Laparoscopic Sleeve Gastrectomy – Technical Tips and Pitfalls

Abstract

Today, bariatric surgery is the most effective treatment for obesity, and the techniques continue to evolve. Laparoscopic sleeve gastrectomy, which is only one step of biliopancreatic diversion/duodenal switch surgery, has become the most common bariatric procedure due to its efficacy when performed alone. Additionally, the rate of complications has decreased as a result of increased technical experience and the development of stapler technology. The widespread adoption of laparoscopic sleeve gastrectomy is also attributable to its technical simplicity. Although it is assumed to be a simple procedure, mistakes at specific stages significantly increase the risk of complications. We focus on our method in detail, including all operative steps, which we believe is the simplest and most effective technique after performing over 5000 surgeries at our institution. Paying attention to the sleeve size, selecting the appropriate stapler, not narrowing the incisura angularis, resecting the fundus without getting too close to the esophagus, creating a smooth, non-rotating staple line, and suturing the staple line are highlighted.

1. Introduction

Gastrectomy for weight loss was first described by Marceau et al. in 1993 as a restrictive component of biliopancreatic diversion [1]. Then they described the vertical sleeve gastrectomy as the first step of the biliopancreatic diversion-duodenal switch procedure in 1998 [2].

Unfortunately, the laparoscopic duodenal switch was associated with significant complications, especially in patients with high body mass index [3]. Thus, Gagner et al. performed laparoscopic sleeve gastrectomy (LSG) as the initial stage of a two-staged approach before BPD/DS and Roux-en-Y gastric bypass to optimize the performance status of patients at high surgical risk or extremely obese [4, 5]. Many of these patients achieved adequate weight loss and improvement in medical comorbidities after the first sleeve gastrectomy, and the second stage was rarely required. Therefore, LSG has evolved into a stand-alone weight loss procedure over time.

Long-term data show that LSG is as similar in weight loss and comorbidity resolution as the Roux-en-Y gastric bypass and has similar mortality and morbidity rates [6]. It is now the most commonly performed bariatric procedure worldwide, owing to its technical simplicity, short learning curve, and effectiveness [7].

The procedure has not been standardized yet. Different technical nuances can be seen at various points throughout the process. In this section, we focus on our method in detail, including all operative steps, which we believe is the simplest and most effective technique after performing over 5000 surgeries at our institution.

2. Mechanism of action

The efficacy of the laparoscopic sleeve gastrectomy leading to sustained weight loss and improvement in comorbidities results from various mechanisms. First, owing to the reduction in stomach volume, there is a dramatic decrease in alimentary intake. Second, the orexigenic hormone ghrelin, which stimulates food intake, fat deposition, and the release of growth hormone, has dropped significantly. One of the primary goals of LSG is to eliminate the fundus, which is the primary source of ghrelin. Moreover, Glucagon-like-peptide-1, Peptide YY, and pancreatic polypeptide may also be factors involved in the mechanism of weight loss [8, 9]. Apparently, this mechanism is most likely multifactorial and still not fully clarified.

2.1 Preoperative considerations

LSG surgery is recommended for patients with a BMI greater than 40 kg/m² or a BMI greater than 35 kg/m² and co-morbid diseases such as type II diabetes, hypertension, obstructive sleep apnea (OSA), non-alcoholic fatty liver disease, osteoarthritis, hyperlipidemia, or heart disease.

All patients considering bariatric surgery should undergo an adequate preoperative evaluation and workup including lab tests (complete blood count, basic metabolic panel, coagulation panel, HgA1C, thyroid function tests, vitamins, B-HCG for women), chest X-ray, and ECG [10].

Although upper GI endoscopy and abdominal ultrasonography are not routinely recommended, they contain important information that may affect the surgical plan. Concomitant hiatal hernia, esophagitis, H. pylori, and occult malignancies can all be evaluated using esophagogastroduodenoscopy. On the other hand, ultrasonography provides information about cholelithiasis, steatohepatitis, and other abdominal pathologies.

The evaluation of patients with gastroesophageal reflux preoperatively is controversial due to the conflicting results of LSG on reflux symptoms. There are studies in the literature claiming that LSG either improves or worsens reflux [11, 12]. Due to the risk of worsening the current situation and the need for revisional surgery, LSG is not the best option for patients with significant gastroesophageal reflux disease (GERD). The ASMBS released a statement declaring that severe GERD symptoms and Barrett’s esophagus are relative contraindications to LSG [13]. Roux en Y gastric bypass, which has long been used as an anti-reflux procedure, should be recommended for this population.

