Sleeve gastrectomy (SG) has become the most commonly performed bariatric procedure worldwide. It is very important to know all the tips and tricks to perform a SG in order to complete a safe and technically adequate procedure. We will take into account aspects regarding patients, anatomy, surgical technique and also the postoperative period.
Preoperative weight loss:
Can greatly facilitate surgical dissection by decreasing the amount of visceral fat and liver size, making dissection easier even in patients with higher BMIs than in patients with lower BMIs but without preoperative weight loss.
Trocar placement:
The use of optical trocars may be a good alternative to try to minimize inadvertent injury to other structures with the placement of the first port.
Intraoperative hemorrhage:
Spleen hemorrhage may be due to excessive traction of the omentum adhesions by the assistant. A good option is to place a gauze and apply pressure to perform hemostasis, since visualization of the origin of the bleeding can be very difficult due to the anatomical characteristics of the patients. On the other hand, if the bleeding is due to the dissection of small vessels, trying to control it quickly is plausible if the source is identified, and the use of a bipolar forceps is recommended.
Gastroepiploic vessels hemorrhage:
in order to avoid it is important to perform a correct dissection of the greater curvature, using hemostatic devices can be helpful. With transient hypotension in some patients during surgery, bleeding can go unnoticed and be the cause of urgent surgical reintervention in the immediate postoperative period.
Stapling of the stomach:
It is important to be symmetrical and take as much of the anterior aspect as of the posterior aspect of the stomach, as well as to avoid stenosis when making the multiple staplings required to complete the SG. The use of buttressing material or manual reinforcement of the stapling line can be considered in an attempt to avoid postoperative hemorrhages and even leaks according to some evidence in the literature.Leaving some space between the GE-junction and the last stapling can help to avoid leaks in this high-risk area.
Postoperative period:
ERAS protocol: enhances postoperative recovery and patients can be discharged soon, even in the first 24 hours after surgery.
The appearance of fistulas occurs in most cases during the first postoperative week, so leaving drains has now been discarded by many surgeons. On the other hand, when there is a suspicion of possible complications, early abdominal CT scan is recommended.
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