Laparoscopic Sleeve Gastrectomy:
Technique and Outcomes
Natan Zundel, Juan David Hernandez,
and Michel Gagner
Chapter Objectives
1. Describe the surgical technique of laparoscopic sleeve
gastrectomy with attention to the steps that prevent
complications.
2. Present technical modifications that may represent
improvement to the procedure.
3. Summarize the outcomes of laparoscopic sleeve gastrec-
tomy and their relation to surgical technique.
Introduction
After 15 years, laparoscopic sleeve gastrectomy (LSG) has a
firm position as a stand-alone procedure to effectively treat
morbid obesity. Low morbidity and mortality have been
advocated as advantages over more complex procedures
such as laparoscopic Roux-en-Y gastric bypass and biliopan-
creatic diversion with duodenal switch or other restrictive
procedures like the laparoscopic adjustable gastric banding
N. Zundel, MD, FACS, FASMBS (*)
Department of Surgery, Herbert Wertheim College of Medicine,
Florida International University, Miami, FL, USA
Bariatric Institute, Jackson North Hospital, Miami, FL, USA
e-mail: nzundelm@fiu.edu; drnazuma99@yahoo.com
J.D. Hernandez, MD, FACS
Department of Surgery, Facultad de Medicina,
Fundacin Santa Fe de Bogot, Universidad de los Andes,
Carrera 1 No 18 A 10 Edificio Q oficina 806, Bogota,
DC 111711, Colombia
e-mail: juandah@yahoo.com
M. Gagner, MD, FRCSC, FACS
Department of Surgery, Herbert Wertheim College of Medicine,
Florida International University, Miami, FL, USA
e-mail: gagner.michel@gmail.com
N.T. Nguyen et al. (eds.), The ASMBS Textbook of Bariatric Surgery: Volume 1: Bariatric Surgery,
DOI 10.1007/978-1-4939-1206-3_17, Springer Science+Business Media New York 2015
17
that can have serious anatomical complications in the mid- to
long-term follow-up. It also avoids intestinal surgery with
associated complications such as internal herniation, small
bowel obstruction, micronutrient deficiencies and malnutrition.
It has also been argued that the follow-up is less demanding
than for the aforementioned procedures. Since long-term
reports are starting to appear, some of these facts are now
supported in the literature. These are some of the reasons that
have made LSG a technique that is growing in popularity and
is offered by most bariatric centers.
The history related to the LSG starts in 1990 with
Marceaus modification of the classic Scopinaros biliopan-
creatic diversion (BPD) by making a parietal cell gastrec-
tomy to reduce the acid load on the ileum in an effort to
decrease the incidence of marginal ulcerations [1]. This gas-
trectomy was vertical and evolved into a loose gastrectomy
over a 60-Fr bougie, which was held against the lesser
curvature of the stomach far away from the GE junction
without mobilization of the antrum.
The senior author reproduced this operation laparoscop-
ically in July 1999, hence performing the first laparoscopic
sleeve gastrectomy over a 60-Fr bougie with a duodenal
switch.
Thereafter, LSG alone was initially conceived as the first
of two stages of the biliopancreatic diversion with duodenal
switch. The rationale was that the procedure would be tech-
nically easier and shorter, therefore reducing morbidity and
mortality, since the more technically demanding part of the
operation would be carried out after a period of weight loss
[2, 3]. The idea came from the observation made by the
senior author, after recording a higher mortality associated
with super-super obesity (BMI > 60) in patients undergoing
BPD-DS. A two-step surgery approach was used to reduce
operating time and surgery complexity [4]. The first step was
the LSG, and after several months the BPD-DS was com-
pleted, with a significant reduction in mortality and good
results in weight loss [5]. In several patients a steady and
205
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surprisingly good weight reduction with the LSG only was
noticed, and it was hypothesized that it could become a
primary bariatric procedure on its own, a procedure that still
left open the possibility of a second intervention in case of
unsatisfactory weight loss or weight regain. This suggestion,
supported by the authors own data, was made by other
researchers [6].
