CHAPTER 28 Sleeve gastrectomy
Step 1. Surgical anatomy
♦ The stomach has a rich blood supply, which includes the left and right gastric arteries, the left and right gastroepiploic arteries, and the short gastric vessels. This operation involves removal of the majority of the stomach, leaving behind a narrow “sleeve” of stomach based along the lesser curvature, with vascularization essentially derived from the left gastric artery. The vagus nerves on the lesser curve of the stomach are left intact.
♦ Special consideration is given at the angle of His to ensure the entire left diaphragmatic crus is freed from attachments, such that transection of the stomach does not leave a posterior pouch of fundus on the proximal portion of the sleeve. Reduction of hiatal hernia may be necessary to ensure complete removal of redundant fundus.
Step 2. Preoperative considerations
Patient preparation
♦ Sleeve gastrectomy may be performed on those patients who qualify for bariatric surgery (i.e., meet National Institutes of Health (NIH) criteria and have satisfied a multidisciplinary evaluation by a weight-loss surgery team). This operation has been generally offered as an “initial stage” in patients who are at high risk for other more traditional bariatric operations. Sleeve gastrectomy is considered for the following high-risk patients:
♦ After significant weight loss, these patients may undergo a “second-stage” operation with conversion to either Roux-en-Y gastric bypass or biliopancreatic diversion with duodenal switch. With excellent initial weight loss results and increasing experience with the operation, many groups are now offering it as a stand-alone procedure in average-risk patients.
♦ Special attention in the history and physical should elicit any signs of liver disease and cirrhosis. In diabetic patients, if there is a clinical suspicion of gastroparesis, gastric emptying studies should be considered. Preoperative upper endoscopy should be performed to diagnose hiatal hernia and rule out gastric lesions or helicobacter pylori infection.
Equipment and instrumentation
♦ Standard laparoscopic instruments are used throughout the case. Depending on the type of stapler used, 15-mm disposable trocars may be necessary. We commonly use a buttress material on the stapler cartridges to aid in hemostasis. Either ultrasonic energy or LigaSure (Covidien, Mansfield, Massachusetts) can be used for division of the vascular attachments.
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