Obesity Surgery

, Volume 24, Issue 12, pp 2069–2074

What to Do When It Is Technically Impossible to Perform Laparoscopic Sleeve Gastrectomy

  • Lionel Rebibo
  • Abdennaceur Dhahri
  • Pierre Verhaeghe
  • Jean-Marc Regimbeau
Original Contributions



Laparoscopic sleeve gastrectomy (LSG) is increasingly popular with surgeons because of its apparent technical ease. However, performing LSG safely is sometimes not possible during laparoscopy. The objectives of the present study were to (i) describe the context of LSG failure and (ii) suggest preoperative care options or strategies that enable secondary LSG to be performed safely.


We studied patients having undergone primary and secondary LSG between January 2008 and July 2013. The primary efficacy criterion was the LSG success rate. The secondary efficacy criteria were preoperative care procedures, the complication rate, the failure rate, and the frequency of conversion to open surgery.


During the study period, 954 patients underwent first- or second-line LSG. Laparoscopic sleeve gastrectomy was technically impossible in 12 patients (1.2 %). The cause of failure was a large left liver lobe in seven cases (58.3 %) and a lack of space in five cases. Of these 12 patients, nine underwent secondary LSG. The median preoperative BMI before the first LSG was 51.5 kg/m2. The median (range) time interval between the two LSG attempts was 6 months (3–37). Prior to secondary LSG, the preoperative weight reduction measure was a diet in seven cases (78 %), an intragastric balloon in one case, and no treatment in one case. The median preoperative excess weight loss (EWL) before the second LSG was 10 % (0–20). Five LSGs were successful, two required conversion to open surgery, and two failed again. There were two postoperative complications (22 %), both of which concerned the two patients with conversion to laparotomy.


In the event of LSG technical failure, preoperative weight loss may enable a second attempt at laparoscopic treatment. A preoperative EWL of at least 10 % appears to be required for the avoidance of conversion to laparotomy.


