Volume 9 Number 6 June 2012 Supplement B

CHECKLIST FOR LAPAROSCOPIC

SLEEVE GASTRECTOMY

from the 2011 International Sleeve Gastrectomy Expert Consensus Conference

An international panel of experts, reached consensus on the best practices to help the surgical community continue to improve patient
outcomes, minimize complications, and adoption of standardized techniques in Laparoscopic Sleeve Gastrectomy. The assembly and work of
the expert surgeon panel that developed the consensus was supported by an educational grant from Ethicon Endo-Surgery, Inc.

Introduction by RAUL J. ROSENTHAL, MD, FACS, FASMBS

Dr. Rosenthal was Chairman for the 2011 International Sleeve Gastrectomy Expert Consensus Conference.
He is Program Director of Minimally Invasive Surgery, Director of the Minimally Invasive Fellowship
Program, Director of the Bariatric and Metabolic Institute, and Director of the General Surgery Residency
Program, Cleveland Clinic FloridaWeston, Fort Lauderdale, Florida.

n the quest of developing best treatment options for the

obesity pandemic, bariatric surgeons continue to search
for a surgical treatment modality that can help patients
with morbid obesity lose their excess body weight and
resolve the associated conditions with minimal morbidity
and negligible mortality. In nearly 50 years of developments
in the field of bariatric surgery, sleeve gastrectomy appears
to be the surgical option we were looking for.
Pioneered by Hess et al1 and Marceau et al2 as a
component of the biliopancreatic diversion and duodenal
switch, the sleeve gastrectomy was first introduced as a
stand-alone treatment modality by Almogy et al,3 who used
an open technique in high-risk patients requiring organ
transplantation. Regan et al4 utilized a laparoscopic
technique, which has since propelled laparoscopic sleeve
gastrectomy as a popular treatment modality for patients
with morbid obesity.
I would like to acknowledge my Co-Chairs: Drs.
Himpens, Ramos, and Lakdawala as well as all panelists
who participated in this consensus meeting. They all
contributed their time and invaluable expertise to develop
these guidelines that review the indications,
contraindications, technique, and management of
complications when performing laparoscopic sleeve
gastrectomy.
I welcome you to a new educational resource
Checklist for LSG; which has been designed to offer
quick reference for surgeons and integrated health
professionals to keep the LSG consensus statement
guidelines top of mind during daily practice. Highly trained

surgeons, with tremendous experience in LSG, have been

invited to provide their thoughts on key aspects related to
techniques utilized during the LSG procedure and the
management of potential complications. Please note that
although the comments of several surgeons relate back to
the consensus statement,5 comments are based on their
opinion and personal experience and may not mirror
consensus results.
Whether you have been performing LSG for years or if
you are just beginning training, I hope the Checklist is
beneficial to your practice. At the end of the supplement,
you will find a link to the original research article of the
consensus statement as well as a link to a video of the
procedure for further reference.
Together, we can continue to standardize LSG as a
primary procedure for the treatment of patients with
obesity, build further clinical evidence, and enhance patient
outcomes.
REFERENCES
1.
2.
3.
4.
5.

Hess DS, Hess DW. Biliopancreatic diversion with a duodenal switch.

Obes Surg. 1998;8(3):267282.
Marceau P, Biron S, St Georges R, et al. Biliopancreatic diversion with
gastrectomy as surgical treatment of morbid obesity. Obes Surg.
1991;1(4):381387.
Almogy G, Crookes PF, Anthone GJ. Longitudinal gastrectomy as a
treatment for the high-risk super-obese patient. Obes Surg.
2004;14(4):492497.
Regan JP, Inabnet WB, Gagner M, Pomp A. Early experience with twostage laparoscopic Roux-en-Y gastric bypass as an alternative in the
super-super obese patient. Obes Surg. 2003;13(6):861864.
Rosenthal RJ, Diaz AA, Arvidsson D, et al. International Sleeve
Gastrectomy Expert Panel Consensus Statement: best practice
guidelines based on experience of >12,000 cases. Surg Obes Relat Dis.
2012;8(1):819. Epub 2011 Nov 10.

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CHECKLIST IN LAPAROSCOPIC SLEEVE GASTRECTOMY

Part 1: SURGICAL TECHNIQUE

View of the
antrum.
Dissection of
short gastric
vessels on the
greater
curvature of
the stomach
starts 26cm
from the
pylorus.

MOBILIZATION

Completely mobilize the fundus
before transection

EXPERT COMMENTARY
Michel Gagner, MD, FRCSC, FACS, FASMBS,
FICS, AFC (Hon.)

