Surgical technical key points of laparoscopic sleeve gastrectomy: how I do it

Introduction

Background

Obesity is growing all over the world, turning it on one of the most important health issues of this century (1,2). The World Health Organization defined obesity as a chronic complex disease secondary to excessive fat deposits that can impair health. The severity of this condition is related to body mass index and metabolic comorbidities (1,3). Surgical treatment has proved to be very effective in weight loss and obesity related diseases control, overcoming clinical dietary and drug treatment (3). In the United States of America, it is estimated that more than 250,000 bariatric operations are performed per year, and most of them are sleeve gastrectomy (SG) with Rou-en-Y gastric bypass coming in second place (4). The preference for SG should be related to the lower complexity of the procedure and the lack of the need for intervention in the small bowel, consequently leading to a lower chance of malnutrition and vitamin deficiency (5).

The relationship between SG, weight loss, weight regain, and the development of gastroesophageal reflux disease (GERD) after the procedures is controversial (6,7). The literature shows a wide range of results with different taxes of weight loss or weight regain in a long-term follow-up. Moreover, and even more curious, are the conflicting results around GERD after SG. Some authors related improvement in GERD after SG, maybe secondary to the weight loss. On the other hand, other authors related a high incidence of GERD or worsen of GERD symptoms after SG, probably related to the anatomical changes inherent to the procedure. Experts believe that SG technical variability might be responsible for the conflicting data published in the literature (6).

Standardization of the technique may improve and homogenize outcomes. Surgical videos are becoming an important tool for learning. Videos of experts may allow remote learning and have the power to further dissemination and democratization of the knowledge and techniques of specialists in the field, avoiding mistakes that can occur with the learning curve of new bariatric surgeons. Moreover, video learning is cheaper and can reach a greater number of surgeons at the same time, sparking discussions and accelerating the evolution of the technique, following the path to standardization.

Objective

The aim of this study is to demonstrate a step-by-step laparoscopic SG, standardizing the procedure focusing on technical key points that may affect the outcomes. Figures will demonstrate the surgical team positioning and videos will cover the main surgical steps that are essential to the final shape of the tube.

Preoperative preparations and requirements

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this study, the accompanying image and videos. A copy of the written consent is available for review by the editorial office of this journal.

Patients with body mass index (BMI) >35 kg/m² with obesity related comorbidities or BMI >40 kg/m² who failed in an initial clinical treatment are candidates for SG. It is recommended that all patients undergo an evaluation and treatment by a multidisciplinary team (clinician, psychologists and nutritionist) to provide better surgical results, making patients aware of their chronic clinical condition and the need for adherence to treatment. Preoperative tests must be individualized based on patient’s clinical conditions. However, we consider it important to have a preoperative upper gastroesophageal endoscopy since the procedure changes gastric anatomy and function. SG changes the gastric anatomy, providing the resection of the gastric fundus, creating a pressurized tube. The stapling near the EGJ may harm the lower esophageal sphincter (LES) and depending on the stapling distance from the pylorus the gastric emptying should be slowed down. Those points may influence postoperative GERD. If there is a preoperative endoscopy demonstrating erosive esophagitis grade B or greater of Los Angeles or Barrett’s esophagus, even when patients are asymptomatic, SG must be avoided (7).

Step-by-step

Patients are positioned in Trendelenburg with horizontal dorsal decubitus, and with the legs open. The main surgeon stands between the legs of the patient with the first assistant on the left of the patient and the second assistant on the right of the patient. It is recommended that the main surgeon must be experienced with a minimum of 50 SG per year. Five ports are placed similar to the classic approach of the gastroesophageal junction. A 10-mm port is placed on the midline 10–15 cm under the xiphoid process, a 5-mm port under the xiphoid process (liver retractor), a 12-mm port in the left hemi clavicular line 4 cm under the ribs, a 5-mm port in the right hemi clavicular line 4 cm under the ribs, and an auxiliary 5 mm port in the left flank. A 12-mm port can be exchanged for the 5 mm port on the right flank in order to facilitate the initial stapling depending on the patient’s inherent difficulties. The video is placed at the right side of the patient above the right shoulder (Figure 1). It is recommended to use energy devices to seal the vessel from the great curvature of the stomach as well as laparoscopic staplers and loads adjusted according to the thickness of the tissue as recommended to each manufacturer.

Figure 1 Ports placement and team position for sleeve gastrectomy operation.

Angle of His dissection

It is important to avoid excessive dissection of the Angle of His, maintaining 2 cm far from the esophagus gastric junction (EGJ), aiming to preserve this natural antireflux barrier, decreasing the possibility of post-operative GERD (8) (Video 1).

Crura dissection

An important parameter to conclude the gastric fundus dissection is the complete visualization of the left crus, providing a subsequent safe proximal gastric stapling. However, care must be taken to avoid improper dissection of the crura that could harm the hiatus, increasing the incidence of post-operative hiatus hernia (9,10) (Video 1).

