Laparoscopic Sleeve Gastrectomy

Golden Steps

Dr. Deep Goel, FACS (USA), FRCS (England)

Director Department of Surgical Gastroenterology, Bariatric & Minimal

Access SurgeryBLK Super Specialty Hospital

New Delhi, India

Positioning

• Supine / Split leg

Port Placement

123 4

5

Liver Retraction

• Proper liver retraction for adequate view

of GE junction

Greater Curvature Mobilization

• Starting from mid body- up and down

• Remain close to stomach wall

• Congenital posterior adhesions

Short Gastric Vessel

• Harmonic

• Enseal

• Clip

Fundal Mobilization

• Complete mobilization

• Visualize left crus

Staple Fire

• First staple fire 2-4 cm from pylorus

• Avoid narrowing at incisura

• Avoid excessive traction on tissue while stapling

• Stapler should go to the tissue rather getting tissue to

the stapler

• Check the angle for loose staples and tissue

• Clean the crotch of stapler before changing cartridge

Choice of Cartridge

• Green

• Gold

• Blue

Gastric Calibration Tube (GCT)

• 36 French Vs UGI endoscope 28 French

Excise Complete Fundus

• Landmark

–Belsy’s fat – medial / lateral

Leak Test

• Air insufflation test

• Methylene blue test

Staple Line Bleed

• Raise BP 150 mmHg systolic

• Clip

• Suture

Bag Vs No Bag

Removal of Excised Stomach

• Port site irrigation

• Closure of port

Controversies

• Buttress material

• Over-sewing

• Post-op gastrografin study

• Drain

Thanks