Clinical Professor of Surgery; Chief, Bariatric

and Metabolic Surgery, Montreal, Quebec, Canada

oncerning this particular aspect of the sleeve

gastrectomy procedure, 96 percent of consensus panel
experts agreed that complete mobilization of the
fundus is necessary in order to perform an adequate
transection of the stomach. In my opinion, this is best
achieved by opening the lesser sac in the mid portion of the
greater curvature with ultrasonic shears. Surgeons can
progress cephalad, adjacent to the gastric serosa, until the
left crus is exposed. In fact, the fundus mobilization is not a
stomach dissection at this height, but rather a diaphragmatic
dissection, dissecting the stomach and perigastric fat from
the left diaphragmatic surfaces including the left crus until
the right one is seen posteriorly. Therefore, experts agreed
that all short gastric vessels needed to be taken down (82%),
of which the specific methods are left to the operator. The
complete mobilization of the fundus also permits better
identification of the exact location of the esophagogastric
junction, identification of a hiatal hernia (and its immediate
repair), and elimination of the transthoracic migration of
upper stomach.

SIZING THE SLEEVE

Use a bougie size: 3236F

Invaginating staple line reduces lumen size
EXPERT COMMENTARY
Raul J. Rosenthal, MD, FACS

Cleveland Clinic FloridaWeston, Fort Lauderdale, Florida

t is important for surgeons to remember that when

performing a sleeve gastrectomy, we create a high-pressure
system. Because of this, the likelihood of staple line
disruptions is higher than in other circumstances.

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[Bariatric Times JUNE 2012, SUPPLEMENT B]

Take down of
phrenoesophageal
membrane and
exposure of
left crus

Alfons Pomp, MD, FACS, FRCSC

Weill Medical College of Cornell University,

New York Presbyterian Hospital, New York, New York

he SG consensus panel of experts agreed that transection

should begin 26cm from the pylorus. In order to
preserve antral motility, I believe the correct distance
from the pylorus to start dissection is likely between 4 and 6cm.
To my knowledge, there is no scientific evidence confirming that
getting closer to the pylorus will result in better outcomes.
After the short gastric vessels have been taken down,
advance the bougie transorally into the distal esophagus and
slowly, under view, bring the bougie to the lesser curvature of
the stomach. Lift the stomach in a ventral direction, in order to
facilitate this maneuver, while you advance the bougie toward
the lesser curvature of the stomach. It is recommended to use a
bougie size 3236F, as the consensus panel agreed. If you
choose to use a bougie size under 32F or closer to 32F, you
might see an increased number of complications, such as
strictures and leaks. Before the division of the stomach is
initiated, the surgeon should dissect the posterior wall of the
stomach and check that all adhesions to the pancreas are taken
down. While applying the stapler and transecting the stomach,
the surgeon should also make sure that the assistant maintains
symmetric traction and that the posterior and anterior walls of
the stomach are maintained in an anatomical position without
rolling them over each other. Otherwise, when stapling the
gastric wall, you can create a corkscrew, which might lead to a
higher incidence of strictures. Due to the elasticity of the
gastric wall, if too much traction is applied, it might result in
the stomach coming back together and cause a stricture.

CHECKLIST IN LAPAROSCOPIC SLEEVE GASTRECTOMY

Part 1: SURGICAL TECHNIQUE

A green load
being used for
transection of
the stomach
during the
sleeve
gastrectomy
procedure.

STAPLE HEIGHT

Use staples of at least 1.5mm closed height

(e.g., blue load) on all steps

If buttressing, use staples of at least 2.0mm

closed height (e.g., green load)

EXPERT COMMENTARY
John Jorgensen, MB, BS, FRACS, MS

St. George Private Hospital, Sydney, Australia

When resecting the antrum, surgeon should

never use any staple with closed height less
than that of a green load (2.0mm)

he sleeve gastrectomy involves a long staple line in a highpressure tube. Uncomplicated healing depends, in part, on
the correct choice of staple height and correct use of the
stapler. Very slow application of the stapler (i.e., waiting at least 15
seconds after stapler closure before firing) is recommended to
allow for additional tissue compression before firing. In terms of
staple height, there is a growing trend to use staples taller than
1.5mm to minimize the chance of crushing tissue and subsequent
staple line failure. At the 2011 SG consensus meeting, the panel
agreed that green loads were the smallest acceptable staple heights
at the antrum and from the gastric body upwards blue or green
loads were recommended. There was an increasing trend to use
taller staples, green load or taller, in these areas. For revision cases,
and when adding buttress material, the green load or taller should
be the choice.
Wide range of cartridges for thin to thick tissue, all fitting through a
12mm trocar.

Transection of
the stomach
starts 26cm
from the
pylorus. Green
load or greater
should be used.
It is important
that the assistant
exercises a mild
and symmetric
lateral traction.

FIRST FIRING AND WHERE TO

START THE TRANSECTION

Transection should begin 26 cm from pylorus

EXPERT COMMENTARY
Alfons Pomp, MD, FACS, FRCSC

Weill Medical College of Cornell University, New York

Presbyterian Hospital, New York, New York

here are two critical points to be made in regard to first firing and starting the transection in a sleeve gastrectomy procedure. First,
appropriate stapler size should be chosen to ensure adequate tissue apposition with hemostasis and to minimize serosal tearing
close to the staple line; usually this requires a green load (2.0mm close height) or greater, as agreed in the SG consensus meeting.
Second, although not addressed in the SG consensus statement, in my opinion, the orientation (angle from the greater curve) of the first
stapler line is also important, particularly if this is a 60mm long cartridge, as the first firing should not compromise the width of the sleeve
near the incisura.

