Main steps to perform a sleeve gastrectomy

These are the main considerations to perform a sleeve gastrectomy:

Step 1: Patient positioning and port placement

The patient is placed in the supine position with open legs. A total of 5 trocars are recommended. The classic configuration is a 12mm port in the supraumbilical position for a 30º scope, two additional 12mm ports at each flank to serve as the working channel for the leading surgeon, two 5mm ports located at the epigastrium for retraction of the liver, and a final more lateral port at the left flank to perform traction of the omentum and the stomach.

In selected cases of female patients the 12mm trocars on the right flank can be placed at the umbilicus. The mechanical suture can be introduced, extracting the specimen and improving the cosmetic result.

Step 2: Inferior landmark for section of the major omentum

The section must begin 5cm away from the pylorus.

Step 3: Dissection of the major curvature

Using the hook a window is opened at the omentum bursa and then the LigaSureTM is used for secure section close to the gastric wall. The assistant should perform traction from the omentum.

Step 4: Mobilization of the posterior wall

The stomach should be individualized from the retroperitoneal organs to achieve correct exposure during the gastrectomy.

Step 5: Superior landmark

This maneuver must be carefully performed to avoid bleeding. The spleen and the short vessels should be kept in mind. The goal is to expose the cardia and the left crus.

Step 6: Calibrated gastrectomy

A 35 French bougie is used to control the diameter of the remaining stomach. The section starts 5cm away from the pylorus. This is an important phase. You must avoid subsequent stenosis and ensure correct weight loss.

Step 7:  Gastric transection

The first mechanical sutures must be green or purple as the tissue near the pylorus is thicker. The assistant surgeon is crucial for this step, as correct traction exposes the stomach and enables the leading surgeon to prevent an angled or rotated gastrectomy.

Avoid placing the mechanical suture too close to the bougie to prevent bleeding, stenosis and leakage.

Step 8: Final section of the stomach

It must be performed 1cm away from the angle of His. Vascularization at this height is poor. With this strategy anastomotic leaks, which are usually difficult to treat, are prevented.

Step 9: Prevention of bleeding and rotation

Several maneuvers have been performed. Our recommendation is to make separate knots between the stapler line junction and the sectioned omentum.