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In the quest of developing best treatment options for the

obesity pandemic, bariatric surgeons continue to search

for a surgical treatment modality that can help patients

with morbid obesity lose their excess body weight and

resolve the associated conditions with minimal morbidity

and negligible mortality. In nearly 50 years of developments

in the field of bariatric surgery, sleeve gastrectomy appears

to be the surgical option we were looking for.

Pioneered by Hess et al1 and Marceau et al2 as a

component of the biliopancreatic diversion and duodenal

switch, the sleeve gastrectomy was first introduced as a

stand-alone treatment modality by Almogy et al,3 who used

an open technique in high-risk patients requiring organ

transplantation. Regan et al4 utilized a laparoscopic

technique, which has since propelled laparoscopic sleeve

gastrectomy as a popular treatment modality for patients

with morbid obesity.

I would like to acknowledge my Co-Chairs: Drs.

Himpens, Ramos, and Lakdawala as well as all panelists

who participated in this consensus meeting. They all

contributed their time and invaluable expertise to develop

these guidelines that review the indications,

contraindications, technique, and management of

complications when performing laparoscopic sleeve

gastrectomy.

I welcome you to a new educational resource

Checklist for LSG; which has been designed to offer

quick reference for surgeons and integrated health

professionals to keep the LSG consensus statement

guidelines top of mind during daily practice. Highly trained

surgeons, with tremendous experience in LSG, have been

invited to provide their thoughts on key aspects related to

techniques utilized during the LSG procedure and the

management of potential complications. Please note that

although the comments of several surgeons relate back to

the consensus statement,5 comments are based on their

opinion and personal experience and may not mirror

consensus results.

Whether you have been performing LSG for years or if

you are just beginning training, I hope the Checklist is

beneficial to your practice. At the end of the supplement,

you will find a link to the original research article of the

consensus statement as well as a link to a video of the

procedure for further reference.

Together, we can continue to standardize LSG as a

primary procedure for the treatment of patients with

obesity, build further clinical evidence, and enhance patient

outcomes.

REFERENCES1. Hess DS, Hess DW. Biliopancreatic diversion with a duodenal switch.

Obes Surg. 1998;8(3):267282.2. Marceau P, Biron S, St Georges R, et al. Biliopancreatic diversion with

gastrectomy as surgical treatment of morbid obesity. Obes Surg.1991;1(4):381387.

3. Almogy G, Crookes PF, Anthone GJ. Longitudinal gastrectomy as atreatment for the high-risk super-obese patient. Obes Surg.2004;14(4):492497.

4. Regan JP, Inabnet WB, Gagner M, Pomp A. Early experience with two-stage laparoscopic Roux-en-Y gastric bypass as an alternative in thesuper-super obese patient. Obes Surg. 2003;13(6):861864.

5. Rosenthal RJ, Diaz AA, Arvidsson D, et al. International SleeveGastrectomy Expert Panel Consensus Statement: best practiceguidelines based on experience of >12,000 cases. Surg Obes Relat Dis.2012;8(1):819. Epub 2011 Nov 10.

from the 2011 International Sleeve Gastrectomy Expert Consensus Conference

CHECKLIST FOR LAPAROSCOPIC

SLEEVE GASTRECTOMY

Introduction

Sponsored by:

Volume 9 Number 6 June 2012 Supplement B

by RAUL J. ROSENTHAL, MD, FACS, FASMBS

Dr. Rosenthal was Chairman for the 2011 International Sleeve Gastrectomy Expert Consensus Conference.

He is Program Director of Minimally Invasive Surgery, Director of the Minimally Invasive Fellowship

Program, Director of the Bariatric and Metabolic Institute, and Director of the General Surgery Residency

Program, Cleveland Clinic FloridaWeston, Fort Lauderdale, Florida.

An international panel of experts, reached consensus on the best practices to help the surgical community continue to improve patientoutcomes, minimize complications, and adoption of standardized techniques in Laparoscopic Sleeve Gastrectomy. The assembly and work ofthe expert surgeon panel that developed the consensus was supported by an educational grant from Ethicon Endo-Surgery, Inc.

B2 [Bariatric Times JUNE 2012, SUPPLEMENT B]

CHECKLIST IN LAPAROSCOPIC SLEEVE GASTRECTOMY

SIZING THE SLEEVE

Part 1: SURGICAL TECHNIQUE

Take down of

phreno-

esophageal

membrane and

exposure of

left crus

It is important for surgeons to remember that whenperforming a sleeve gastrectomy, we create a high-pressuresystem. Because of this, the likelihood of staple line

disruptions is higher than in other circumstances.