LSG is technically easier when compared to gastric
bypass or biliopancreatic diversion, a primary reason for its
growing popularity among surgeons and patients. It does,
however, as with any other surgical procedure, have a poten-
tial for complications that range from 0.7 to 4 % in different
series [7, 8]. Some of these complications can be severe and
potentially fatal. Therefore, it is important to be thorough in
the proper technique and to follow patients closely after sur-
gery to avoid long-term complications or failure.
Surgical Technique
A multidisciplinary bariatric expert team evaluates all
patients to ascertain the indication for a bariatric procedure
and to prepare the patient for the operation. This includes
gastroscopy, Helicobacter pylori treatment if present, and
control of comorbidities, diet, and respiratory-related
measures.
Patients are placed in supine, legs spread (French posi-
tion), in a steep Fowler (reverse Trendelenburg) position,
and the table is slightly tilted right side down for an adequate
visualization of the gastroesophageal (GE) junction. This
requires the patient to be secured to the table. Additionally,
anti-embolic stockings and intermittent compression devices
are employed to prevent venous thromboembolism.
Fig. 17.1 (a) Five-trocar setting.
(b) Six-trocar setting
N. Zundel et al.
Our current LSG technique uses five or six ports.
Figure 17.1 shows our options of port distribution. The first
trocar, 1012 mm, is placed at the umbilicus, using an open
technique to reach the peritoneal cavity. Two more 5- or
12-mm ports are placed in the supraumbilical region, one sub-
xiphoid and another in the right upper quadrant. Two 15-mm
trocars, wide enough to allow the insertion of the largest
staplers, are placed in the mid-abdomen just medial to the
midclavicular lines. Finally, a 5-mm trocar used by an assis-
tant for retraction is placed in the left upper quadrant, high
enough to reach the top of the gastric fundus.
A 10-mm, 30 scope is used. The left lobe of the liver is
retracted to expose the entire GE junction and the lesser
curve. The procedure starts by cutting the small branches of
the gastroepiploic arcade and opening the lesser sac. Then,
dissection is carried out along the greater curve, staying very
close to it, dividing the branches of both gastroepiploic arter-
ies, until short gastric vessels are divided using an advanced
bipolar cutting device or the ultrasonic scalpel. The assistant
retracts the omentum laterally during the maneuver and
keeps repositioning the instrument superiorly to improve
exposure of the vessels and avoid bleeding. The remainder
of the gastrocolic ligament (without gastroepiploic vessels
transection) is severed distally up to 2 cm proximal to the
pylorus. The objective of cutting the omentum right by the
edge of the greater curve is to minimize the amount of fat
attached to the stomach, to make its extraction from the
abdomen easier at the end of the operation. The stomach is
then lifted to expose its posterior aspect, and all lesser sac
attachments of the stomach are freed. This will allow the
appropriate positioning of the mechanical suture and avoid
bleeding. When cutting these adhesions, it is necessary to be
aware of the presence of the branches of the left gastric artery.
17 Laparoscopic Sleeve Gastrectomy: Technique and Outcomes
If the left gastric branches were cut, the blood supply to the
sleeve would be compromised. Other anatomic relations the
surgeon needs to be aware of are the splenic artery and vein,
running along the superior edge of the pancreas. Splenic
artery in older patients may be redundant and therefore may
be in harms way during the posterior dissection.
The gastrophrenic ligament is divided and the angle of
His is exposed to determine the presence of a hiatal hernia,
adding the full exposure of the left crus to complete the
dissection. In case a hiatal hernia is discovered, the distal
esophagus is freed of mediastinal attachments and brought
down into the abdomen and a posterior crural approximation
is conducted to close the gap, using nonabsorbable suture.
Stomach division starts 4 cm proximal to the pylorus, to pre-
serve a part of the gastric emptying mechanism of the antrum.
