Back to Annual Meeting Posters

Introduction: Medical attempts at durable weight loss are fraught with failures related to durability and lack of clinically significant outcomes. Metabolic surgery promotes long-term weight loss and resolution or improvement of obesity-related comorbidities. The laparoscopic sleeve gastrectomy (LSG) is currently the fastest growing metabolic procedure in the world. Standardization of the procedure has yet to be adopted by the bariatric surgical society. We have identified reliable anatomic landmarks for the safe and reproducible creation of the gastric sleeve independent of body habitus.
Methods: Anatomic landmarks identified include the pylorus, location of the incisura, the crossing lesser curvature vessels, the left crus and the angle of His. The procedure begins by lysing the gastrocolic ligament beginning 6 - 8 cm from the pylorus with the Harmonic Scalpel. This location coincides with the transition between the gastric body and antrum based on anatomic landmarks from the incisura angularis and vagus nerve. Dissection is continued proximally ligating the short gastric vessels and posterior gastric attachments from the retroperitoneum to facilitate exposure of the left crus and mobilization of the stomach. Belsey's fat pad is then dissected so as to identify the angle of His and expose the gastroesophageal junction to ensure proper stapler placement while dividing the stomach. A 1.2 cm (36 French) gastroscope is then used as a guide to identify the boundaries of the lesser curvature as excess adipose tissue often obscures this landmark. A linear stapler is used to divide the stomach. Variable staple heights decreasing from 4.1 mm to 3.5 mm are used as the transection line moves cephalad. Using the angle of His as the target of the proximal staple line eliminates the risk of retained fundus, creating a gastric sleeve with the same caliber as the esophagus. The transection margin is then inspected for integrity during gastroscopy and positive pressure pneumogastrium for identification of leaks and discerning of sleeve anatomy.
Conclusion: Obesity has become a problem of epidemic proportions in westernized societies. As the LSG becomes more commonplace, standardization will be essential for safe, reliable and reproducible results. Arbitrary bougie sizing has been the classic approach for calibrating sleeve size. This technique has the potential to result in dysphagia and reflux when to narrow or suboptimal weight loss if too wide. Moreover, the inclusion of remnant fundus at the gastroesophageal junction may be susceptible to enlargement with an associated s ataple line failure. Using the endoscope and the aforementioned anatomic visual cues have been successfully used to tailor a gastric sleeve with a caliber mirroring that of the esophagus and without a gastric cuff at the proximal margin.