Bariatric surgery
Laparoscopic Sleeve
Gastrectomy
By
Dr Hosam Ghazy El-Banna
Assistant Professor of General surgery
Mansoura Faculty of Medicine
Introduction
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Laparoscopic Sleeve gastrectomy (LSG) is a
new
restrictive
bariatric
procedure
increasingly indicated in the treatment of
morbid obesity.
LSG is a reproducible and seems to be an
effective treatment to achieve significant
weight loss after 12 months follow-up.
Indications
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LSG was indicated for weight reduction
only for patients with a BMI > 40 or >
35 kg/m2 with severe comorbidity.
Patients assessed by a dietician, a
nutritionist, and a psychologist before
surgery.
Preoperative preparation
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Start Atkins diet for 2 weeks before the
surgery to reduce the fat around your
liver.
Make sure to be on a regular intake of
clear fluids 48 hours before surgery.
Stop any medication unless indicated and
recommended by your doctor.
Operative procedure
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Operations are performed under general anesthesia
using the supine position.
Each procedure required only 4 trocars.

Two 12-mm ports were placed in the supraumbilical
region and in the left upper quadrant.
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One 10-mm port was placed in the right upper quadrant
for liver retraction.

One 12-mm port used for stapling was placed in the left
mid-abdomen, just medial to the mid-clavicular line .
Placement of 4 trocars
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Pneumoperitoneum was induced by primary
trocar insertion and maintained at a pressure of
16 mm Hg.
Dissection began on the greater curvature, 6 cm
from the pylorus.
The gastrocolic ligament along the greater
curvature of the stomach was opened using a
coagulator and was freed as far as the
cardioesophageal junction.
A 36-F plastic tube was then inserted perorally
into the stomach by the anesthesiologist and
was directed toward the pylorus.
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A laparoscopic linear stapler was introduced into the
peritoneal cavity and was positioned so that it
divided the stomach parallel to the orogastric tube
along the lesser curvature.
The instrument was fired, reloaded, and the
maneuver was repeated; 60-mm green cartridge was
used to staple the antrum followed by 3 or 4
sequential 60-mm gold cartridges to staple the
remaining gastric corpus and fundus.
After 5 or 6 firings of the stapler, the greater
curvature was completely
detached from the
stomach.
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A methylene blue test was performed
to exclude staple-line leakage.
The gastric suture line was not
systematically reinforced except in the
case of bleeding or positive methylene
blue test, in which case a drain was
placed along the staple line.
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A nasogastric tube was left in place.
A water-soluble upper gastrointestinal (GI)
contrast study was performed on the first
postoperative day, and oral fluids were
allowed if no leakage was demonstrated.
Patients were discharged except in the case
of a complication resulting in prolongation of
the hospital stay.
Follow up
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Patients were reviewed at 1 month
and then every 3 months.
Mortality and morbidity were defined
as death or complications and
reoperations during the first 30 days
after the operation or during the
hospital stay, respectively.
Eating after surgery
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Immediately after surgery, the patient is
restricted to a clear liquid diet.
The next stage provides a blended or
pureed sugar-free diet for at least two
weeks.
Post-surgery, overeating is curbed
because exceeding the capacity of the
stomach causes nausea and vomiting.
Advantages
1.
2.
3.
4.
5.
6.
Stomach tends to function normally so most food items
can be consumed in small amounts.
Removes the portion of the stomach that produces the
hormones that stimulates hunger (Ghrelin).
No dumping syndrome because the pylorus is preserved.
Minimizes the chance of an ulcer occurring.
The chance of intestinal obstruction, anemia,
osteoporosis, protein deficiency and vitamin deficiency
are significantly reduced.
Results appear promising as a single stage procedure for
low BMI patients (BMI 35–45 kg/m2).
Complications
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Leakage: can be treated easily by
performing a second procedure that helps
in strengthening the staple lines.
Stapple line bleeding:
Gastroesophageal Reflux: It might be
happening because of the changes in the
shape of the stomach.
Gastric Fistula: may occur and another
surgery may be needed to treat this
condition.
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Narrowing of Stoma: A tube used for dilation
is passed from the mouth to pass into the
stomach as this expands the stoma.
Hernia: Another surgery may be needed to
repair this condition.
Malabsorption of Vitamins and Minerals:
1.
2.
3.
Anemia and vitamin B12 deficiency can cause
neurological diseases.
Changes in the absorption of phosphates, calcium
and oxalates can result in kidney stone formation.
Similarly, deficiency of vitamin D and calcium can
also give rise to different disorders of the bone.
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Microbial infections : as pneumonia and
intraabdominal abscess are most common.
Deep vein thrombosis (DVT).
Hair loss.
Hair thinning.
Mood swings.
General feeling of weakness.
Dry skin .
Outcomes of SG & other
bariatric procedures
GB
AGB
BPD
BPD+D
switch
SG
65-70%
(EBW)
50%
(EBW)
70%
70%
50-80%
Morbidity 5%
5%
5%
5-10%
5%
Mortality
0.1%
1%
1-5%
……
Weight
loss
0.5-1%
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