After the short gastric vessels have been taken down,advance the bougie transorally into the distal esophagus andslowly, under view, bring the bougie to the lesser curvature ofthe stomach. Lift the stomach in a ventral direction, in order tofacilitate this maneuver, while you advance the bougie towardthe lesser curvature of the stomach. It is recommended to use abougie size 3236F, as the consensus panel agreed. If youchoose to use a bougie size under 32F or closer to 32F, youmight see an increased number of complications, such asstrictures and leaks. Before the division of the stomach isinitiated, the surgeon should dissect the posterior wall of thestomach and check that all adhesions to the pancreas are takendown. While applying the stapler and transecting the stomach,the surgeon should also make sure that the assistant maintainssymmetric traction and that the posterior and anterior walls ofthe stomach are maintained in an anatomical position withoutrolling them over each other. Otherwise, when stapling thegastric wall, you can create a corkscrew, which might lead to ahigher incidence of strictures. Due to the elasticity of thegastric wall, if too much traction is applied, it might result inthe stomach coming back together and cause a stricture.

EXPERT COMMENTARY

Michel Gagner, MD, FRCSC, FACS, FASMBS,

FICS, AFC (Hon.)Clinical Professor of Surgery; Chief, Bariatric and Metabolic Surgery, Montreal, Quebec, Canada

EXPERT COMMENTARY

Concerning this particular aspect of the sleeve

gastrectomy procedure, 96 percent of consensus panel

experts agreed that complete mobilization of the

fundus is necessary in order to perform an adequate

transection of the stomach. In my opinion, this is best

achieved by opening the lesser sac in the mid portion of the

greater curvature with ultrasonic shears. Surgeons can

progress cephalad, adjacent to the gastric serosa, until the

left crus is exposed. In fact, the fundus mobilization is not a

stomach dissection at this height, but rather a diaphragmatic

dissection, dissecting the stomach and perigastric fat from

the left diaphragmatic surfaces including the left crus until

the right one is seen posteriorly. Therefore, experts agreed

that all short gastric vessels needed to be taken down (82%),

of which the specific methods are left to the operator. The

complete mobilization of the fundus also permits better

identification of the exact location of the esophagogastric

junction, identification of a hiatal hernia (and its immediate

repair), and elimination of the transthoracic migration of

upper stomach.

Alfons Pomp, MD, FACS, FRCSC Weill Medical College of Cornell University, New York Presbyterian Hospital, New York, New York

The SG consensus panel of experts agreed that transection

should begin 26cm from the pylorus. In order to

preserve antral motility, I believe the correct distance

from the pylorus to start dissection is likely between 4 and 6cm.

To my knowledge, there is no scientific evidence confirming that

getting closer to the pylorus will result in better outcomes.

View of the

antrum.

Dissection of

short gastric

vessels on the

greater

curvature of

the stomach

starts 26cm

from the

pylorus.

MOBILIZATION

Completely mobilize the fundus

before transection

Raul J. Rosenthal, MD, FACSCleveland Clinic FloridaWeston, Fort Lauderdale, Florida

Use a bougie size: 3236F

Invaginating staple line reduces lumen size

B3[JUNE 2012, SUPPLEMENT B] Bariatric Times


The sleeve gastrectomy involves a long staple line in a high-

pressure tube. Uncomplicated healing depends, in part, on

the correct choice of staple height and correct use of the

stapler. Very slow application of the stapler (i.e., waiting at least 15

seconds after stapler closure before firing) is recommended to

allow for additional tissue compression before firing. In terms of

staple height, there is a growing trend to use staples taller than

1.5mm to minimize the chance of crushing tissue and subsequent

staple line failure. At the 2011 SG consensus meeting, the panel

agreed that green loads were the smallest acceptable staple heights

at the antrum and from the gastric body upwards blue or green

loads were recommended. There was an increasing trend to use

taller staples, green load or taller, in these areas. For revision cases,

and when adding buttress material, the green load or taller should

be the choice.