Laparoscopic sleeve gastrectomy Technical failure Weight loss 


  1. 1.
    Silecchia G, Boru C, Pecchia A, et al. Effectiveness of laparoscopic sleeve gastrectomy (first stage of biliopancreatic diversion with duodenal switch) on co-morbidities in super-obese high-risk patients. Obes Surg. 2006;16:1138–44.PubMedCrossRefGoogle Scholar
  2. 2.
    Topart P, Becouarn G, Ritz P. Comparative early outcomes of three laparoscopic bariatric procedures: sleeve gastrectomy, Roux-en-Y gastric bypass, and biliopancreatic diversion with duodenal switch. Surg Obes Relat Dis. 2012;8:250–4.PubMedCrossRefGoogle Scholar
  3. 3.
    Boza C, Gamboa C, Salinas J, et al. Laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy: a case–control study and 3 years of follow-up. Surg Obes Relat Dis. 2012;8:243–9.PubMedCrossRefGoogle Scholar
  4. 4.
    Gastrectomie Longitudinale [sleeve gastrectomy] pour obésité. Hautes autorité de la santé. Recommandations 2008.Google Scholar
  5. 5.
    Verhaeghe P, Dhahri A, Qassemyar Q, Regimbeau JM. Technique de la gastrectomie longitudinal (sleeve gastrectomy) par laparoscopie. EMC (Elsevier Masson SAS, Paris), Techniques chirurgicales–Appareil digestif, 40–385, 2011.Google Scholar
  6. 6.
    Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–13.PubMedCentralPubMedCrossRefGoogle Scholar
  7. 7.
    Deitel M, Greenstein RJ. Recommendations for reporting weight loss. Obes Surg. 2003;13:159–60.PubMedCrossRefGoogle Scholar
  8. 8.
    Kissane NA, Pratt JS. Medical and surgical treatment of obesity. Best Pract Res Clin Anaesthesiol. 2011;25:11–25.PubMedCrossRefGoogle Scholar
  9. 9.
    Sjöström L, Lindroos AK, Peltonen M, et al. Swedish Obese Subjects Study Scientific Group. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. 2004;351:2683–93.PubMedCrossRefGoogle Scholar
  10. 10.
    Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med. 2012;366:1567–76.PubMedCentralPubMedCrossRefGoogle Scholar
  11. 11.
    Ikramuddin S, Korner J, Lee WJ, et al. Roux-en-Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: the Diabetes Surgery Study randomized clinical trial. JAMA. 2013;309:2240–9.PubMedCentralPubMedCrossRefGoogle Scholar
  12. 12.
    Kaul A, Sharma J. Impact of bariatric surgery on comorbidities. Surg Clin N Am. 2011;91:1295–312. ix.PubMedCrossRefGoogle Scholar
  13. 13.
    Christou NV, Sampalis JS, Liberman M, et al. Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients. Ann Surg. 2004;240:416–23. discussion 423–4.PubMedCentralPubMedCrossRefGoogle Scholar
  14. 14.
    Kehagias I, Spyropoulos C, Karamanakos S, et al. Efficacy of sleeve gastrectomy as sole procedure in patients with clinically severe obesity (BMI ≤50 kg/m(2)). Surg Obes Relat Dis. 2013;9:363–9.PubMedCrossRefGoogle Scholar
  15. 15.
    Fuks D, Verhaeghe P, Brehant O, et al. Results of laparoscopic sleeve gastrectomy: a prospective study in 135 patients with morbid obesity. Surgery. 2009;145:106–13.PubMedCrossRefGoogle Scholar
  16. 16.
    Pequignot A, Fuks D, Verhaeghe P, et al. Is there a place for pigtail drains in the management of gastric leaks after laparoscopic sleeve gastrectomy? Obes Surg. 2012;22:712–20.PubMedCrossRefGoogle Scholar
  17. 17.
    Rebibo L, Mensah E, Verhaeghe P, et al. Simultaneous gastric band removal and sleeve gastrectomy: a comparison with front-line sleeve gastrectomy. Obes Surg. 2012;22:1420–6.PubMedCrossRefGoogle Scholar
  18. 18.
    Luyckx FH, Desaive C, Thiry A, et al. Liver abnormalities in severely obese subjects: effect of drastic weight loss after gastroplasty. Int J Obes Relat Metab Disord. 1998;22:222–6.PubMedCrossRefGoogle Scholar
  19. 19.
    Rebibo L, Gerin O, Verhaeghe P, et al. Laparoscopic sleeve gastrectomy in patients with NASH-related cirrhosis: a case-matched study. Surg Obes Relat Dis. 2014. doi:10.1016/j.soard.2013.09.015.Google Scholar
  20. 20.
    Schwartz ML, Drew RL, Chazin-Caldie M. Factors determining conversion from laparoscopic to open Roux-en-Y gastric bypass. Obes Surg. 2004;14:1193–7.PubMedCrossRefGoogle Scholar
  21. 21.
    Fris RJ. Preoperative low energy diet diminishes liver size. Obes Surg. 2004;14:1165–70.PubMedCrossRefGoogle Scholar
  22. 22.
    Iannelli A, Martini F, Schneck AS, et al. Preoperative 4-week supplementation with omega-3 polyunsaturated fatty acids reduces liver volume and facilitates bariatric surgery in morbidly obese patients. Obes Surg. 2013;23:1761–5.PubMedCrossRefGoogle Scholar
  23. 23.
    Rafi AN. Abdominal field block: a new approach via the lumbar triangle. Anaesthesia. 2001;56:1024–6.PubMedCrossRefGoogle Scholar
  24. 24.
    Sinha A, Jayaraman L, Punhani D. Efficacy of ultrasound-guided transversus abdominis plane block after laparoscopic bariatric surgery: a double blind, randomized, controlled study. Obes Surg. 2013;23:548–53.PubMedCrossRefGoogle Scholar
  25. 25.
    Banka G, Woodard G, Hernandez-Boussard T, et al. Laparoscopic vs open gastric bypass surgery: differences in patient demographics, safety, and outcomes. Arch Surg. 2012;147:550–6.PubMedCrossRefGoogle Scholar
  26. 26.
    Khan O, Irukulla S, Sanmugalingam N, et al. Simultaneous intra-gastric balloon removal and laparoscopic sleeve gastrectomy for the super-super obese patients—a prospective feasibility study. Obes Surg. 2013;23:585–7.PubMedCrossRefGoogle Scholar
  27. 27.
    Mohamed ZK, Kalbassi MR, Boyle M, et al. Intra-gastric balloon therapy and weight reduction. Surgeon. 2008;6:210–2.PubMedCrossRefGoogle Scholar
  28. 28.
    Leeman MF, Ward C, Duxbury M, et al. The intra-gastric balloon for pre-operative weight loss in bariatric surgery: is it worthwhile? Obes Surg. 2013;23:1262–5.PubMedCrossRefGoogle Scholar
  29. 29.
    Zerrweck C, Sepúlveda EM, Maydón HG, et al. Laparoscopic gastric bypass vs. sleeve gastrectomy in the super obese patient: early outcomes of an observational study. Obes Surg. 2014;24:712–7.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Lionel Rebibo
    • 1
  • Abdennaceur Dhahri
    • 1
  • Pierre Verhaeghe
    • 1
  • Jean-Marc Regimbeau
    • 1
  1. 1.Department of Digestive SurgeryAmiens University Hospital and Jules Verne University of PicardieAmiens cedex 01France

Personalised recommendations