Sleeve Gastrectomy

Sleeve Gastrectomy

Sherif Awad


Sleeve gastrectomy (SG) is the most commonly performed bariatric and metabolic surgery (BMS) procedure in the world. The latest 6th Global Registry report from International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) reported that 50.2% of all procedures performed were SG.

SG was originally proposed as the first stage of a two‐stage operation for patients at too high a body mass index (BMI) or too high risk (due to medical co‐morbidities) to undergo definitive weight‐loss procedures, such as Roux‐en‐Y gastric bypass (RYGB) or duodenal switch. However, data demonstrated SG achieved excellent and long‐standing weight‐loss outcomes allowing it to be utilised as a stand‐alone bariatric surgery procedure. Since its conception SG has gained widespread acceptance amongst bariatric surgeons and patients due to its lower complexity as an operation, side effect profile and reduced potential for future surgical complications and reoperations.

Patient Selection

Standard criteria for BMS (see Chapter 8 for indications of bariatric surgery) are utilised for selecting patients for SG.

SG is particularly suitable and the preferred procedure for the following cases:

  • Patients with extremely high BMI and/or significant central obesity.
  • Patients with history of previous intestinal/abdominal surgery who may have extensive small bowel adhesions.
  • Patients with biliary disease who may need endoscopic intervention in future (procedures such as ERCP can be performed after SG).
  • Significant liver (early cirrhosis due to non‐alcoholic fatty liver disease) and renal (renal failure/patients awaiting renal transplant) disease.
  • Inflammatory bowel conditions (Crohn’s and ulcerative colitis).
  • Malabsorptive conditions (e.g. coeliac disease) and patients with specific dietary requirements (e.g. vegans, vegetarians and lactose/dairy intolerance).
  • Patients with poorly controlled diabetes or who are at higher risk of developing postprandial hypoglycaemia.
  • Patients who prefer reduced occurrence of dumping syndrome.
  • Surgical candidates who the multi‐disciplinary team (MDT) feel may not fully adhere with post‐operative vitamin/mineral supplementation regimen or who may not attend regular follow‐up.

SG should be avoided in the following cases:

  • Patients with severe gastro‐oesophageal reflux (GORD) or hiatal hernia greater than 3 cm in size.
  • Patients already known to have Barretts’ oesophagus.
  • Patients, rarely, with strong family history of oesophageal or gastric cancer.

Pre‐Operative Preparation

Having completed the pre‐operative MDT assessment, patients are commenced on a pre‐operative liver reducing diet (LRD) for a period of one to four weeks depending on pre‐operative BMI. This LRD diet comprises 800–1000 kcal per day and comprises foods/meal replacement shakes low in carbohydrate and fat. The LRD helps shrink the left lobe of the liver, which usually overlies the stomach and needs retraction at the start of surgery.

Pre‐operatively, patients should also be counselled on the principles of enhanced recovery after surgery (ERAS), which will ensure improved recovery and reduced occurrence of complications after surgery (see Chapter 13 for pre‐operative management – surgical considerations for more details).

Operative Technique

SG is performed utilising laparoscopic (keyhole) surgery, performed under general anaesthesia. Patients are admitted on the day of surgery and, if able, it is of importance they mobilise to the operating theatre (as opposed to being wheeled in/placed on a trolley). This will help imbed the principles of ERAS and early mobilisation into patients.

Patients are positioned on a bariatric operating table (able to support high weights up to e.g. 350 kg) with arms outstretched on arm boards and legs either bound together (supported by foot plates; Figure 16.1) or spread apart to allow the surgeon to stand in the middle. Patients are neither required to undergo bladder catheterisation nor insertion of nasogastric tubes (in keeping with ERAS principles). However, they are administered pre‐operative antibiotic prophylaxis and have pneumatic calf compression pumps applied to reduce risk of peri‐operative venous thromboembolism (VTE).

A photograph of typical patient positioning on operating table prior to bariatric and metabolic Surgery.

Figure 16.1 Typical patient positioning on operating table prior to bariatric and metabolic Surgery. Footplates are used at the base of the operating table to stop patient sliding down on table tilt. Arms are positioned outstretched to enable access to intravenous lines. Large abdominal apron is strapped to the table. Ankle and knees are strapped to prevent knee flexion and ankle eversion during surgery. The table is tilted 30° head up to allow increased space in upper abdomen to perform surgery.

At the commencement of surgery, the operating table will be positioned with a head up tilt of 15°–30° to allow intra‐abdominal fat to fall away from the upper abdomen, thereby creating more upper intra‐abdominal space. Laparoscopic ports are inserted into the abdomen (4–5 ports are usually needed), and pneumoperitoneum is established to 12–15 mmHg. A liver retractor is inserted to lift the left lobe of the liver away from the stomach and enable dissection and mobilisation of the stomach.

SG involves vertical resection of the outer 75% of the stomach extending from the antrum up to the angle of His (Figure 16.2). The surgery involves utilising an energy device to seal the blood vessels that supply the outer aspect of the stomach along the area to be resected and freeing the back surface of the stomach from adhesions. A specialised stapling device is used to transect and seal the stomach along the resection margin. Usually, an orogastric bougie is used (typical sizes range from 34 to 42 French depending on surgeon preference) to facilitate achieve a uniform and standardised gastric resection. It is key that the correct technique is used in transecting the stomach to ensure a straight staple line along the lateral margin of the stomach. If the staple line ‘twists’ along the stomach, this will likely result in a helical/functional twist in the sleeve on eating which can lead to significant future problems (see below).

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May 14, 2023 | Posted by in GENERAL SURGERY | Comments Off on Sleeve Gastrectomy

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