John Jorgensen, MB, BS, FRACS, MSSt. George Private Hospital, Sydney, Australia

Part 1: SURGICAL TECHNIQUE

FIRST FIRING AND WHERE TO

START THE TRANSECTION

Transection should begin 26 cm from pylorus

STAPLE HEIGHTUse staples of at least 1.5mm closed height

(e.g., blue load) on all steps

If buttressing, use staples of at least 2.0mm

closed height (e.g., green load)

When resecting the antrum, surgeon should

never use any staple with closed height less

than that of a green load (2.0mm)

EXPERT COMMENTARY

Wide range of cartridges for thin to thick tissue, all fitting through a

12mm trocar.

There are two critical points to be made in regard to first firing and starting the transection in a sleeve gastrectomy procedure. First,

appropriate stapler size should be chosen to ensure adequate tissue apposition with hemostasis and to minimize serosal tearing

close to the staple line; usually this requires a green load (2.0mm close height) or greater, as agreed in the SG consensus meeting.

Second, although not addressed in the SG consensus statement, in my opinion, the orientation (angle from the greater curve) of the first

stapler line is also important, particularly if this is a 60mm long cartridge, as the first firing should not compromise the width of the sleeve

near the incisura.

Alfons Pomp, MD, FACS, FRCSC Weill Medical College of Cornell University, New York

Presbyterian Hospital, New York, New York

EXPERT COMMENTARY

Transection of

the stomach

starts 26cm

from the

pylorus. Green

load or greater

should be used.

It is important

that the assistant

exercises a mild

and symmetric

lateral traction.

A green load

being used for

transection of

the stomach

during the

sleeve

gastrectomy

procedure.



Part 1: SURGICAL TECHNIQUE continued

STAPLE LINE REINFORCEMENT

Use staple line reinforcement to reduce

bleeding along staple line

Bovinepericardiumbeing used forstaple linereinforcement

Traction on thefundus andtransection ofthe stomachagainst thebougie, lateralto the fat padat the GEjunction.

Gregg H. Jossart, MD, FACSCalifornia Pacific Medical Center, San Francisco, California

EXPERT COMMENTARY

The current generation of staplers have a reinforced anvil and higher compressive forces than prior generations. In my opinion,

surgeons should select the correct size staple cartridge and should not add thick buttress material without considering how much

the staple line will be compromised. I believe that early leaks and segmental staple line disruptions will occur from these types of

errors. On sleeve gastrectomies made with Bougie size 3240F and antrectomies, made within 23 cm of pylorus, no smaller than green

cartridges should be used. I recommend avoiding buttress material on the antrum, as I have observed that 10 to 20 percent of staple lines

will disrupt the seromuscular layers and additional sutures are required. I think that buttress materials along the mid-body (above

incisura) are reasonable, but keep in mind that overlapping buttress material at the staple line junctions may occupy up to 40 percent of

staple line height and could be a potential site for disruption. It is well known that the cardia is where the majority of leaks occur, even

with buttress material. Therefore, I hypothesize that suture inversion of the cardia with 1 to 2 Lembert type sutures is probably the most

effective way to manage this high-risk area.

LAST FIRING AND WHERE

TO END THE TRANSECTION

Stay away from GE junction on last firing

In my experience, the last firing during construction of the

sleeve gastrectomy should be oriented vertically toward

the angle of His, slightly staying away from the bougie to

avoid stapling onto the GE junction (as recommended by the

SG panel of experts). This staple line of the last firing (i.e.,

the most proximal aspect of the sleeve or the proximal one-

third of stomach) is particularly prone to developing leaks.

The consensus panel experts agreed that the use of staple

line reinforcement (buttress or over sewing) will reduce

staple-line bleeding. In my opinion, bleeding may weaken the

integrity of the staple line leading to dehiscence.

EXPERT COMMENTARY

Ninh T. Nguyen, MDUniversity of California Irvine Medical Center, Irvine, California

Confidence Through Compression. Performance Demonstrated in Thick Tissue*

*Superior is defined as fewest malformed staples. Thick tissue defined as 3mm to 5mm as measuredwith an 8g/mm2 thickness measuring device. Study conducted by Ethicon Endo-Surgery in a porcinemodel. Data on file. ECHELON FLEX 60mm with Green Cartridge (88 staples per cartridge) vs. ENDOGIA Universal with 60mm Green Roticulator (90 staples per cartridge) (not compared withEGIA60AMT/EGIA60AXT). Please read and follow the Instructions for Use for important information,including indications, contraindications and complete steps for use.



