Laparoscopic sleeve gastrectomy: surgical treatment of morbid obesity

Laparoscopic sleeve gastrectomy (LSG) as a stand alone procedure for the surgical management of morbid obesity represents 2% of the bariatric operations in the United States of America. In the USA, this technique was developed as a modification of the biliopancreatic diversion in 1988; and in the United Kingdom, the concept of LSG evolved as a modification of the Magenstrasse and Mill procedure. In the latter, SG is essentially a completion of the Magenstrasse distally by completely separating the greater curvature and antrum.

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Laparoscopic sleeve gastrectomy (LSG) as a stand alone procedure for the surgical management of morbid obesity represents 2% of the bariatric operations in the United States of America. In the USA, this technique was developed as a modification of the biliopancreatic diversion in 1988; and in the United Kingdom, the concept of LSG evolved as a modification of the Magenstrasse and Mill procedure. In the latter, SG is essentially a completion of the Magenstrasse distally by completely separating the greater curvature and antrum.
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1. Introduction
Laparoscopic sleeve gastrectomy (LSG) as a stand alone procedure for the surgical management of morbid obesity represents 2% of the bariatric operations in the United States of America. In the USA, this technique was developed as a modification of the biliopancreatic diversion in 1988; and in the United Kingdom, the concept of LSG evolved as a modification of the Magenstrasse and Mill procedure.
Its acceptance as an alternative surgical treatment for obesity in the last years is due to the fact that it is a rapid and less traumatic operation and thus far is showing good resolution of co-morbidities and good weight loss. A further second surgical step is then easily feasible, if necessary.
An excessive weight loss (EWL) of 54 to 81% on average by 12 months have been reported (Himpens et al., 2006; Tucker et al., 2008), as well as the improvement in co-morbidities of obesity (2004 ASBS Consensus Conference on Surgery for Severe Obesity, 2005).
2. Basics of procedure
Definition and principles
The sleeve gastrectomy is also known as the greater curvature gastrectomy, vertical or longitudinal gastrectomy.
A gastric tube of 60 to 120mL is created by resecting the greater curvature of the stomach.
The volume of the gastric pouch varies according to the gastric calibration tube (<40 French).

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms:
1) mechanical restriction by reducing the volume of the stomach and impairing stomach mobility;
2) hormonal modification by removing a great part of the Ghrelin production tissue. Ghrelin is a 28 amino-acid-peptide, secreted by the oxyntic glands of the gastric fundus (Ariyasu et al., 2001). It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area (Mognol et al., 2005; Himpens et al., 2006). The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum. In the SG, resection of the fundus removes the major site of ghrelin release, therefore appetite decreases.

The sleeve gastrectomy is an effective primary bariatric procedure in the short term; the overall excessive weight loss (EWL) at 6 and 12 months ranges from 35 to 71% and 33 to 81% respectively.
The EWL at 3 years has been reported to be similar to that after RYGB (Gumbs et al., 2007; Baltasar et al., 2005; Lee et al., 2007).
Long-term results are influenced by the size of the bougie used as a guide. Its size must be inferior to 40 French. The volume of the gastric remnant will then be reduced (Weiner et al., 2007).

Weight loss failure
Weight regain after a sleeve gastrectomy is associated with the dilatation of the gastric remnant. Differences on surgical techniques can explain why this event may happen to any patient:
- excessive large bougie;
- true gastric dilatation over time;
- inadequate resection of posterior gastric folds;
- excessive pressure against the pouch wall by large meals, repeated vomiting or distal obstruction;
This weight loss failure can be surgically managed by (Baltasar et al., 2006; Gagner and Rogula, 2003):
- laparoscopic re-sleeve gastrectomy again reducing the gastric pouch;
- gastric bypass;
- laparoscopic duodenal switch (LDS).
3. Anatomy
• Anatomical relations
• Greater curvature
It contains different anatomical relations.
- superiorly: greater curvature is fixed to the diaphragm by the gastrophrenic ligament, it is a real suspensory ligament to the stomach.
- medially: the gastric body corresponds to the vertical segment of the greater curvature. It is attached to the splenic hilum by the gastrosplenic omentum, which contains the short gastric vessels.
• Lesser curvature
It is located deeper than the greater curvature
1. Lesser curvature
2. Greater curvature
3. Spleen
• Vascular supply
The vascular supply of the stomach largely depends on the coeliac trunk and its branches: left gastric, splenic, and hepatic artery.
1. The arterial arch on the lesser curvature shaped by the larger left gastric artery and the smaller right gastric artery;
2. The arterial arch on the greater curvature shaped by the right and the left gastroepiploic arteries;
3. Four or five short gastric arteries leaving the terminal branches of the splenic artery close to the spleen, ant the left gastroepiploic artery.
- left gastroepiploic artery: branch of the inferior division of the splenic artery,
- short gastric vessels: they originate from the splenic artery and mainly irrigate the gastric fundus, in a number of 6 to 8.
4. Indications and contraindications
Standard indications:
As for all morbid obesity surgery, standard rules apply:
- BMI >40;
- BMI >35 with co-morbidities;
- medical treatment followed by the patient for one year fails;
- regular physical activity.