Prior to the creation of the sleeve, the anesthetist introduces
a 3440-Fr bougie to guide the stapling and maintain an ade-
quate lumen of the gastric sleeve. Continuous communication
between surgeon and anesthetist is paramount to ensure ade-
quate positioning of the bougie in a safe fashion. The bougie
should be placed prior to stapling, guiding it to reach the
pylorus, and positioned close to the lesser curve. Care is
taken not to divide the stomach too close to the incisura
angularis to avoid kinking or stenosis at this level. Green
(4.8 mm) or black (5 mm) stapler cartridges are used with
absorbable buttress material (Gagner). Green or black for the
first two firings and blue for the rest if no absorbable but-
tressing materials are used (Zundel). In any case, all of them
are 60 mm in length. Stapling is performed in a way that no
kinking or twisting of the sleeve is produced at any level. To
achieve this, the stomach is held by the assistant stretching it
to the patients left, while the surgeon places the stapler mak-
ing sure that anterior and posterior edges are at the same dis-
tance from the lesser curve. In other words, the distance of
the anterior aspect of the remaining stomach should not be
shorter than its posterior counterpart. Additionally, a stapler
should be placed right at the angle of the previous one, avoid-
ing dog-ears created on the edge of the stomach that may
produce ischemia. After each firing, the anesthetist is asked
to wiggle the bougie to ensure the sleeve is not too tight or
that the bougie has not been stapled or cut.
Although the senior author recommended in the past to cut
the fundus at least 1 cm from the gastroesophageal junction,
his current practice is to divide it as close as the GE junction
as possible, without actually compromising the esophagus.
The other authors still cut the fundus 0.5 cm away from
the GE junction and imbricate the staple line with absorbable
suture in an effort to reduce leak rates. This is done without
the presence of buttressing material.
The senior authors intention is to create a sleeve that goes
in straight line from the GE junction down into the stomach,
since a funnel-shaped sleeve may be more likely to produce
gastroesophageal reflux by dilatation and stretching of the
207
lower esophageal sphincter. Additionally, the perigastric fat
is mobilized, permitting better identification of the esopha-
gogastric junction, and this may be used to buttress the staple
line. In this technique, the staple line is reinforced only at the
GE junction, where leaks are more frequent, and at the bot-
tom of the staple line on the antrum, the thickest part of the
stomach. This is done using through-and-through figure-
eight stitches with 30 absorbable monofilament sutures.
The other authors (Zundel and Hernandez) do not rou-
tinely use absorbable buttressing material; conversely, with
the bougie in place, the full length of the staple line is over-
sewn with a running suture of 30 absorbable suture.
The anesthetist removes the bougie under direct vision to
check the final shape of the sleeve. The stomach is removed
through one of the 12-mm ports. The integrity of the staple
line is tested with the instillation of 50100 ml of methylene
blue in saline solution. No drains are left.
Postoperative Period
Appropriate hydration and pain and nausea control is initi-
ated. During in-hospital stay, patients are observed for signs
of leak or bleeding such as tachycardia, tachypnea, or fever.
Abdominal pain and left shoulder pain are not reliable symp-
toms at this point, but should not be dismissed as normal.
Anti-embolic stockings and intermittent sequential compres-
sion devices can be removed as soon as the patient is ready to
walk. Next day, an upper gastrointestinal contrast X-ray is
done to identify any possible leaks. If the study is negative
for leaks, liquid diet is started and patients are encouraged to
ambulate. Respiratory therapy is initiated and previous home
medication is restarted. Patients are usually discharged home
on the first or second postoperative day with liquid pain
medications for a few days and a proton pump inhibitor for
68 weeks.
Results
Weight Loss and Comorbidities
More reports on outcomes of LSG with patients followed for
more than 5 years are starting to appeara fact that will pro-
duce long-term efficacy data. However, it is important to
point out that the large number of variations in surgical tech-
nique causes great difficulty in establishing comparable out-
comes at the present time. The bariatric community has
made an effort to come to an agreement in major technical
issues through the consensus on LSG. Four of these meetings
explored the opinions of experts and the evidence in the
literature, creating concurrence that has reduced technical
variations in topics such as bougie size, starting point of
208
stapling, etc. [9]. Recommendations have been made and a
more homogeneous technique has been developed. These
consensus meetings started in 2007, so outcomes that could
be attributable to these agreements will only be available in
the coming years.
The LSG summit of 2012 [9] reported on a survey
answered during the meeting by 130 surgeons with experience
of more than 1 year doing the operation, with a total of
46,133 LSGs. The survey included surgeons with short expe-
rience and minimum follow-up. A calculation on what sur-
geons reported rendered a mean %EWL of 59.3 % in year 1,
59.0 % in year 2, 54.7 % in year 3, 52.3 % in years 4 and 5,
and 50.6 % in year 6 [9]. The authors recommend caution
when analyzing these numbers, since they determined that
surgeons marked 0 change in EWL% when they should have
left a blank for not having patients that far in time. Since it
was not possible to discard the 0 % EWL option, they did not
eliminate those numbers, but adjusting the analysis for this
bias, % EWL could be even higher.
