A vertical sleeve gastrectomy involves a greater curve resection to fashion a longitudinal gastric tube that produces a restrictive bariatric procedure. To perform this procedure the greater curve must be dissected free of all its attachments from a point 5 cm proximal to the pylorus to the angle of His and left crura. To begin the operation the camera is placed in the midclavicular, left upper quadrant port site and held by the assistant on the patient’s left side who also uses the left-lateral port to assist. The surgeon stands on the patient’s right and uses an atraumatic grasper and energy device in the 15-mm and 5-mm right-sided ports. Typical dissection begins along the greater curve near the angularis in an area where it is easier to gain access to the lesser sac. The gastroepiploic vessels are divided close to the stomach and this is continued up toward the short gastric vessels (figure 2). Division of the vessels can be performed using bipolar or ultrasonic dissectors. Extra care must be taken as you approach the superior pole of the spleen where the stomach may be in close approximation to the spleen to avoid thermal injury to the stomach or cause bleeding (figure 3). At this point the energy device may be moved to the left lateral most port to facilitate dissection. The dissection continues to completely mobilize the angle of His until the left crura is identified. Dissection and division of the most proximal and posterior short gastric vessel is often necessary. When this dissection is complete the hiatus should be examined for evidence of a hernia. If one is found the sac and stomach should be reduced and the crura repaired. Once proximal dissection is completed, attention is then taken distally to divide the greater curve attachments to approximately 5 cm proximal to the pylorus (figure 4). Once the greater curve is completely dissected free of attachments and hemostasis is achieved, attention is taken to ensure the stomach is mobilized posteriorly. Only attachments on the most medial aspect of the posterior wall of the lesser curve should be left behind in order to allow the staplers to be safely fired and be able to divide the stomach completely.
The orogastric tube is removed and a nontapered Bougie is placed into the stomach under laparoscopic vision and directed along the lesser curve toward the pylorus below the divided attachments (figure 5). Sequential firings of a stapler are used to divide the stomach along the Bougie. The initial firing begins at a point approximately 5 cm proximal to the pylorus and should be fired at angle that is close to parallel with the proximal lesser curve (figure 5). With each subsequent firing, care should be taken to ensure the stapler is in close proximity to the Bougie but avoids excessive tension on the tissue. In addition, care should be taken to have nearly equal lengths of anterior and posterior stomach in the sleeve to avoid “spiraling” the sleeve, which can lead to future complications. As the division approaches the angle of His many surgeons will angle the stapler around the esophageal fat pad and preserve it. Once the greater curve is completely amputated (figure 6) the stomach is removed through the 15-mm port site with or without a specimen retrieval bag.
The Bougie is removed and the sleeve should be examined intraoperatively for length and caliber, integrity of the staple line, hemostasis, and to identify areas of potential narrowing from technical errors. This may all be done with careful upper endoscopy.
Technical variations of the procedure include varying stapler sizes that best match staple height to the thickness of the tissue, adding buttress material to some or all of the stapler firings, oversewing of the staple lines, and Bougie size. Bougie size may be varied to optimize weight loss versus prevention of complications such as leaks of the staple line. Bougie sizes between 32-Fr and 36-Fr have been thought to induce the best weight loss however, sizes under 40-Fr have correlated to higher leak rates.