Sleeve gastrectomy. A point of technique.

Sleeve gastrectomy is a surgical technique producing volume restriction with early satiety and a corresponding fall in the appetite stimulating hormone ghrelin [1]. It may be offered as the first stage of a gastric bypass or duodenal switch or as the definitive surgery for obesity [2]. The technique is particularly useful in the very young and old (short operative time), high risk patients (simple surgery), inflammatory bowel disease (no small bowel manipulation) or if access to the remaining stomach is required (intestinal continuity remains with access to the remaining stomach) 3). It is contraindicated in few patients e previous gastrectomy, severe gastro-oesophageal reflux, Barrett's oesophagus and is unsuitable for patients who graze feed [3]. There are 4 operating stages for performing Sleeve Gastrectomy. 1/ Release of the greater curve. Tension is applied to the gastrocolic ligament, which is opened parallel with the stomach beginning at the middle of the greater curve, as it is easier to open the posterior omental cavity at that point. It is then released towards the antrum and then upwards towards the left pillar using a 5 mm Ligasure (Covidien, USSC, Norwalk, CT). 2/ Exposure of the left pillar. This is the key point in the surgery. It is essential not only to visualise the left pillar but also to release the upper part of the posterior aspect of the fundus from the pillar. The pillar may be approached anteriorly, or posteriorly. 3/ Division of the stomach and checking haemostasis. Stapling is performedwith the 36Fr gastric tube in position in the antrum before stapling to avoid stenosis at the angle of the lesser curve. Before each division, the cannula is mobilised to check that it has not been caught in the stapler [4]. Depending on the stapler used, the tissues should be stapled very slowly (EndoGIA, covidien USSC, Norwalk, CT). The correct procedure for the final stapling is to move the stomach which has already been divided upwards and to rotate the stapler to the left in order to clearly see and apply tension to the posterior aspect of the fundus. Once the stapling has been completed, it is important to wait to check that there is no bleeding. 4/ Leak test and extracting the gastrectomy specimen. An air and/or methylene blue test is recommended with the gastric tube positioned in the lower oesophagus and the antrum clamped [5]. The specimen is extracted into a bag through the 15 mm opening [6]. In order to facilitate extraction, a ligature may be placed around the narrowest end of the gastrectomy specimen and cut long, so that its end comes out of the bag.