After intubation and initiation of general anesthesia, an upper endoscopy is first performed to evaluate the intraluminal health of the stomach and esophagus. We advocate only proceeding if there is no evidence of gastritis, ulcer, or other pathologies of the stomach or esophagus. If an abnormality is detected, then the operation should be aborted until a later time when optimal medical management is complete. After evaluation, either the scope or a separate sizing device such as a bougie can be left in the stomach as a guide for resection later.

The first step in performing a transvaginal sleeve gastrectomy is to obtain transvaginal access. Sterile surgical draping should be donned over the patient’s abdomen and perineal area. The vagina is examined for any inflammation or infections, which would be a contraindication to proceeding. Early on in our learning curve, this examination should be done by a gynecologist experienced in vaginal surgery, who would assist for the colpotomy access as well. After several procedures, the bariatric surgeon should be comfortable performing the colpotomy access independently, although they may need to get separate operative privileges for this from their institution.

A 5-mm trocar is placed through the umbilicus under direct visualization and pneumoperitoneum is established via CO₂ through this trocar. An exploratory laparoscopy is then performed via a 5-mm laparoscope before proceeding with the colpotomy. The abdomen is examined for any aberrant anatomy, adhesions, and mobility of the uterus. Once complete, we proceed with the colpotomy.

A speculum is placed into the vagina for visualization. Either a uterine manipulator or a surgical clamp is placed on the cervix. This is used in order to elevate the uterus into an anteverted position. At this point, the patient is placed in steep Trendelenburg position. The posterior vaginal mucosa is exposed, and an incision is made through the cul-de-sac just anterior to the rectum but posterior to the cervix. A 15-mm dilating trocar is then inserted through the colpotomy under direct visualization both externally as well as intra-abdominally (Fig. 19.2).

After establishing transvaginal access, a liver retractor can be placed (though not required) through the subxiphoid region to elevate the left lobe of the liver in order for adequate visualization of the crus and gastroesophageal junction. A 5-mm transabdominal trocar is placed in the right upper quadrant of the abdomen to assist in the procedure. Finally, a 12-mm transabdominal trocar is placed in the left upper quadrant to accommodate the passage of a linear laparoscopic stapler. The insufflation throughout the case will be provided through this trocar via standard CO₂ laparoscopic insufflator. [9] At this point, visualization is switched to the 15-mm transvaginal port via the flexible endoscope.

The gastrocolic ligament and short gastric vessels are divided with the ultrasonic dissector or similar advanced energy dissector starting 8 cm from the pylorus, and extending cranially to the left crus. The posterior aspect of the fundus is cleared of its attachments until the decussation of the left crus is identified as well to ensure adequate mobilization.

A laparoscopic stapler is then placed through the 12-mm transabdominal port to perform a vertical gastrectomy and create a tubular gastric remnant (Fig. 19.3). Sequential staple firings are used with thicker staplers toward the antrum (Fig. 19.4). The endoscope used at the beginning of the case now serves as a bougie for the gastric sleeve. If one is to use this method rather than a larger bougie, care needs to be taken not to hug the endoscope as this would result in a narrow caliber sleeve, predisposing the patient to leak. One must be extremely mindful of over-narrowing the sleeve at the level of the incisura, the result of which can be problematic.