Laparoscopic Sleeve Gastrectomy Technique

Sleeve gastrectomy is a partial, longitudinal gastrectomy removing the entire greater curvature of the stomach and leaving a gastric volume of approximately 100 ml, which empties physiologically into the duodenum. Elevating the left lobe of the liver with the retractor allows easy identification of the vagus nerves and the crow's foot of the nerve of Latarjet at the lesser curvature of the stomach, an important landmark for initial dissection of the greater curvature. Dissection begins on the horizontal part of the greater curvature (approximately 6 cm proximal to the pylorus) and proceeds proximally up to the angle of Hiss at the level of the hiatal orifice, completely mobilizing the greater curvature. Once the greater curvature has been freed, the NG tube is removed and replaced by a 34-French rubber calibration bougie. The surgeon guides the descent of the bougie along the lesser curvature of the stomach with a fenestrated grasper. The bougie is advanced through the pylorus to avoid displacement during the gastric partition. A longitudinal gastric tube is fashioned by several firings of the linear stapler parallel to the lesser curvature just alongside the calibration bougie. The staple line is tested for water tightness with 150 ml of methylene blue injected through the NG tube, which has been reinserted and after clamping the pylorus with atraumatic forceps. If a leak is detected, the surgeon adds a few figure of eight absorbable stitches and tests the suture line once again for water tightness. Hemostasis along the staple line is checked visually and figure of eight slowly absorbable stitches can be added as necessary. A low-pressure Jackson-Pratt's type suction drain is inserted and left near the suture line. The stomach remnant is then placed in a 15 cm bag and extracted by pulling on the specimen with an adapted grasper inserted through the 15-mm port site, which may be widened as required. The pneumoperitoneum can then be exsufflated and the trocar orifices closed.