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Aktokmakyan et al. Mini-invasive Surg 2020;4:23 I http://dx.doi.org/10.20517/2574-1225.2019.72 Page 5 of 7

restriction. According to the consensus statement, LSG is a valid independent procedure and is a viable
bariatric surgery option for high-risk patients, transplant candidates, and patients with lower BMI (30-35),
[6]
patients with inflammatory bowel disease, and the elderly .
Although LSG is currently the most commonly used technique in the bariatric surgical repertoire and is
even considered as a gold standard technique, technical controversies continue. However, many discussion
points on the procedure create a range probability without consensus: the distance from the pylorus,
the routine use of intraoperative seal testing the size of the bougie used as a calibrator, the necessity for
reinforcement of the staple line, and the considerations in case of revision LSG (re-LSG) requirement.

The end of the lower dissection is argumentative because the antrum is divided at 2 or 7 cm from the
[8]
[9]
pylorus, determined by the surgical team . Sánchez-Santos et al. , according to the results of the National
Register of Spain, reported that they had better weight loss results in the follow-up of groups that started
gastrectomy closest to the pylorus. Our reason for dissection 2-4 cm from the pylorus is to decrease the
pressure in the gastric tube and allow preferable gastric emptying. It should be noted that the increase in
pressure in the gastric tube is the main cause of leakages. Furthermore, gastric tube volume above and
below incisura angularis and their ratio are important factors that affect weight loss. From our preliminary
results published in 2018, an antrum volume of approximately one-third of the total remaining stomach
[5]
volume appears to be ideal for optimal weight loss . Getting closer to the pylorus does not change weight
loss and has a negative impact on using a non-touched antrum during revision surgery.

Another point of controversy is leak testing. The methylene blue test was initially defined to diagnose
the post-gastrectomy fistulas. It is one of the most commonly used tests in bariatric surgery, consisting
of oral administration of methylene blue and observation of any intraoperative outlet through the gastric
[10]
tube . Methylene blue and/or air testing is recommended when the gastric tube is inserted into the distal
esophagus and the antrum is clamped . There is a discrepancy between surgeons about which leak test
[11]
[12]
they use, and whether it is performed . We apply methylene blue as a leakage test intraoperatively and on
Postoperative Day 2. However, it should be kept in mind that a negative test does not warrant that there
will be no postoperative complications including fistulas.

There is also the diameter of the remnant stomach in technical discussions about SG. Various evaluations
have analyzed the results of surgery with different gastric tube calibration standards of more than 28-50 Fr.
[13]
For example, Gagner defines an inverse relationship among the size of the bougie and the rate of leaks
and support the use of catheters between 50 and 60 Fr. In the Fifth International Consensus Conference, it
[14]
was recommended that a large bougie should be used (median was 36 French) and we also use 36 Fr.
Despite its simplicity, LSG can have serious complications. Gastric leakage is one of the most hesitated
complications. Numerous maneuvers have been suggested to decrease the incidence of leak
[15]
intraoperatively . Another discussion is in the reinforcement of the staple line. The main objectives of
reinforcement of the staple line are to reduce hemorrhage rates and staple line leaks. There is no current
consensus in recommendations about staple line reinforcement use. Its usage is surgeon-dependent
and remains controversial . For instance, Bellanger et al. showed a series of 529 patients who did not
[16]
[3]
leak without using any reinforcing material after the gastric section except fibrin administration. In a
recent meta-analysis, there was no statistically significant difference in leak ratio. Therefore, we do not
prefer reinforcement methods. According to our experience with more than 1000 patients, only three
leakages, three bleedings, and one stenosis were detected as complications. Two of the three leakages were
detected in the patient who underwent re-sleeve as revision surgery. While percutaneous drainage and
the endoscopic stent were applied to one of these two leakages, the other was treated with re-laparoscopy
drainage and stent. The third case of leakage was followed conservatively. In terms of hemorrhage, two