Laparoscopic Sleeve Gastrectomy Technique

Raul J. Rosenthal

Wasef Abu-Jaish

Indications and Contraindications

The morbid obesity epidemic continues to spread throughout industrialized nations. Bariatric surgery continues to be the only proven method to achieve sustained weight loss in the majority of patients. Currently, the four most common bariatric operations in the United States are Roux-en-Y gastric bypass (RYGB), adjustable gastric band (LAGB), laparoscopic sleeve gastrectomy (LSG), and biliopancreatic diversion with duodenal switch (BPD-DS). These operations are now performed laparoscopically at most bariatric centers. The adoption of laparoscopic techniques has led to a dramatic increase in the annual number of bariatric procedures performed.

Sleeve gastrectomy (SG), a relatively new surgical approach, was initially conceived as a restrictive component of the BPD-DS in the era of open bariatric surgery. With the advent of minimally invasive surgery in the late 1980s, LSG has been proposed as a step procedure in high-risk patients, followed by a second step RYGB or BPD-DS, and, recently, as a stand-alone bariatric approach.

When evaluating a potential patient for bariatric surgery, a multidisciplinary team should be used. This team includes a dietitian and a mental health professional who are familiar with bariatric surgery. Their purpose is to obtain past dietary and behavioral eating history, discuss postoperative dietary expectations, and decide whether the individual is an appropriate candidate for this type of operation. Support for the surgery from family members and friends is important. If the team believes that the patient is not appropriate for the procedure, then consideration should be given to nonoperative medical management with appropriate counseling.

Since the National Institutes of Health (NIH) Consensus Conference convened in 1991, surgical approaches have been identified as the best course of treatment for patients with clinically severe obesity, who have a body mass index (BMI) of at least 35 kg/m² and associated comorbid conditions.

In most institutions, LRYGB, LAGB, and LSG are offered to all patients. Following the NIH recommendations, most centers in the United States recommend LRYGB as the procedure of choice or gold standard in patients with a BMI over 40 kg/m² with or without comorbidity. As the experience with LSG increases, attempts are being made to define indications for LSG as a first or final step. Most centers agree that there is enough evidence to recommend LSG in the presence of serious contraindications or for poor risk surgical candidates for LRYGB, BPD-DS, and LAGB. Owing to the two International Consensus Summits for SG, held in 2007 and 2009, this procedure has been recognized as an established bariatric procedure and is rapidly becoming accepted as an acceptable procedure for morbid obesity.

Table 30.1 Indications

Indication/Procedure	Characteristics
Two-stage procedure
First step in super-super morbidly obese patient	Followed by RNYGB or BPD
First step to a nonbariatric second procedure	Low BMI of 35–40 Followed by hip replacement, recurrent incisional hernia, pull through procedure for ulcerative colitis, renal/liver transplantation
Single-stage procedure
Final step in ASA IV morbidly obese patient	Low EF, heart/liver/kidney transplant recipient
Final step in poor candidate for LRYGB or BPD-DS	Smoker Warfarin
Final step in extremes of age	Adolescents Elderly age ≥70 yrs
Final step in a high-risk stomach	Chile, Colombia, Japan: high incidence of gastric cancer
Patient preference/refusal to undergo anatomic rearrangement of their intestinal anatomy or placement of an implanted device
Low BMI of 35–40 with comorbidity
Final step in Crohn’s/Celiac disease or UC
BMI 30–35 with the metabolic syndrome	Under protocol only
Other indications: liver cirrhosis. Dense adhesions of small bowel, expected complex colorectal surgery in patients with diverticular disease, huge abdominal hernia, necessity to continue specific medications (immunosuppressant, anti-inflammatory)
BPD-DS, biliopancreatic diversion and duodenal switch; BMI, body mass index; BPD, biliopancreatic diversion; EF, ejection fraction; LRYGB, laparoscopic Roux-en-Y gastric bypass; RYGBP, Roux-en-Y gastric bypass; UC, ulcerative colitis.

Additional indications include patients with liver cirrhosis (without severe portal hypertension), dense adhesions of small bowel (high risk for bowel obstruction after RYGB or BPD-DS), large recurrent abdominal wall hernias in the presence of obesity (lower incidence of recurrence after weight loss), and expected complex colorectal surgery in patients with diverticular or inflammatory bowel disease. More controversially, LSG may have a role in patients with a low BMI of 30 to 35 kg/m² with the metabolic syndrome. The latter should be conducted under Institutional Review Board protocol only (Table 30.1).

