1. Laparoscopic Sleeve Gastrectomy
Dr Girish juneja
Head of surgery deptt.
Specialist laparobariatric surgeon
Al Noor Hospital, abu dhabi, uae

2. SG was developed as a modification of the biliopancreatic diversion in 1988

3. 1999 SG was first performed by laparoscopy, as part of BPD-DS, by Michel Gagner
This operation became an independent procedure when it was found that supersuper-obesity (BMI _ 60 kg/m2) and male gender were associated with elevated morbidity and mortality when those patients underwent BPD-DS.
2000, Gagner first proposed the SG as the first step of a two-stage laparoscopic duodenal switch as an alternative to this high-risk group of patients to decrease morbidity and mortality

4. LSG
2003, SG was proposed as the first step of a two-stage laparoscopic Roux-en-Y gastric bypass (LRYGB)
Since then, many surgical teams have already adopted this procedure with good results.

5. SG produces weight loss by two mechanisms
1- produces early satiety as a purely restrictive procedure 2- reduces plasma ghrelin levels by removing a great part of the Ghrelin production tissue. - Ghrelin is a 28 amino-acid-peptide, secreted by the oxyntic glands of the gastric fundus - potent orexigenic (appetite-stimulating) hormone. - In SG, resection of the fundus removes the major site of ghrelin release, therefore appetite decreases

6. KEY POINTS
• Sleeve gastrectomy causes a volume reduction of the stomach by 80 percent or more.
• It decreases serum ghrelin and leptin levels, increases GLP-1 and PYY 3-36,and reverses type 2 diabetes in the majority of cases.
Gastric and intestinal transit time appears to be reduced, causing an early stimulation of the distal GI tract.

7. LSG

8. LSG

9. Gastric sleeve resection technique
Total excision of fundus
Sparing of antrum
Transection of stomach just lateral to lesser curve vessels endings
Oversewing entire staple line?
Staple line reinforcement ?

10. Technique of SleeveGastrectomy

11. Anatomy

12. “Three Angles” Surgeons must pay special attention
1. The Incisura angularis or the
angle of the stricture.
2. The gastrosplenic ligament or
the angle of bleed
3. The Angle of His or the angle of
the leak

14. LSG

15. Port placement

16. start by dividing the greater omentum with the ultrasonic shears at a midpoint along the greater curvature
The branches of the gastroepiploic artery are divided near the gastric wall
We then proceed with the division of the short gastric vessels that is performed up to the fundus

19. L. S.G.

22. LSG

23. L.S.G.

24. LSG-debatable points First stage or definitive
Sleeve Calibration (bougie size)
Distance from pylorus to initiate sleeve
Oversewing entire staple line?
Staple line reinforcement ?
Section shape at OG junction
Routine use of intraoperative leak testing
Routine versus selective upper GI series for leak test
Higher rate of leaks after revisional surgery

25. FIRST STAGE OR DEFINITIVE
LSG has become safe & effective both as a first stage bariatric procedure in high risk or superobese pts
& as a
primary operation

26. KEY POINTS In BPD-DS maximal gastric pouch or tube of 150 to 200 mL
In SG isolated procedure, the gastric pouch size usually varies from 50 to 120 mL, depending on the size of the bougie we introduce into the stomach to perform the SG.

27. Long term results Five-year EWL after sleeve gastrectomy
is 50 to 55 percent.
A subset of patients will require a second-stage bypass procedure to achieve optimal weight loss after sleeve gastrectomy.
High BMI, high-risk patients can achieve excellent long-term weight loss
STACY A. BRETHAUER & PHILIP R. SCHAUER
obesity times 2011;8

28. Long-term Results After Laparoscopic Sleeve Gastrectomy
EWL was 72.8% (±25.6) after three years and 57.3% (±29.1) after 6 years(p=0.0017).
BMI increased from 27.3 kg/m2 (±5.0) at three years to 30.1kg/m2 (±6.5) at six years(p=0.0050)
JACQUES HIMPENSBariatric Times. 2011;8(5 Suppl):11–12

29. Long-term Results After Laparoscopic Sleeve Gastrectomy
LSG has a failure rate of 43% after 6+years.
One out of four patients develops GERD symptoms after 6+ years.
Treatment can be either resection of a neo-fundus or Roux-en-Y gastric bypass.
DS constitutes an effective solution for poor weight loss or weight regain after LSG.
JACQUES HIMPENSBariatric Times. 2011;8(5 Suppl):11–12.

30. LSG-debatable points First stage or definitive
Sleeve Calibration (bougie size)
Distance from pylorus to initiate sleeve
Oversewing entire staple line?
Staple line reinforcement ?
Section shape at OG junction
Routine use of intraoperative leak testing
Routine versus selective upper GI series for leak test
Higher rate of leaks after revisional surgery

31. Sleeve Calibration (bougie size) EWL with varying bougie size
Auther
preop
bougie
6m EWL
12m EWL
Mognol 64 32
41%
51%
Lee et al 49 NA
59%
Himpens 39 34
58%
Langer 48
46%
56%
Parikh surg obesity relat 008;4

32. Parikh surg obesity relat 2008;4
Calculation of volume of 25cm long gastric tube based on varying bougie size(excluding antrum)
Bougie diameter volume
32 f cm cc
36f cm cc
40f cm cc
50f cm cc
60f cm cc
Parikh surg obesity relat 2008;4

33. BOUGIE SIZE
For all LSG as part of a BPD-DS, used the 60-Fr bougie to ensure adequate protein intake.
For primary LSG, we use a 36-Fr bougie but it could be smaller or greater (28-54 Fr).

34. LSG
Distance from pylorus to initiate sleeve
2cms– 6 cms

35. LSG There is a trend towards smaller bougie(32 f) &
Initiating sleeve 2cm px to the pylorus, for a more restrictive effect.

36. LEAK Meta analysis 4888cases & 29 publications Overall leak rate 2.4%
Superobese BMI> %
for BMI < %
BOUGIE F % <40F %
SITE OF LEAK – PX THIRD %
Staple height& buttressing material– no effect
Most leaks were diagnosed after discharge
surg endosc 2011: dec. 17

37. STAPLE LINE REINFORCEMENT?
*STAPLE –LINE BUTTRESSING SIGNIFICANTLY INCREASED STAPLE LINE STRENGTH *DECREASES BLEEDING

38. STAPLE LINE REINFORCEMENT?
Reinforcement does not necessarily reduce the rate of staple line leaks after sleeve gastrectomy.
Obes Surg Feb;19(2):

39. STAPLE LINE REINFORCEMENT?
IFSO 2010
Michele Gagner reduces rate of leak

40. OVERSEWING
Full thickness over sewing of staple lines significantly weakened all staple lines
Risk of tearing
Baker RS et al,obes surgery,2004,14

41. Section shape at OG junction
At the uppermost portion of the stomach, the transection line is allowed to deviate away from the bougie to avoid severe stenosis at the gastroesophageal junction but going further from the bougie may lead to fundus dilation and weight regain
Incorporation of esophagus can weaken the staple line

42. Section shape at OG junction

43. Routine UGI contrast study
very low sensitivity(50%) to detect leak
Expansive
Sometimes fails to detect
M.schiesser ,obesity surgery,vol-21,1238