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Page 2 of 7 Aktokmakyan et al. Mini-invasive Surg 2020;4:23 I http://dx.doi.org/10.20517/2574-1225.2019.72

Removed
Gastric Stomach
Tube

Figure 1. Demonstration of sleeve gastrectomy

Several endoscopic and surgical procedures have been advanced to achieve the best outcomes in obesity.
Sleeve gastrectomy was first performed in 1990 as the first of a two-stage operation for biliopancreatic
[2]
diversion with duodenal switch (BPD-DS) . Then, the first Laparoscopic Sleeve Gastrectomy (LSG) was
applied in 1999. The original indication for sleeve gastrectomy was to initiate weight loss in super-obese
patients [body mass index (BMI) > 60] to safely enter the second stage, BPD-DS. When these patients
were followed, the excellent decrease in excess body weights was found, and in 2008 these findings were
[3]
published with indications for LSG . When compared to other bariatric surgeries, sleeve gastrectomy is
technically easier with relatively less morbidity and thus has become a commonly performed bariatric
surgery as an obesity control modality. LSG has become the most common bariatric surgical procedure
in recent years, and its short-term results have been reported to be effective and safe. ASMBS (American
Society for Metabolic and Bariatric Surgery) considers sleeve gastrectomy (SG) to be an acceptable
option for the primary bariatric procedure or as a first-stage procedure in high-risk patients. However, its
[4,5]
effectiveness and long-term consequences are still being discussed .
LSG is a restrictive bariatric technique consisting of subtotal partial vertical gastrectomy with the
preservation of the pylorus. A gastric tube is created as a continuation of the esophagus along the lesser
curvature with the resection of the fundus, corpus, and antrum [Figure 1]. Although LSG is claimed as a
restrictive procedure, it has neuro-humoral effects that stimulate recovery in weight loss and concomitant
diseases. Moreover, SG induces fast gastric emptying and causes early food transportation into the small
[6]
bowel . Despite the established safety and efficacy of LSG, controversy still exists on optimal operative
techniques. This review aims to present the LSG technique with controversial aspects in the light of our
clinical experience and skills as a technical note.

SURGICAL TECHNIQUES
The operation is performed in reverse Trendelenburg position on an operating table with an angle of 30°
and the surgeon takes position between the legs of the patient. Pneumo-peritoneum is performed with
the Veress needle in the left upper quadrant. The five-trocar technique is used. The first (10-mm) trocar is
placed at the upper abdomen 1-2 cm above the umbilicus as an optical trocar. A 5-mm trocar is inserted
at the sub-xiphoid area for the Nathanson liver retractor [Figure 2]. A 15-mm trocar is introduced at the
right upper quadrant and a 12-mm trocar is inserted at the left upper quadrant. Finally, a 5-mm trocar is
introduced at the left subcostal anterior axillary line.

Firstly, the stomach is decompressed via a nasogastric tube by the anesthesiologist. Then, the omentum is
released and ligated from the greater gastric curvature with the energy-based device continuing proximally
into the esophagus and 2-4 cm proximal to the pylorus [Figure 3].