The potential benefits of performing SG (Table 30.2) include that, due to its “relative” technical simplicity, it can be performed laparoscopically in high BMI patients (super-super morbid obesity). Minimal follow-up is required when compared with other well-established procedures such as LAGB (no need for adjustments with LSG) and RYGB/BPD-DS (no marginal ulcerations and micronutrient malabsorption with LSG). It is an attractive option for patients with chronic conditions, such as Crohn’s/celiac disease or ulcerative colitis, which preclude extensive intestinal surgery.

As mentioned before, LSG provides an effective decrease in operative risk and alleviates technical difficulties when implemented as a first-stage procedure for super-obese and high-risk patients. It can be converted to a malabsorptive procedure such as BPD-DS or to a LRYGB in case of failure of weight loss and/or severe GERD.

When contemplating bariatric surgery indications, factors that are taken into consideration by surgeons and patients are the following: insurance coverage, age, BMI, associated comorbid illnesses, efficacy, and morbidity. There is also the so-called patient preference when discussing surgical options. LSG is attractive to patients who do not want to undergo anatomic rearrangement of their intestinal anatomy (RYGBP or BPD-DS) or placement of an implanted device (LAGB). While all procedures are similar in their “final effect,” by inducing rapid weight loss and resolution of comorbidities, there can be a significant difference in its efficacy and morbidity.

Table 30.2 Advantages and Disadvantages

Advantages

The stomach is reduced without major changes in either anatomy or continuity
The pyloric preservation prevents dumping syndrome and might add to the restrictive component
The patient can be discharged from hospital within 2 days postoperatively
It provides an effective first-stage procedure for super-obese patients
It is useful for patients with conditions such as Crohn’s disease, celiac disease, or ulcerative colitis, which preclude intestinal bypass.
It can be performed laparoscopically, even in patients who weigh over 500 lbs
Minimal follow-up is required when compared with other well-established procedures such as laparoscopic adjustable gastric banding and Roux-en-Y gastric bypass
There are no problems with malabsorption and nutritional deficiencies as seen in biliopancreatic diversion with duodenal switch
It provides a good educational base for resident doctors lacking experience in the surgical treatment of gastric ulcers
It can be converted to a malabsorption procedure (biliopancreatic diversion with duodenal switch) in case of failure or to laparoscopic Roux-en-Y gastric bypass for severe gastroesophageal reflux disease

Disadvantages

The risk of stapling complications such as leaks, bleeding, and stenosis
The irreversibility of the procedure

The disadvantages of LSG include the risk of stapling complications, such as leaks, bleeding, and stenosis, and the irreversibility of the procedure.

There are to our knowledge no studies that discuss in the detail the contraindications for LSG (Table 30.3). Three clinical scenarios can be considered as absolute contraindications:

Patients with severe and documented GERD. The performance of LSG in this clinical scenario could worsen the GERD by creating a high-pressure system in a patient who already has insufficient lower esophageal sphincter. Furthermore, LSG removes the gastric fundus, and as a result an antireflux procedure becomes impossible for those patients who are not candidates for RYGB or BPD-DS.
Patients with Barrett’s esophagus. There is scientific evidence that for morbid obesity patients with severe GERD, gastric bypass is the procedure of choice. Additionally, by removing the greater curvature of the stomach with LSG, we eliminate the portion of the stomach that can potentially be used as a graft (interposition) in those cases when esophagectomy is indicated.
Patients with liver cirrhosis and severe portal hypertension (Childs B/C).

In this clinical scenario, LSG has a high risk for complications and mortality, as with any other surgical procedure. It would be of interest to evaluate LSG as a treatment option for morbidly obese patients with liver cirrhosis and portal hypertension who would undergo a decompressive procedure, such as transjugular intrahepatic portosystemic shunt followed by a LSG.

Table 30.3 Contraindications

Absolute

Severe and documented gastroesophageal reflux disease
Barrett’s esophagus
Liver cirrhosis and severe portal hypertension

Relative

Perioperative risk of cardiac complications
Poor myocardial reserve
Significant chronic obstructive airways disease or respiratory dysfunction
Noncompliance of medical treatment
Psychological disorders of a significant degree
Significant eating disorders
Large hiatal hernias

There are several relative contraindications for LSG that are common in other surgical procedures, including the following: perioperative risk of cardiac complications, poor myocardial reserve, significant chronic obstructive airways disease or respiratory dysfunction, noncompliance of medical treatment, psychological disorders of a significant degree, and significant eating disorders (Table 30.3).

