple line is sometimes hidden from view, and medial retraction of the stomach is necessary to visualize it. Using both hands to fashion a traditional knot makes it difficult to maintain visualization of the maneuver. Additionally, a greater portion of the suture material is required to create the knot, leaving less to complete oversewing with a single suture strand, as is typical.

We use a non-sliding knot at the tail, as the authors properly pointed out. The authors’ description of a sliding component is interesting and has practical application in their method of oversewing, because they involve the omentum in the first stitch. The sliding component of a self-locking first stitch has also been used with success in other procedures well described by Baltar [2] and Baltasar [3]. We place a small omental patch at the top of the sleeve at the end of the case, because this is where leaks overwhelmingly occur [1]. I believe that including the omentum throughout the staple line during oversewing makes it difficult to correct irregularities of the sleeve, to prevent adhesions, and to test and correct small torsions of the sleeve at the end of the procedure, which I do routinely with a saline solution test.

The authors properly cited our original contribution, titled “Self-Locking First Stitch in Suture Reinforcement of the Laparoscopic Gastric Sleeve”, published in Obesity Surgery, vol. 23 in 2013 [4]. They also mentioned a second manuscript by Albanopoulos et al. in the same publication, which is a response letter to our article, hence their use of our title. Also worth mentioning is an elegant letter from Baltar et al. in response to our initial paper [2].

While I agree with the authors that new studies are needed to prove that oversewing of the staple line is a necessary part of laparoscopic gastric sleeve surgery, surgeons who practice oversewing may find this simple maneuver to be useful.