Increased reflux symptoms after LSG can be associated with a concomitant hiatal hernia. There is an emerging consensus on concomitant hiatal repair [14]. According to the International Consensus Conference on Sleeve Gastrectomy, 84% of bariatric surgeons believe it should be repaired if present [15].

Smoking cessation and OSA management are critical for preventing respiratory complications in bariatric patients whose oxygen delivery to tissues may be compromised.

Furthermore, the following elements must be addressed: evaluation and optimization of comorbidities; consultation with a dietician, psychiatrist, and endocrinologist; and informed consent and thorough education regarding expectations [7].

2.2 Anesthesia

The procedure requires general endotracheal tube anesthesia. The anesthesiologist should be prepared for the possibility of difficult intubation, which is common in obese patients, and should have a flexible bronchoscope to assist with endotracheal tube placement.

3. Patient positioning and operative field

The patient is positioned in reverse Trendelenburg and supine with both arms abducted and the legs split (French position). The patient is fixed to the operation table from both legs and the infraumblical site. The surgical covers and instruments are placed after the iodine wash of the abdominal skin. A 5-mm vessel sealer is prepared for dissection. A urinary catheter is not routinely placed. Patients are administered antithrombotic medication (enoxaparin) 12 hours before surgery in addition to sequential pneumatic compression stockings and prophylactic antibiotics.

The surgeon starts on the patient’s right during trocar placement and then stands between the legs at the center. The assistant holds the camera with the left hand and uses grasper with the right hand on the patient’s left and a nurse on the patient’s right (Figure 1).

Figure 1.

Operative positioning.

3.1 Surgical technique

3.1.1 Trocar placement and Pneumoperitoneum

Pneumoperitoneum can be established with a variety of techniques (open, visualizing trocars or Veress needle), but we prefer the direct entry method. Although the direct entry method has a long learning curve and requires experience, it is a fast and safe method when performed by experienced surgeons. Only five patients in our series had lacerations in the gastric serosa, and one patient with extensive intra-abdominal adhesions had full-thickness colon injury, which was noticed and repaired during the surgery (Figure 2).

Figure 2.

Direct entry of the camera trocar (left-handed surgeon). The surgeon grasps the fascia with a towel clamp and lifts it upward to avoid any intraabdominal injury.

The first trocar for a 10-mm camera is placed 10–12 cm below the xiphoid, and CO₂ is insufflated up to 14–16 mm Hg. A laparoscope with 30° camera is introduced, and the abdominal cavity is inspected to rule out injury from the trocar and any other anatomic abnormalities such as adhesions. Three more trocars and a retractor are placed as shown in Figure 3:

1. A 15-mm trocar in the right upper quadrant provides passage of the black staple load. The remainder of the cartridges (purple) fit through a 12-mm port. This is also used for the left-hand working port.

2. A 5-mm trocar in the left upper quadrant on the midclavicular line. This working port is for the surgeon’s right hand.

3. A 5-mm trocar in the lateral left upper quadrant on the anterior axillary line. It is used by the first assistant for retraction.

4. The Nathanson® liver retractor is placed via an additional 5-mm incision in the superior epigastrium.

Figure 3.

(a, b) Trocar placement.

With the surgeon’s command, the orogastric tube is placed to evacuate the stomach and should be taken to 30–35 cm of the esophagus.

Tip: The entry point of the camera trocar should not be adjusted to the umbilicus, but to the xiphoid, which is a more reliable and stable mark. The location of the umbilicus may vary depending on the patient’s BMI and anatomical features. Also, the location of the umbilicus has changed in patients who have undergone abdominoplasty. If the camera trocar is inserted lower than it should be, fundus dissection will be difficult, especially in patients with high BMI.

Tip: Adequate aspiration of the stomach provides serious convenience, especially during fundus and left crus dissection. Dissection can be difficult while the tube is in the stomach.

Pitfall: To avoid any injury, a nasogastric or orogastric tube should not be inserted without the knowledge of the surgeon. In case of carelessness or miscommunication, the tube is fired between the staplers.

3.1.2 Gastrocolic omentum dissection

Dissection begins from the corpus-antrum junction of the greater curvature. The gastrocolic omentum is divided off the greater curvature of the stomach with the energy device on the surgeon’s right hand, beginning approximately 3–4 cm proximal to the pylorus and proceeding to the angle of His, completely mobilizing the greater curve (Figure 4).

Figure 4.

(a-c) Gastrocolic Omentum Dissection (a) shows the first movement to enter the lesser sac via stomach traction and omentum contra-traction. Surgeon separates the omentum up to 3 cm proximal to the pylorus in (b). Dissection is continued close to the stomach, along the greater curvature to the angle of His in (c).