Preoperative Planning

All patients undergoing surgery should meet the NIH criteria for obesity surgery and have completed a comprehensive, multidisciplinary, preoperative program. The standardized comprehensive preoperative program includes an initial information session conducted by one of the bariatric surgeons.

After the initial information session, patients are preliminarily evaluated by a specialized bariatric nurse clinician, a psychologist, and the patient’s own primary care physician. During these visits, the patients are provided with written materials, in addition to direct contact with care providers, with regard to weight loss and weight loss surgery. Patients are then evaluated by a bariatric surgeon, who conducts a preoperative quiz and full consultation. The consultation includes discussion of surgical options and expectations of postoperative life.

After the surgical consultation, the patients see a nutritionist, who provides further written information. Additionally, patients are required to adhere to a strict preoperative high-protein liquid diet 2 weeks before the date of surgery. This serves two functions: it minimizes liver size and prepares patients for the postoperative experience.

Preoperative evaluation should include a thorough history, a complete endocrinological workup, psychological testing, and counseling by a dietician, as with any other bariatric procedure. At our institutions (Cleveland Clinic Florida & University of Vermont/Fletcher Allen Health care) as well as most bariatric centers, patients undergo upper abdominal sonography to exclude gallstones and barium swallow/upper GI or an esophagogastroduodenoscopy (EGD) to exclude anatomic variations of the upper digestive tract, such as hiatus hernias. Hiatus hernias are repaired when present.

The planned procedure (LSG, possible open procedure, possible gastric bypass, intraoperative EGD/upper endoscopy), the risks, benefits, and alternatives of the procedure are explained to the patient and his/her family in detail. The risks include but are not limited to medical, surgical, intraoperative, postoperative, and early and late complications. Medical complications include but are not limited to death, anesthesia and medically adverse effects, deep vein thrombosis, pulmonary embolism, myocardial infarction, stroke, and respiratory and renal failure. Surgical complications include but are not limited to early and late complications, intra-abdominal bleeding, injury to nearby structures such as liver, spleen, esophagus, small and large bowel, infection with abscess formation, staple line leak, stenosis, stricture, reflux symptoms, and delayed gastric emptying. Other potential risks and complications include wound infection or bleeding at the trocar sites, incisional hernia, and failure to lose weight or regain weight. A consent form is obtained after all of the patient’s and their family’s questions are answered.

Surgical Technique

Mechanism of Action

LSG involves removing most of the stomach (70% to 80%), including the fundus, and creating a gastric “tube” 100 to 130 mL in capacity. The efficacy of SG has been attributed to the reduction of gastric capacity (restrictive effect) and/or to the orexigenic and anorexigenic intestinal hormone modification (hormonal effect). Currently, both hormonal changes and a hindgut theory have been postulated to be involved. The mechanism of
weight loss following LSG is mainly due to a restricted calorie intake, which results from the combination of the small capacity, low distensibility of the sleeve, and the resultant immediate high intraluminal pressure. Both might be responsible for the satiety effect of this procedure.

The role of the pylorus as another potential mechanism of increased intragastric pressure remains to be determined. There are, however, other mechanisms that must be considered, such as hormonal changes that result in alliesthesia and anorexia. Although resection of the fundus may lower ghrelin levels by reducing the volume of ghrelin-producing cells, it has been suggested that the low levels of this hormone after surgery are in fact attributable to the paracrine effect exerted by endogenous gastrointestinal hormones, such as glucagon-like peptide-1 (GLP-1), GLP, ghrelin, and other hormones. However, it is doubtful that decreased levels of ghrelin are the sole reason for the weight loss achieved by LSG. The insulin, GLP-1, and peptide YY levels increase similarly after LRYGB and LSG with marked improvement in glucose homeostasis, as well as appetite suppression and excess weight loss (EWL). Adequate weight loss plays a key role in alleviating comorbidities and can be achieved by complete removal of the gastric fundus, which is not only important for eliminating ghrelin production but also for making the inlet of the stomach small enough so that the patient will feel full quickly.

The incorporation of laparoscopy in bariatric surgery has increased the demand and application of minimally invasive techniques in the treatment of morbid obesity. The adoption of these techniques has led to a dramatic increase in the annual number of bariatric procedures performed. SG can be performed by open or conventional multiport laparoscopy. More recently, some surgeons have performed the procedure using a single-incision or hybrid NOTES transvaginal approach.

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