Part 2: PERIOPERATIVE PREVENTION: Complications Management

LEAKS

According to the observation period, leaks

can be acute, early, late, and chronic

If a leak lasts >12 weeks,

it is considered chronic

EXPERT COMMENTARY

X-ray image of

a patient who

developed a

leak after

undergoing

sleeve

gastrectomy.

In my opinion, the following group of conditions may contribute

to higher rate of SG leaks that do not respond to conservative

or traditional surgical approach (e.g., suturing) and become

chronic:

1. The inherent poor vascular supply at the angle of His

2. The absence of the remnant stomach that could block the

leak

3. The physiologic obstruction of the pylorus

4. The narrowing at the level of incisura angularis

5. The deviation on the antrums axis

6. The possible curling/twisting of the sleeve

7. The fact that SG has the longest staple line of all bariatric

surgeries

8. The fact that being so high, the sleeve is under negative

pressure of the thorax

9. The fact that the SG is a high-pressure closed system instead

of a draining system like the gastric bypass.

The SG consensus experts agreed that stenting is a valid

treatment option for acute proximal leaks and has limited utility

for chronic leaks. In our experience, endoscopic treatment with

stents in early leaks, and pneumatic dilation in chronic leaks, play

a major role after initial surgical or percutaneous sepsis control.

Also in our experience, surgical repair is usually appropriate if

endoscopic approach fails and can be done by means of

seromyotomy, converting the sleeve to a Roux-en-Y gastric bypass,

bypassing the leak with a bowel limb and even with a total

gastrectomy.

STRICTURESEarly strictures are symptomatic in first

6 weeks after surgery

The smaller the bougie size, the tighter

the sleeve, the greater stricture rate

EXPERT COMMENTARY

X-ray image of

a patient who

developed a

stricture after

undergoing

sleeve

gastrectomy.

We now better understand the technical aspects that can

cause strictures after a laparoscopic sleeve gastrectomy.

The SG consensus expert panel agreed with other

published data that the incisura angularis is the site with the

greatest potential for strictures, but we should not forget that

strictures can occur elsewhere in the sleeve. The consensus panel

also agreed that maintaining symmetric lateral traction, while

stapling, will reduce the potential for strictures. The symptoms of

stricture usually start in the first six weeks after surgery, so

aggressive but nonsurgical management should be implemented.

Management includes close observation followed by endoscopic

dilation up to six weeks. The option of using stents to keep the

lumen open was not presented to the panel but is occasionally

necessary in our experience.

The consensus panel agreed largely (88%) that laparoscopic

Roux-en-Y gastric bypass (RYGB) is the treatment of choice after

failed interventions for strictures. On the other hand, even though

seromyotomy was mentioned as an option, it did not reach

consensus (69%) as a valid option for failed endoscopic treatment.

We need to learn more about this complication, especially

because it often appears at the same time as leaks and we cannot

treat one without treating the other.

Manoel Galvao Neto, MDGastro Obeso Center, So Paulo, Brazil

Natan Zundel, MD, FACSFlorida International University College of Medicine,

Miami, Florida



HIATAL HERNIA

Aggressive identification of hiatal hernia

intraoperatively

Repair hiatal hernia if found

Close the diaphragmatic defect after the

sleeve procedure is completed

Kelvin Higa, MD, FACS, FASMBSUniversity of California, San Francisco; Fresno Heart andSurgical Hospital; Advanced Laparoscopic SurgeryAssociates, Fresno, California

EXPERT COMMENTARY

The recommendations of the SG consensus panel of experts on hernia repair are important because weight recidivism,

proximal leaks, and late gastroesophageal reflux disease (GERD) can be related to imprecise proximal dissection and

underestimating the importance of undiagnosed hiatal hernia at the time of performing a sleeve gastrectomy. It is

clear that endoscopy and contrast studies are not reliable at predicting the presence of hiatal hernias preoperatively;

therefore, aggressive hiatal dissection with subsequent repair is recommended

Part 3: CONSIDERATIONS

Hiatal hernia is commonly present in the morbidly obese. It is well known that up to 40 percent of patients

undergoing bariatric surgery have a hiatal hernia identified on preoperative studies, such as upper gastrointestinal

contrast studies or endoscopy. It is also well known that hiatal hernia contributes to the development of GERD. The

SG consensus reports that GERD is the most prevalent complication observed after SG and is likely due to it being a high-

pressure system. Therefore, a hiatal hernia should be repaired concomitantly with a sleeve gastrectomy. In my experience,

small hiatal hernias can be closed with primary repair, while moderate and large hiatal hernias can be repaired posteriorly

with an absorbable or biologic mesh in an effort to reduce postoperative hernia recurrence.