Tip: The surgeon’s left hand pulls the stomach to the upside while the assistant catches the gastrocolic ligament and pulls gently to the downside. It allows working close to the great curvature, which reduces the risk of bleeding from gastroepiploic vessels and facilitates specimen extraction at the end of the operation (Figure 5).

Figure 5.

Bleeding from the gastrocolic omentum.

Pitfall: If a dissection close to the stomach is not performed, bleeding from the gastroepiploic vessels may occur and take time to stop .

3.1.3 Posterior adhesions dissection

All posterior attachments to the pancreas must be divided, taking care not to injure the lesser curvature and left gastric vessels because the blood supply to the sleeve originates solely from the lesser curvature vasculature.

Tip: The most efficient maneuver to achieve adequate exposure for the posterior dissection is to retract the posterior aspect of the stomach upward with two graspers.

Pitfall: It is important to divide these attachments before stapling because these attachments can tear and create bleeding. However, left gastric and splenic vessels should be preserved (Figure 6).

Figure 6.

Posterior Dissection (Retracting the stomach upwards with two graspers provides an adequate exposure).

3.1.4 Fundus dissection

The entire fundus should be freed posteriorly from the left crus. In order to properly diagnose a hiatal hernia and ensure that no fundus tissue is left behind, the left crus and gastroesophageal junction must be fully exposed. A gastric fat pad (especially if it is large and complicates the resection) can be resected.

Tip: The surgeon pulls the stomach slightly to the right-downward via the left hand, and the first assistant gently performs various maneuvers, such as pulling the fundus up or to the right to provide the best visualization. This is the most efficient maneuver to achieve adequate exposure for the fundus dissection.

Pitfall: During this portion of the procedure, care should be taken to avoid excessive traction and bleeding from short gastric and splenic vessels. Possible bleeding in this splenic region can be difficult to control, especially in patients with a higher BMI. A sponge can be placed in this area to control the bleeding (Figure 7).

Figure 7.

(a, b) Traction of the fundus (The surgeon pulls the stomach slightly to the right-downward, and the assistant does the active maneuvers).

3.1.5 Orogastric tube insertion

Although the preferred orogastric tube size varies between 32 Fr and 42 Fr, the average bougie size used by experts today is 36–37 French [6].

Before the first staple firing, a 36 French orogastric tube is placed by the anesthesia team. The surgeon can guide the bougie using graspers for proper placement. The tube is positioned in the antrum along the lesser curvature and not passed through the pylorus.

Tip: The stomach should be placed in its anatomical position, and the orogastric tube should stay parallel to lesser curvature. Also, stretching the stomach by excessive pushing of the tube compromises the straightness of the stapler line (Figure 8).

Figure 8.

Orogastric tube insertion (No excessive stretching of the stomach).

3.1.6 Transection

Transection of the stomach begins on the antrum 3–4 cm proximal to the pylorus with a black 60-mm-long cartridge with an articulating stapler. Transection of the stomach should begin no less than 3 cm proximal to the pylorus [7]. Then purple 60-mm-long cartridges are used for the remainder. The thickness of the stomach tissue becomes thinner from the antrum to the fundus. Therefore, surgeons choose the tallest cartridges (black, green) at the antrum level, and while going proximal in the stomach, shorter (purple, blue, and golden) cartridges are chosen. It is crucial to ensure adequate resection of the fundus. Approximately 75–80% of the stomach is resected.

Tip: The incisura angularis should not be narrowed during stapler placement, the stomach should be laid in its anatomical position with equal apposition of the anterior and posterior aspects of the sleeve, and the orogastric tube should not be approached with excessive traction. This technique creates a straight staple line resistant to strictures, kinks, twists, and leaks.

Tip: Gastric tissue thickens due to contractions in some cases, making transection difficult. In our experience, administering intravenous Hyoscine butylbromide (Scopolamine) before transection, which reduces contractions with its anticholinergic effect, may result in a straighter and smoother staple line in these patients. However, there are no clinical studies to back up this assertion (Figure 9).

Figure 9.

a-c Staplings (Surgeon avoids narrowing the incisura angularis during the first stapling as shown in (a) and makes control with a clamp to be sure during the second stapling in (b). Last staple that is not adjacent to the esophagus is shown in (c)).

Pitfall: The last fire has to be done 0.5–1 cm lateral to the His angle to avoid the risk of ischemia-related leak and fistulas (Figure 10).

Figure 10.

(a, b) (a) shows a straight and smooth staple line that should be aimed. The false stapling technique results in an irregular staple line that is prone to complications (b).