Specific indications:
The SG is preferred over a gastric bypass or a biliopancreatic diversion in the case of:
- hepatic cirrhosis;
- inflammatory bowel disease;
- major bowel adhesions;
- major co-morbidities;
- ASA III or IV morbidly obese patient;
- gastric polyps; gastric endocrine tumors.

The SG will be the first stage of the procedure, followed by a gastric bypass or a biliopancreatic diversion when:
- BMI >60;
- BMI >50 with ASA III -IV patients.

Absolute contraindications:
- BMI <35;
- contraindication to general anesthesia;
- pregnancy;
- severe psychiatric disorders;
- drug and alcohol addiction;
- untreated esophagitis;
- giant hiatal hernia.
5. Preoperative period
Laboratory evaluation: basic chemistry panel, full blood count, thyroid function tests, serum cortisol, urine cortisol, serum cholesterol, serum triglycerides, measurements of vitamins (A, B1, B6, B9, B12, C).

Upper endoscopy:
- rule out inflammatory ulcerous gastric pathology, search and treat H pylori infection when present.

Ultrasound of the abdomen:
- to rule out cholelithiasis, which would indicate cholecystectomy along with the gastric sleeve.

Cardiovascular evaluation:
- exclude any contraindications to anesthesia.

Psychiatric evaluation:
- to rule out any behavioral abnormalities that would contraindicate limited food intake.

Endocrine evaluation:
- rule out an endocrine abnormality as the etiology of morbid obesity.

Dental evaluation
6. Operating room set-up
• Patient
Standard position:
- supine position with both legs abducted;
- intermittent pneumatic leg compression for preventing deep vein thrombosis;
- both arms extended;
- stirrups for feet positioning;
- all contact zones are carefully checked and padded to avoid nerve and arterial compression or pressure sores.
• Team
Standard position:
1. The surgeon stands between the patient’s legs.
2. The first assistant stands on the patient’s right.
3. The second assistant stands on the patient’s left.
4. The scrub nurse stands on the surgeon’s right.
5. The anesthesiologist stands at the head of the patient.
• Equipment
1. Operating table: conventional operating tables should accommodate a weight up to 250 Kg.
2. Anesthetic equipment
3. Laparoscopic video unit
4. Two high-resolution monitors
5. Electrocautery device
7. Pneumoperitoneum
The pneumoperitoneum is established in a standard fashion, with the usual precautions, at a maximal intraperitoneal pressure of 15mmHg.

Insufflation pressure:
Due to the thickness of the wall, it may be necessary to increase the pressure of the pneumoperitoneum to 14 or even 15mm Hg. The anesthesiologist should be warned of the increase in insufflation pressure and asked to monitor the capnograph.
8. Trocar placement
• Trocars
Due to the abdominal wall’s thickness and the depth of the surgical field, trocar placement is of utmost importance.
This technique is usually performed with 5 trocars:
A: optical trocar
B and C: operating trocars
D and E: retracting trocars
• Optical trocar
The optical trocar is the first one. Its position is one and a half hand’s breadth below the xiphoid process. The main difficulty in this region is the presence of the large, fatty, round ligament that can be avoided by just placing the trocar slightly to the left of the midline.
• Reverse Trendelenburg
The patient is then placed in reverse Trendelenburg position, lowering the abdominal viscera and freeing the operative field in the upper abdomen.
• Operating trocars
The other trocars are then introduced under visual control.
Trocars B and C are operating trocars.
• Retracting trocars
Trocar D accommodates the liver retractor.
Trocar E accommodates the stomach retractor.
9. Instruments
1. 30° laparoscope
2. Hook dissector
3. Scissors
4. Bipolar grasper
5. Fenestrated grasper
6. Suction-irrigation device
7. Linear stapler
8. Needle holder
9. Circular liver retractor
10. Ligasure device
10. Exposure and dissection
• Identification of the pylorus
The gastric resection starts at 6cm proximal to the pylorus. The pylorus has to be carefully identified. Another anatomical landmark is achieved by the vertical division of Latarjet’s nerve.
The pyloric region is exposed by retracting the anterior surface of the gastric antrum. All the omentum must be pushed aside.
The pylorus is then easy to palpate.
6cm of pylorus are then measured proximally. This corresponds to the location of the Latarjet’s nerve vertical division.
The greater omentum is then opened to enter the lesser peritoneal sac. This prepares the gastrolysis of the greater curvature.
• Cardia dissection
Liver retraction:
The left lobe of the liver is retracted cephalad and laterally to visualize the upper part of the stomach and the hiatal region.
The contact area between the retracting device and the liver must be large enough in order to avoid rupture of the fibrous capsule of the liver.
Any bleeding will impair visualization of the operative field and will absorb part of the light intensity.