Studies with a long-term follow-up support better results
in weight loss than those reported by the survey. Bohdjalian
et al. found a 5-year %EWL of 54.8 6.9, which was compa-
rable to the results at 1 year, commenting that LSG leads to
stable weight loss in the long-term follow-up [10]. In a study
with a large number of super obese patients that extended
follow-up to 3 and 5 years, Saif et al. showed that the per-
centage of excess BMI lost was maintained. The mean per-
centage of excess BMI lost was statistically significant for all
cohorts, being 58.5 % at 1 year, 65.7 % at 3 years, and 48 %
at 5 years [11]. Zachariah et al. report the data collected from
228 patients treated with LSG and followed for 5 years since
2007. They showed a mean %EWL of 71.2 21 at 3 years
and 63 20 at 5 years, with BMI going down to 26 and 28,
respectively. Mortality was reported at 0.43 % [12]. At 5
years, resolution of diabetes was 66 %, 50 % for hyperten-
sion, and 100 % for hyperlipidemia. In fact, results for diabe-
tes resolution have been found to be as good as that of
laparoscopic Roux-en-Y gastric bypass [13].
Several studies have shown that after LSG, plasma ghre-
lin levels were significantly reduced in the early postopera-
tive period [14, 15] and remain consistently low during
5-year follow-up studies [10]. A general belief of minimal
nutritional deficiencies has accompanied the practice of
LSG, which originated in the fact that nutrients follow the
normal path in the gastrointestinal tract, as opposed to gastric
bypass and biliopancreatic diversion, where large segments
of the small intestine are excluded from the passage of nutri-
ents. Scarce documentation is available to support or dismiss
this assumption. Gehrer et al. [16] found nutritional deficien-
cies both before gastric bypass and after LSG with a mean
follow-up of 24 months. Deficiencies in zinc, vitamin D3,
N. Zundel et al.
folic acid, iron, and vitamin B12 were present but not clinically
significant and less important than after gastric bypass,
and all were easily treated and resolved. A 5-year follow-up
study showed a different picture, with values for parathyroid
hormone, hemoglobin, and hematocrit just under the normal
values but with no deficiencies [11]. For the authors, the
results show clear health improvements with nutrient indica-
tor levels reaching up to normal values with no signs of nutri-
tional deficiencies and conclude that long-term follow-up is
fundamental to assist patients in maintaining the good weight
loss results.
Complications
One of the most feared complications, fortunately rare, are
leaks. However, fistula, stenosis, GERD, and pouch dilata-
tion, among others, also can be present [7]. Leakage usually
appears as an acute complication (within 7 days), causing
tachycardia, tachypnea, and fever very early on, indicating
most often that the patient requires immediate intervention.
The most common site for leak is along the staple line imme-
diately below the gastroesophageal junction. Several strate-
gies can be used including diagnostic laparoscopy with
drainage, insertion of a T-tube in the opening to control the
fistula, insertion of an esophagogastric stent to occlude the
perforation and to open any associated distal narrowing, or
percutaneous drainage with endoscopic stents. Some
European groups have used endoluminal double pigtail cath-
eters to the same end. The most frequent location of the fis-
tula is near the angle of His (at the top of the stapled line),
and secondly in the antrum at the beginning of the gastric
stapled line. Sometimes fistulae can become chronic and
therefore will need a different and more complex treatment
[17]. A laparoscopic Roux-en-Y fistula-jejunal anastomosis
can be performed as early as several weeks after a leak, with
a high success rate, thus avoiding total gastrectomy, a proce-
dure with higher morbidity.
