Bariatric surgery (BS) has proved its role in treating obesity and related comorbidities. The number of Laparoscopic Sleeve Gastrectomies (LSGs) performed globally has increased markedly and has become “trendy” among bariatric surgeons in the last few years [1]. LSG has attained its position as the primary procedure of choice in bariatric surgery for morbid obesity. In this procedure, 80% of the stomach, mainly the body and fundus are removed longitudinally, leaving behind a sleeve of the stomach along the lesser curve [2, 3]. The procedure can be performed by minimally invasive approaches as well as single incision access or even robotic surgery with comparable results [4, 5]. The weight loss is achieved by restricting the food entering the stomach. Another factor in the effectiveness of weight loss in sleeve gastrectomy is the decrease in blood levels of ghrelin, “the hormone that stimulates hunger,” and a majority of cells responsible for producing this hormone is found in the fundus which is removed during this procedure. This procedure can be performed as the first stage in more complex bariatric cases including cases of super-obesity before procedures like Roux-en-Y gastric bypass or the duodenal switch can be performed [6]. The objective is to achieve an initial weight loss that would help to perform more extensive mixed restrictive or malabsorptive procedures safely and effectively [7,8,9].

Indications

  • First stage procedure before a more complex procedure for BMI > 60.

  • Preferred bariatric procedure for the high-risk obese BMI 35–40.

  • Revision of previous laparoscopic adjustable gastric banding (LAGB).

  • Redo LSG.

Contraindications

  • Extensive previous surgery.

  • Crohn’s Disease.

  • Elderly patients with extensive comorbidities.

Preoperative Preparation

  • Weight and height measurement on a standard electronic scale.

  • Nutritional parameters.

  • Evaluate cardiopulmonary function.

  • Obstructive sleep apnea tests.

  • 2 weeks on low or very low caloric diet

  • Upper GI endoscopy.

  • Testing for Helicobacter pylori.

  • Psychiatric evaluation.

  • Chemoprophylaxis.

  • Thromboprophylaxis.

Instruments

For LSG, Laparoscopic tray with full set of instruments is required, including endoscopic gastrointestinal anastomosis (GIA) staplers, and silk and polyglactin sutures

  • Energy device (Ultrasonic or Advanced bipolar or combined).

  • 3 × 5 mm ports

  • 1 × 10 mm ports

  • 1 × 15 mm port

  • 1 × Optical-view Trocar

  • 1 × Dissecting forceps

  • 2 × Bowel graspers

  • 1 × Babcock forceps

  • 1 × Bowel Grasper Single Action

  • 1 × Curved scissors

  • 1 × L-hook

  • 1 × Suction Irrigation 5 mm/10 mm cannula

  • Nathanson/Snake liver retractor.

  • Clip Applicator with Hemolock.

  • 1 × Needle holder curved

  • 1 × Veress Needle.

Patient and Trocar Positions

  • Supine with reverse-Trendelenburg position.

  • Foot support on board.

  • Anti-embolic precautions.

  • Prophylactic antibiotics.

  • 12 mm Optical port is placed under direct vision approximately 15 cm below the xiphoid process and almost 4 cm left to the midline.

  • Pneumoperitoneum is created and 30 laparoscope is introduced.

  • A 5 mm port is placed in left lateral flank at the same level as the optical port.

  • Another 5 mm port is placed in right epigastric region for liver retraction.

  • Another 12/15 mm port is placed in mid epigastrium in the midline.

  • Another 5 mm port is placed on the right side lateral to the 12/15 mm port.

  • Left lobe of the liver is retracted using a snake retractor.

Operative Techniques

After the pneumoperitoneum is created, a diagnostic laparoscopy is done to exclude other pathologies. The liver is retracted cranially, and the GE junction is exposed (Fig. 1). A point in the greater curve is identified and marked at 6 cm proximal to the pylorus as the distal extent of the resection (Fig. 1).

Fig. 1
A photograph of a thin and flexible surgical instrument called a bougie, along the gastroesophageal junction. Two other surgical instruments are depicted.

Placement of boogie and placing it on suction

Full size image

Division of the greater omentum to enter the lesser sac and division of short gastric vessels is achieved by using an energy device along the gastrocolic and gastrosplenic ligaments from the greater curvature up to the angle of His (Figs. 2, 3, and 4). Be aware of gastroduodenal and right gastric artery at pylorus and stop dissection about 5 cm proximal to it to prevent injury to these vessels and to preserve perfusion of the pylorus and the distal antrum [7]. Make sure to dissect closely along the greater curvature leaving no fat behind.

Fig. 2
A photograph of a dissecting device at the entry point of the lesser sac.

Dissection started at 6 cm proximal to pylorus to enter lesser sac

Full size image
Fig. 3
A photograph of a dissecting device making its way and cutting through the lesser sac.

Lesser sac entry

Full size image
Fig. 4
A photograph of a dissecting device on the posterior wall of the stomach.

Posterior wall of stomach

Full size image

Next step is to lift and pull the stomach to the right of patient to have a better view of gastroesophageal (GE) junction along with left crus and spleen to dissect down any adhesions on posterior wall of stomach (Fig. 4). Last of few short gastric vessels in this area can be divided along the left crus. The greater curvature must be completely freed up to the left crus of the diaphragm.