Ninh T. Nguyen, MDUniversity of California Irvine Medical Center, Irvine, California

X-ray image of

a patient who

developed a

hiatal hernia

after

undergoing

sleeve

gastrectomy.



Part 3: CONSIDERATIONS

GASTROESAPHOGEAL REFLUX DISEASE (GERD)

REVISIONS

Randal S. Baker MD, FACSGrand Health Partners, Grand Rapids Michigan

Reflux and hiatal hernias are common in the morbidly

obese and often, as noted in the SG consensus

statement, exacerbated by a sleeve gastrectomy

without a hiatal hernia repair. It is well known that

preoperative studies, such as endoscopy and upper

gastrointestinal (GI) contrast, can fail to diagnose a hiatal

hernia. Hence, the recommendation of intraoperative

examination of the hiatus anteriorly and along the left crus

in all patients undergoing a sleeve gastrectomy. I think that

opening the pars flaccida to probe for a hernia along the

right crus may be the most sensitive technique. In my

experience, hiatal hernia repair should always include

circumferential dissection and mobilization of the distal

esophagus, suture approximation of the posterior and

anterior crus, as well as attachment of the cardia to the

insertion point of the left phrenoesophageal ligament on

the left diaphragm. This may restore the Angle of His and

reduces recurrence rate.

Anumber of studies and the SG expert panel have

indicated that sleeve gastrectomy can lead to new

onset or increased GERD. Discussion of the panel

revealed that many were concerned about performing the

sleeve in patients with significant pre-operative GERD not

caused by hiatal hernia (as worsening GERD and bile

reflux has been reported after SG), but no consensus vote

was taken regarding this issue. The panel agreed that

Barretts esophagus is a definite contraindication to

performing a sleeve. In addition, we felt that during

surgery the phreno-esophageal membrane must be

explored to help identify, and subsequently repair, any

hiatal hernias. It is easier to perform this after the sleeve

is created and the excluded stomach is out of the way. To

avoid retching and injury to the crural repair, sleeve

patients, especially those with hiatal hernias, should wait

at least two weeks after surgery to start solid food. GERD

after a sleeve should first be treated with proton pump

inhibitor medications and, during the panel meeting,

many voiced the consideration of revision to Roux-en-Y

gastric bypass if severe GERD is not responsive to

conservative treatment.

Revisions continue to be controversial, as evidenced by the

lack of consensus reached by the SG panel on the topic of

what to do after a laparoscopic sleeve gastrectomy fails. I

think this most likely represents the heterogenous nature of the

SG patient rather than ignorance of outcomes. For example, a

patient with initial body mass index (BMI) of 65 kg/m2 might be

best served by conversion to duodenal switch for inadequate

weight loss; whereas, a patient with 80-percent excess weight loss

(EWL) with intractable gastroesophageal reflux disease (GERD),

would be better off converted to gastric bypass.

Gregg H. Jossart, MD, FACSCalifornia Pacific Medical Center, San Francisco, California

Kelvin Higa, MD, FACS, FASMBSUniversity of California, San Francisco; Fresno Heart and

Surgical Hospital; Advanced Laparoscopic SurgeryAssociates, Fresno, California

EXPERT COMMENTARY

EXPERT COMMENTARY

Last firing = green

or greater

LSG is acceptable to

convert a successful, but

complicated, gastric band

When converting from gastric

banding to LSG, the operation

can be done in 1 or 2 steps

The first line of treatment in patients with GERD = proton pump inhibitors

Volume 9 Number 6 June 2012 Supplement B

Sponsored by:

To view a video of the sleeve gastrectomy procedure by Dr. Raul J. Rosenthal, visit

EES.com/SleeveSolution

For a direct link to the DIGITAL EDITION of this supplement,

scan the QR code below with your smart device.

FOR THE FULL, ORIGINAL ARTICLE

International Sleeve Gastrectomy Expert Panel Consensus Statement:

best practice guidelines based on experience of >12,000 cases,

published in Surgery for Obesity and Related Diseases (Surg Obes Relat Dis), visit

http://www.soard.org/article/S1550-7289%2811%2900764-7/fulltext

DSL 12-0611

DSL# 12-0173

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