Another complication and common cause for leakage is
stricture or stenosis at the level of the gastric incisura [18], a
cause of obstruction. Clinical presentation both for acute and
late LSG obstruction is similar, with dysphagia appearing
weeks to months after the LSG operation in the latter, start-
ing with dysphagia to solids followed by symptoms to liq-
uids, salivation, and vomiting. Endoscopy with balloon
dilatation is the preferred method for management of the
stricture. Zundel recommends an achalasia balloon with
higher controlled pressure [18]. Acute obstruction cases may
be due to gastric mucosal edema and external compression
and in some cases due to kinking of the sleeve [5]. Cottam
et al. noted that kinking is independent of bougie size and
17 Laparoscopic Sleeve Gastrectomy: Technique and Outcomes
more correlated with the oversewing of the suture line rather
than with the diameter of the sleeve [19]. Stricture can be
avoided by keeping a safe distance from the bougie at the
level of the incisura angularis. This also applies when the
staple line is oversewn to reinforce it. All along the staple
line, the bougie will prevent stitching through the stomachs
lumen or further reducing the size of the sleeve. In all these
cases, kinking may appear. The recommended bougie size is
36 F [20], as nearly 40 % of surgeons are using this size [9].
The alteration of the pouch architecture caused by asymmet-
ric stapling of the anterior and posterior walls of the stomach
may lead to twisting of the gastric tube, which may also
cause dysphagia [21]. Also, leaving an excessively large pos-
terior wall may twist the sleeve as the stapler is applied, leav-
ing an uneven line of staples. If a stricture becomes permanent
and does not respond to endoscopic treatment such as dilata-
tion or stent, then a laparoscopic longitudinal lateral gastrot-
omy with transverse hand-sewn closure (like a Mikulicz
pyloroplasty) can be performed. Alternatively an anterior
seromyotomy, rarely performed due to the risk of mucosal
perforation and leak, or conversion to Roux-en-Y gastric
bypass can be performed.
Severe GERD and hiatal hernias (untreated at the time of
the initial surgery) are potential late complications that may
require prolonged medical therapy, or surgical reoperation
with re-sleeve and hiatal hernia repair, or conversion to
Roux-en-Y gastric bypass. Hiatal hernia repair with the use
of nonabsorbable mesh is avoided due to the risk of erosion
into the gastric lumen.
Weight regain, inadequate weight loss, or inadequate res-
olution of comorbidities may require late reintervention,
after proper endoscopic and radiological evaluation. Choice
of operation will be dependent on the initial BMI (super
obese will respond better with a duodenal switch), presence
or absence of GERD (Roux-en-Y gastric bypass is pre-
ferred), or re-sleeve gastrectomy for fundus dilatation.
Conclusions
LSG has demonstrated to be a safe, reproducible, and effective
operation on its own to treat morbid obesity with a rate of suc-
cess that is at least as good as the Roux-en-Y gastric bypass.
Attention to details in the surgical technique is fundamental to
avoid complications both in the short and long term.
The advantages of LSG, which until recently were only
suspected, are being confirmed today. If one considers that
the surgical technique has only been well defined in the last
5 or 6 years, it is possible to hypothesize that outcomes
reported in the future may be even better than those currently
found in literature.
209
Question Section
Questions
1. What is the most common site of leak after laparoscopic
sleeve gastrectomy?
A. Along the staple line at the gastric antrum
B. Along the staple line at the level of the gastric
incisura
C. Along the staple line at the level of the angle of His
D. Above the staple line in the distal esophagus
2. What is the recommended bougie size for construction of
the sleeve?
A. 2430 Fr
B. 3440 Fr
C. 4450 Fr
D. 5460 Fr
References
1. Marceau P, Biron S, Bourque RA, Potvin M, Hould FS, Simard
S. Biliopancreatic diversion with a new type of gastrectomy. Obes
Surg. 1993;3(1):2935.
2. Ren C, Patterson E, Gagner M. Early results of laparoscopic
biliopancreatic diversion with duodenal switch: a case series of 40
consecutive patients. Obes Surg. 2000;10:51423.
3. Regan J, Inabnet W, Gagner M. Early experience with two-stage
laparoscopic Roux-en-Y gastric bypass as an alternative in the
super-super obese patient. Obes Surg. 2003;13:8614.
4. Kim WW, Gagner M, Kini S, et al. Laparoscopic versus open bilio-
pancreatic diversion with duodenal switch: a comparative study.
J Gastrointest Surg. 2003;7:5527.