Cardia dissection:
After having exposed the starting point of the gastrolysis, we expose the hiatal region to dissect and free the angle of His. This step prepares for the last part of the gastrolysis and the gastric section.
11. Gastrolysis
Division of the greater omentum is performed from distal to proximal, with the aid of the Ligasure® device. The greater omentum is divided close to the stomach. In the upper third, we run into the short gastric vessels. The freeing of the greater curvature is continued up to the angle of His.
12. Resection
• Beginning of the staple line
The sleeve gastrectomy is begun with sequential firings of linear stapler (60mm) placed through the left 15mm trocar, starting at the level of the crow’s foot just distal to the incisura angularis. The stomach should be retracted laterally.
The first 60mm stapler (4.8 mm staples, green cartridge) is positioned approximately 2cm from the lesser curvature in order to ensure adequate blood supply and avoid obstructing the gastric lumen.
The anterior and posterior vagus nerves are preserved for normal gastric emptying.
• Calibration of the gastric pouch
Then a 36 French bougie is inserted into the stomach by the anesthesiologist and aligned medially along the lesser curvature into the duodenum to continue with the SG. This bougie may be replaced by a gastroscope allowing for a correct visualization of the gastric pouch at the end of the procedure.
• Gastric resection
Sequential firing of 60mm linear staplers is performed up to the angle of His (3.5mm staples, blue cartridges).
• Staple line reinforcement
Staple-line reinforcement is used to reduce the risk of intraoperative bleeding and leakage.
The following materials may be used:
- continuous absorbable suture;
- bio-absorbable glycolide copolymer (Seamguard, W.L. Gore & Associates);
- fibrin glue.
13. Extraction
The resected specimen is placed in an extraction bag and removed through the 12mm left lateral port or through the optical port.
14. Postoperative period
No nasogastric tube is placed at the end of the procedure.

A water-soluble upper gastrointestinal study is performed in selected cases (intraoperative difficulties), and for patients with clinical symptoms and signs of leakage (fever, tachycardia, tachypnea, severe leukocytosis).

If the examination is performed and reveals no anomalies, the patient is allowed to drink.
From POD2 to POD9, the patient remains on a liquid diet. Over the next 3 weeks, the food must be soft or chopped. After this period, the patient can progressively return to normal drinking and eating habits, with the recommendation to chew adequately.

The patient is usually discharged on POD2.

The first follow-up is performed one week after discharge, when sutures or clips are removed, and then at 1, 3, 6 and 12 months.
15. Advantages/disadvantages
- no digestive anastomosis involved;
- no mesenteric defect is created;
- no foreign material is used (no foreign body complication nor adjustments);
- digestive tract accessible to endoscopy;
- low risk of peptic ulcer;
- vitamins and mineral absorption not altered;
- short hospital stay;
- avoidance of foreign material to create a restrictive band;
- maintenance of normal GI continuity with preservation of antrum and nerve supply permitting adequate gastric emptying;
- ability to convert this procedure into multiple other operations (such as gastric bypass or biliopancreatic diversion).

- stapling complications;
- irreversibility.
16. Complications
Acute (intraoperatively)
- hemorrhage;
- splenic injury;
- liver injury;
- abscess;
- sleeve stricture.

- incisional hernia;
- gastroesophageal reflux;
- stenosis;
- thrombosis;
- pulmonary embolism;
- gastric atony;
- Wernicke’s syndrome due to thiamine deficiency from excessive vomiting;
- leaks;
- weight regain due to gastric reservoir dilatation.
17. Reference
Ariyasu H, Takaya K, Tagami T, Ogawa Y, Hosoda K, Akamizu T et al. Stomach is a major source of
circulating ghrelin, and feeding states determines plasma ghrelin-like immunoreactivity levels in
humans. J Clin Endocrinol Metab 2001;86:4753-8.
2004 ASBS Consensus Conference on Surgery for Severe Obesity. Surg Obes Relat Dis 2005;1:297-
Baltasar A, Serra C, Perez N, Bou R, Bengochea M, Ferri L. Laparoscopic sleeve gastrectomy: a
multi-purpose bariatric operation. Obes Surg 2005;15:1124-8.
Baltasar A, Serra C, Perez N, Bou R, Bengochea M. Re-sleeve gastrectomy. Obes Surg
Braghetto I, Korn O, Valladares H, Gutiérrez L, Csendes A, Debandi A, et al. Laparoscopic sleeve
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Clinical Issues Committee of American Society for Metabolic and Bariatric Surgery. Sleeve
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Deitel M, Crosby RD, Gagner M. The first international consensus summit for sleeve gastrectomy
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