Next step is to position the bougie (size 36 Fr) in the stomach before using stapler. Afterward linear cutting staples are used to vertically transect the stomach creating a narrow gastric tube with an estimated capacity of less than 150 ml. Check location of anvil and cartridge both anteriorly and posteriorly to achieve optimized stapling (Figs. 5 and 6). It is important to compress the line of transection of the gastric tissue with the staple for 15 s prior to firing, to get adequate hemostasis and stapling of gastric tissues. First, stapler is usually 60 mm black or green cartridge for the antrum. Gold cartridges can be used together with Seamguards to prevent staple line bleeding and leaks. Second, cartridge should be green, black, or purple depending on the surgeon’s choice, but smaller cartridges than those mentioned above are not recommended in this region. Care must be taken to avoid stenosis at incisura (Fig. 7). It is good practice to rotate the stomach and stapler anteriorly to have a look at the posterior wall before firing the stapler and distal end must be at least 2 cm from GE junction (Fig. 8). Hold the “new” stomach and ask anesthetist to off the suction and remove the bougie, observe for few minutes for any bleed or leak at this point. Next reinforcement sutures can be applied to any areas of bleeding and omentopexy to prevent volvulus; however, these measures are debatable and must be practiced as tailored approach for individual cases.

Fig. 5
A photograph depicts the use of cutting staples on the stomach.

First cutting staples

Full size image
Fig. 6
A photograph of the correct position of the stapler in relation to the posterior wall and less curve.

View of posterior wall and less curve to check the position of stapler

Full size image
Fig. 7
A photograph of the correct position of the staple line on the gastric tissues. Proper stapling prevents narrowing in the notch of the stomach.

Observe staple line

Full size image
Fig. 8
A photograph depicts the position of the last stapler. It is approximated to have a distal end of 2 centimeters from the gastroesophageal junction.

last stapler 2 cm from GE junction

Full size image

Role of drains in the subhepatic space adjacent to the gastric tube is controversial and is not recommended. The resected stomach is placed in a specimen bag or even can be directly extracted through the epigastric 15 mm port site. Fascial sutures are not routinely used for 5 mm or 10 mm port sites, but 15 mm port site fascia should be closed to prevent future port site hernia.

When to Convert

  • Massive blood loss.

  • Dense adhesions.

Major Post-op Complications and Management

Hemorrhage

Risk of postoperative bleeding is from 1–5% and the source could be intraluminal or extraluminal. Intraluminal bleeds can present as melena or hematemesis due to bleeding from staple line. Upper GI bleeding protocol should be followed. Large-bore IV cannula, fluid resuscitation, Input/output monitoring, and blood transfusion if needed should be practiced. Urgent Upper GI endoscopy to locate and control the bleeding is warranted.

Extraluminal bleeding is commonly from staple line, injury to abdominal viscera, or from port site. These patients presents with drop of serial hemoglobin, tachycardia, or occasionally hypotension. Urgent diagnostic laparoscopy helps to make the diagnosis and to evacuate hematoma along with control of source of bleeding. Even if source is not identified, hematoma evacuation and drain placement serve as a treatment.

Staple Line Leak

Staple line leak is the most dreadful complication of LSG which can occur in approximately 2–3% of patients [10]. Based on upper GI contrast studies and radiological findings, leaks are divided into two types: Type I is a controlled leak and could be easily managed with aspiration, drainage, or through a natural fistulous tract formation; Type II is a disseminated variety and needs an urgent diagnostic laparoscopy, wash out and surgical repair of leak if technically feasible. Enteral nutrition with feeding jejunostomy is preferred as the mode of feeding in these patients. Early and delayed presentations are classified based on the time of presentation after surgery (either within 3 days or after 8 days, respectively).

Treatment of delayed and disseminated variety is challenging because of hemodynamic instability of patient and inflammatory reaction leading to sepsis [11]. Treatment in this condition involves vigorous resuscitation with fluids, IV antibiotics, holding off oral feeding, aspiration/drainage under radiological guidance, followed by surgical repair of leak as a definitive procedure [12].

Stenosis

This rare complication is observed in less than 2% of patients and needs urgent attention once diagnosed. Patients present with vomiting, regurgitation, or feeling of fullness [13]. It is further subdivided into two subtypes anatomical or functional stenosis which determines the treatment options in both groups. Upper GI endoscopy is a good initial investigation to diagnose anatomical variety but tridimensional CT with 3D reconstruction is a diagnostic modality with good sensitivity for functional groups [14].

Intraoperatively to prevent stenosis, the endoluminal bougie should be placed along the lesser curvature going all the way distal to the antrum and avoid excessive lateral traction and twisting of the stomach. Avoid pushing the bougie too distally which can result in shorter and larger than expected gastric tube when bougie is removed. Endoscopic balloon dilatations with multiple sessions can be used to treat stenosis with or without an alternative option of stenting. If recurrent or unresolved after dilatation then Roux-en-Y Gastric Bypass (RYGB) is a treatment option.

Portal Thrombosis

This rare complication occurs in almost 0.3–0.5% of cases. Several factors like splenic ischemia, dehydration in early postoperative period, variation in blood flow after resection of vessels along greater curvature, and thrombophilia can contribute to this. Clinical severity is the predictor of the outcome of treatment which includes holding off oral feeding and providing IV fluids for rehydration. Anticoagulation should be considered even on slightest suspicion. Treatment with therapeutic dose of low molecular weight heparin for 5–7 days and bridging therapy with oral anticoagulation with Warfarin to keep INR between 2–3 for 3–6 months is needed. Surgical options for portal thrombosis are reserved for complicated cases like thrombosis leading to splanchnic ischemia [15, 16].

Postoperative Care

  1. 1.

    Admit to ICU or Surgical High Dependency unit for close monitoring for signs of obstructive sleep apnea.

  2. 2.

    Diet is maintained on general liquids for 1 week and gradually progressed by the dietician.

  3. 3.

    Encourage early sitting up on the bed and if possible early ambulation.

  4. 4.

    Chest physiotherapy.

  5. 5.

    Continue mechanical deep vein thrombosis prophylaxis during the rest of hospitalization.

  6. 6.

    Gradual exercise is started 1 month after the operation with advice from a physiotherapist.