Stapling distance from the EGJ

The stapling ideal distance is 2 cm far from the EGJ. This distance is important to preserve the fibers of the LES and local vascularization. The vascularization after ligation of the short gastric vessels will depend on left diaphragmatic artery and descending esophageal arteries which may lead to ischemia. Stapling too close to the EGJ may favor fistulas secondary to ischemia and a high-pressure area, or injury to the LES fibers leading to increasing transient LES relaxations or hypotonia (11,12). Nonetheless, the distant stapling of the EGJ may favor the formation of wide tubes that may be associated with poor weight loss or weight regain (13) (Video 2).

Stapling distance from the pylorus

The stapling distance from the pylorus is controversial. Stapling near to the pylorus should be better for weight loss but worsen GERD symptoms (14,15). On the other hand, antral preservation should improve gastric emptying resulting in better GERD control but increase in the chance of insufficient weight loss or weight regain (16). We believe that better results are obtained with antral preservation and stapling 5 cm from the pylorus (Video 2).

Gastric pouch calibration

Although there is no consensus in the literature about the bougie caliber that should be used for SG, a bougie must be located for guidance when stapling, avoiding constrictions and rotations of the gastric tube. Wide tubes increase the risk of GERD preserving grater parietal cells population, also increasing the chance of insufficient weight loss (17). Nonetheless, narrower tubes could lead to increased intragastric pressure and constrictions consequently higher chances of dysphagia, GERD and vomiting (18). In our team we prefer a 32-Fr bougie and stapling 2–3 cm far from the bougie, stapling very carefully to avoid constrictions and rotations (Video 3).

Gastric dissection and gastric presentation for stapling

We believe that a wide dissection of the stomach promoting the release of all gastric adhesions from the pancreas and spleen is important to favor gastric mobilization, allowing a better view for stapling. Considering the different sizes of the anterior and posterior gastric wall, gastric presentation for stapling is essential to avoid redundancy and twists that may increase the chance for dysphagia and GERD (19). It is essential the maintenance of the stomach in its anatomical position during the introduction of the bougie and during stapling. Excessive traction of the stomach should be avoided, mainly in incisura angularis preventing stenosis. Special attention should be provided for the posterior gastric wall, keeping off redundancies and rotations during the stapling (Video 3).

Oversewing of the staple line

In general, stapler manufacturers do not support oversewing the stapling line, since invaginating sutures may hypothetically interfere with the fixation/traction mechanism of the staples, thus increasing the risk of complications, although this has not been seen in practice. However, fear of the most common SG complications such as fistula and bleeding are responsible for the preference of the surgeons for a reinforcement suture of the stapling line (20-22), although there is no proof of fistula improvement, and low evidence of bleeding improvement. Our recommendation is to perform an invaginating running oversewing, careful not to interfere in the final gastric tube shape (Video 4).

Final considerations

SG is a less complex procedure than the traditional Roux-en-Y gastric bypass. In experienced hands the total duration of the procedure is around 50 minutes. Due to the lack of evidence, we do not support routine closure of the hiatus. On the other hand, when a hiatal hernia is diagnosed intra-operatively, it is mandatory to close the hiatus, avoiding GERD development (23). Omental fixation is not recommended once gastric fixation in a mobile structure seems not reasonable. Moreover, this technique increases operation time, the risk of bleeding and hematomas in the omentum. Conversion to open surgery is very rare and most of the conversions are related to bleeding from the short gastric vessels or spleen injury.

Postoperative and tasks

The total operating time ranges from 50 minutes to 1 hour and 20 minutes. The most common early complications are bleeding or fistula from the gastric pouch. An incidence of 0.5–1% of this early complication is acceptable.

We offer a liquid diet in the immediate postoperative time maintaining for 15 days. Then the diet is adjusted by an experienced nutritionist. Patients are commonly discharged from the hospital on the first day postoperative if they accept the prescribed diet without vomiting, abdominal pain or tachycardia. GERD symptoms should be evaluated during the short and long-term outcome. The expected excessive weigh loss after 12 months is around 40% (24). A multidisciplinary follow-up is essential to avoid weight regaining.

Tips and pearls

The pearls of a well-done SG must respect important points. Firstly, a careful dissection of the EGJ is important to avoid harm of the anti-reflux barrier. Secondly, all adhesions of the stomach from the pancreas and spleen must be dissected to allow complete mobilization of the stomach facilitating the stapling, avoiding torsions. Thirdly, a bougie must be used to calibrate the pouch. Fourthly, stapling must respect a minimum distance of 2–3 cm from the bougie. Stapling 2 cm far from the EGJ is crucial to preserve the fibers of LES. Moreover, stapling 5 cm far from the pylorus preserves part of the gastric antrum providing adequate gastric emptying. Finally, running invaginating oversewn may prevent bleeding.

Conclusions

The wide range of outcomes after SG must be secondary to the lack of technical standardization. Following technical patterns should be useful to improve outcomes.

Acknowledgments

None.

Footnote

Peer Review File: Available at https://jovs.amegroups.com/article/view/10.21037/jovs-25-7/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jovs.amegroups.com/article/view/10.21037/jovs-25-7/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this study, the accompanying image and videos. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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