3.1.7 Bleeding control and staple line reinforcement

Staple line bleeding (SLB) is a common intraoperative complication following resection in LSG [16]. A hemostatic clip (10 mm) is a quick and simple tool for controlling bleeding, particularly oozing. Clips are also used at stapler transition points as they are considered potentially vulnerable areas, though this has not been proven.

Staple line reinforcement is a controversial step of the procedure. Although it has not been demonstrated that routine reinforcement of the staple line is necessary, we usually reinforce the staple line with sutures in our practice. During this process, we prefer to sew the dissected omentum majus line to the stapler line. With this reinforcement, we hope to reduce complications including leakage and stenosis (due to the formation of a twist or kink) and most notably, bleeding. The decision to reinforce should be based on the stapler used and the patient’s condition. According to recent studies on bariatric surgery, the following risk factors for postoperative bleeding are stated: male sex, >45 years of age, body mass index <40 kg/m², cardiovascular disease, and current procedure of LSG, bougie size, prior cardiac procedure, hypertension, renal insufficiency, therapeutic anticoagulation, diabetes, obstructive sleep apnea, and operative length [17, 18].

Perioperative control of blood pressure is another important measure to prevent bleeding. Because it is assumed that some of the bleeding is due to the sudden increase in blood pressure during the operation or in the post-anesthesia care unit [19] (Figure 11). It should be ensured that the blood pressure is kept below a certain level, especially from the firing stage to the early postoperative period. Karaman et al. found that keeping the systolic blood pressure below 120 mm Hg during surgery reduced staple line bleeding [9]. In our practice, we keep our systolic blood pressure target around 100–110 mm Hg throughout the surgery. Blood pressure control is achieved by titration of remifentanil infusion and, if necessary, glyceryl trinitrate infusion is started (Figure 12).

Figure 11.

a,b Clips to the staple line. A hemostatic clip is a straightforward tool for bleeding and also can be used at staple transition points for reinforcement.

Figure 12.

Omentopexy and sewing.

3.1.8 Drain placement

We routinely place a soft drain to take early measures for bleeding, but it is known that many surgeons have recently abandoned the use of drains (Figure 13).

Figure 13.

Drain.

3.1.9 Resected stomach (specimen) extraction

The specimen is extracted with jaws grasper through the-15 mm trocar incision under direct visualization.

Pitfall: Specimen removal can be quite difficult, especially in large stomachs, and will result in a rupture if the correct gentle maneuvers are not performed with patience.

Tip: To prevent this situation, the specimen should be removed by pulling the greater curvature, not the staple line, because the staple line is weaker (Figure 14).

Figure 14.

Specimen removal with a jaws grasper.

3.1.10 Closure of Trocar sites

The 15- and 10-mm trocar fascial defects are closed with a suture passer.

Pitfall: If not repaired, trocar site hernias may occur, mainly due to 15-mm fascial defects (Figure 15).

Figure 15.

Fascial closure with a suture passer device.

3.2 Early postoperative care

It is critical to resume analgesics and antiemetics in the recovery unit. To prevent vomiting or retching, aggressive nausea prevention and early mobilization are provided. The combination of antiemetics such as ondansetron and metoclopramide with multimodal analgesia is effective.

In our practice, patients are mobilized 2–4 hours after surgery. After the anesthetic drugs have worn off, small sips of water are taken. Clear liquids are usually started on the first postoperative day, followed by a high-protein liquid diet on the second day. The majority of patients are ready for discharge home on the second day. Daily micronutrient supplements are required due to inadequate dietary intake. Anticoagulation prophylaxis is provided for 2 weeks after discharge. A proton pump inhibitor is recommended for 3 months.

Many obese patients have OSA, and if their personal device is present, it is safe and preferred. However, some may require continuous pulse oximetry and positive airway pressure in the ICU following surgery.

CRP levels and complete blood count are highly correlated with postoperative complications and can be taken every 24 hours.

The postoperative diet is varied. Usually, practices begin with clear liquids, increasing the volume gradually. Intake should be in small portions. The daily intake goal is 2 L. If the patient tolerates this, liquid foods such as milk and yogurt can be safely started without delay. After 1–2 weeks, patients progress to a mashed or pure diet. It is recommended to separate liquids from solids. After 2 weeks, patients can start a soft diet. The solid foods are started at 1 month [7].

4. Summary

Although LSG can be performed with different technical methods at various stages, to avoid postoperative complications and obtain the best weight loss results, it is necessary to pay attention to the following key points:

1. Pay attention to the sleeve size, which determines the weight loss results.

2. Choose the stapler suitable for tissue thickness.

3. Avoid narrowing the incisura angularis.

4. Resect the fundus as much as possible without getting too close to the esophagus.

5. Create a smooth non-rotating staple line.

6. Reinforce the staple line.