5. Gagner M, Inabnet WB, Pomp A. Laparoscopic sleeve gastrectomy
with second stage laparoscopic biliopancreatic diversion and duo-
denal switch in the superobese. In: Inabnet WB, DeMaria EJ,
Ikramuddin S, editors. Laparoscopic bariatric surgery. Philadelphia:
Lippincott, Williams & Wilkins; 2005.
6. Mognol P, Chosidow D, Marmuse JP. Laparoscopic sleeve gastrec-
tomy as an initial bariatric operation for high-risk patients: initial
results in ten patients. Obes Surg. 2005;15:10303.
7. Frezza EE, Reddy S, Gee LL, Wachtel MS. Complications after
sleeve gastrectomy for morbid obesity. Obes Surg. 2009;19:6847.
8. Lalor PF, Tucker ON, Szomstein S, Rosenthal RJ. Complications
after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis.
2008;4:338.
9. Gagner M, Deitel M, Erickson AL, Crosby RD. Survey on laparoscopic
sleeve gastrectomy (LSG) at the Fourth International Consensus
Summit on Sleeve Gastrectomy. OBES SURG, DOI 10.1007/s11695-
013-1040-x. Published on-line on 04/08/2013.
10. Bohdjalian A, Langer FB, Shakeri-Leidenmuhler S, Gfrerer L,
Ludvik B, Zacherl J, Prager G. Sleeve gastrectomy as sole and
definitive bariatric procedure: 5-year results for weight loss and
ghrelin. Obes Surg. 2010;20:53540.
11. Saif T, Strain GW, Dakin G, Gagner M, Costa R, Pomp A. Evaluation
of nutrient status after laparoscopic sleeve gastrectomy 1, 3 and
5 years alter surgery. Surg Obes Relat Dis. 2012;8:5427.
210
12. Zachariah SK, Chang PC, Ooi AS, et al. Laparoscopic sleeve gas-
trectomy for morbid obesity: 5 years experience from an Asian
center of excellence. Obes Surg. 2013;23:93946. doi:10.1007/
s11695-013-0887-1.
13. Shelley Yip & Lindsay D. Plank & Rinki Murphy Gastric Bypass
and Sleeve Gastrectomy for Type 2 Diabetes:A Systematic Review
and Meta-analysis of Outcomes. Obes Surg, DOI 10.1007/s11695-
013-1030-z. Published on-line 17/08/2013.
14. Sanchez-Santos R, Masdevall C, Baltasar A, et al. Short- and mid-
term outcomes of sleeve gastrectomy for morbid obesity: the experi-
ence of the Spanish National Registry. Obes Surg. 2009;19:120310.
15. Anderson B, Switzer NJ, Almamar A, Shi X, Birch DR, Karmali S.
The impact of laparoscopic sleeve gastrectomy on plasma ghrelin
levels: a systematic review. Obes Surg. 2013;23:147680.
doi:10.1007/s11695-013-0999-7.
16. Gehrer S, Kern B, Peters T, Christofel-Courtin C, Peterli R. Fewer
nutrient deficiencies after laparoscopic sleeve gastrectomy (LSG)
N. Zundel et al.
than after laparoscopic Roux-Y-gastric bypass (LRYGB)-a pro-
spective study. Obes Surg. 2010;20:44753.
17. Zundel N, Hernandez J. Revisional surgery after restrictive proce-
dures for morbid obesity. Sur Laparosc Endosc Percutan Tech.
2010;20:33843.
18. Zundel N, Hernandez J, Galvao Neto MG, Campos J. Strictures
after laparoscopic sleeve gastrectomy. Surg Laparosc Endosc
Percut Tech. 2010;20:1548.
19. Cottam D, Qureshi F, Mattar S, et al. Laparoscopic sleeve gastrec-
tomy as an initial weight-loss procedure for high-risk patients with
morbid obesity. Surg Endosc. 2006;20:85963.
20. Gagner M. Leaks after sleeve gastrectomy are associated with
smaller bougies: prevention and treatment strategies. Surg Laparosc
Endosc Percutan Tech. 2010;20:1669.
21. Kakoulidis TP, Karringer A, Gloaguen T, Arvidsson D. Initial
results with sleeve gastrectomy for patients with class I obesity
(BMI 3035 kg/m2). SOARD. 2009;5:4258.