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Laparoscopic sleeve gastrectomy (LSG) for treatment of morbid obesity was first described as a part of the more complex operation, biliopancreatic diversion with duodenal switch (BPD/DS). The LSG was developed as a first-stage procedure in high-risk patients with a body mass index (BMI) of more than 60 to obtain an initial weight loss with low morbidity and mortality.1 Early series of laparoscopic BPD/DS reported a 38% rate of major complications, with 6% mortality rate in patients with BMI greater than 65. Our group described a two-stage laparoscopic BPD/DS on these patients. With this approach, the mortality rate dropped to 0% and morbidity rate to 6%. LSG has been described increasingly as a first-stage procedure of gastric bypass, and even more as an alternative to other restrictive procedures such as gastric banding in patients with lower BMI. Recent studies have shown encouraging results during the first year with low morbidity and good quality of life.2

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The sleeve gastrectomy (not laparoscopic) was incorporated by Marceau and colleagues3 as an improvement of the distal gastrectomy performed by Scopinaro in BPD.4 This modification decreased the capacity of the gastric reservoir and lowered the parietal cell mass to minimize the ulcerogenicity. However, it maintained the antropyloric pump and avoided the dumping syndrome. Conceptually, a similar technique has been described with good results: The Magenstrasse and Mill procedure. The “street of stomach” (gastric tube) is created by dividing the gastric mill completely from a hole performed in the antrum with a circular stapler, and multiple firings on linear staplers toward the angle of His. In this procedure, the stomach is left in place.5

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As a restrictive procedure, the LSG could have an advantage over the adjustable gastric banding and vertical banded gastroplasty, because of the hormonal effect of the procedure. Complete removal of the greater curvature and fundus produces lower levels of ghrelin, which enhances the results on the control of food intake.

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Patients are positioned with the legs split in the reverse Trendelenburg position with assurance of proper support to the extremities. The surgeon stands between the legs with the assistants on both sides. Seven ports are inserted routinely. Pneumoperitoneum is established to 15 mm Hg and a 30° angled scope is used. The short gastric vessels of the greater curvature and retrogastric attachments are divided with the Harmonic Scalpel (Ethicon Endosurgery, Cincinnati, OH) or a sealer/divider instrument (LigaSure, Valleylab, Boulder, CO). The dissection extends proximally to the esophagogastric junction and distally toward the pylorus.

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The antrum is preserved and the greater curvature of the stomach divided 8–10 cm from the pylorus. This procedure is performed using two firings of 60-mm green cartridge (4.8-mm staple height) endoscopic linear stapler (Tyco Healthcare, Norwalk, CN). A 40F Maloney bougie is then inserted transorally and aligned along the lesser curvature (a 40F bougie is used for sleeve alone, and a 50–60 one is used if a complete DS ...

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