[JUNE 2012, SUPPLEMENT B]

Bariatric Times

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CHECKLIST IN LAPAROSCOPIC SLEEVE GASTRECTOMY

Part 1: SURGICAL TECHNIQUE continued

LAST FIRING AND WHERE

TO END THE TRANSECTION

Stay away from GE junction on last firing

Traction on the
fundus and
transection of
the stomach
against the
bougie, lateral
to the fat pad
at the GE
junction.

EXPERT COMMENTARY
Ninh T. Nguyen, MD

University of California Irvine Medical Center,

Irvine, California

n my experience, the last firing during construction of the

sleeve gastrectomy should be oriented vertically toward
the angle of His, slightly staying away from the bougie to
avoid stapling onto the GE junction (as recommended by the
SG panel of experts). This staple line of the last firing (i.e.,
the most proximal aspect of the sleeve or the proximal onethird of stomach) is particularly prone to developing leaks.
The consensus panel experts agreed that the use of staple
line reinforcement (buttress or over sewing) will reduce
staple-line bleeding. In my opinion, bleeding may weaken the
integrity of the staple line leading to dehiscence.

STAPLE LINE REINFORCEMENT

Use staple line reinforcement to reduce

Confidence Through Compression. Performance Demonstrated in Thick Tissue*

*Superior is defined as fewest malformed staples. Thick tissue defined as 3mm to 5mm as measured
with an 8g/mm2 thickness measuring device. Study conducted by Ethicon Endo-Surgery in a porcine
model. Data on file. ECHELON FLEX 60mm with Green Cartridge (88 staples per cartridge) vs. ENDO
GIA Universal with 60mm Green Roticulator (90 staples per cartridge) (not compared with
EGIA60AMT/EGIA60AXT). Please read and follow the Instructions for Use for important information,
including indications, contraindications and complete steps for use.

Bovine
pericardium
being used for
staple line
reinforcement

bleeding along staple line

EXPERT COMMENTARY
Gregg H. Jossart, MD, FACS

California Pacific Medical Center, San Francisco, California

he current generation of staplers have a reinforced anvil and higher compressive forces than prior generations. In my opinion,
surgeons should select the correct size staple cartridge and should not add thick buttress material without considering how much
the staple line will be compromised. I believe that early leaks and segmental staple line disruptions will occur from these types of
errors. On sleeve gastrectomies made with Bougie size 3240F and antrectomies, made within 23 cm of pylorus, no smaller than green
cartridges should be used. I recommend avoiding buttress material on the antrum, as I have observed that 10 to 20 percent of staple lines
will disrupt the seromuscular layers and additional sutures are required. I think that buttress materials along the mid-body (above
incisura) are reasonable, but keep in mind that overlapping buttress material at the staple line junctions may occupy up to 40 percent of
staple line height and could be a potential site for disruption. It is well known that the cardia is where the majority of leaks occur, even
with buttress material. Therefore, I hypothesize that suture inversion of the cardia with 1 to 2 Lembert type sutures is probably the most
effective way to manage this high-risk area.

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[Bariatric Times JUNE 2012, SUPPLEMENT B]

CHECKLIST IN LAPAROSCOPIC SLEEVE GASTRECTOMY

Part 2: PERIOPERATIVE PREVENTION: Complications Management

X-ray image of
a patient who
developed a
leak after
undergoing
sleeve
gastrectomy.

LEAKS

According to the observation period, leaks
can be acute, early, late, and chronic

If a leak lasts >12 weeks,

it is considered chronic

n my opinion, the following group of conditions may contribute

to higher rate of SG leaks that do not respond to conservative
or traditional surgical approach (e.g., suturing) and become
chronic:
1. The inherent poor vascular supply at the angle of His
2. The absence of the remnant stomach that could block the
leak
3. The physiologic obstruction of the pylorus
4. The narrowing at the level of incisura angularis
5. The deviation on the antrums axis
6. The possible curling/twisting of the sleeve
7. The fact that SG has the longest staple line of all bariatric
surgeries
8. The fact that being so high, the sleeve is under negative
pressure of the thorax
9. The fact that the SG is a high-pressure closed system instead
of a draining system like the gastric bypass.
X-ray image of
a patient who
developed a
stricture after
undergoing
sleeve
gastrectomy.

EXPERT COMMENTARY
Manoel Galvao Neto, MD

Gastro Obeso Center, So Paulo, Brazil

The SG consensus experts agreed that stenting is a valid

treatment option for acute proximal leaks and has limited utility
for chronic leaks. In our experience, endoscopic treatment with
stents in early leaks, and pneumatic dilation in chronic leaks, play
a major role after initial surgical or percutaneous sepsis control.
Also in our experience, surgical repair is usually appropriate if
endoscopic approach fails and can be done by means of
seromyotomy, converting the sleeve to a Roux-en-Y gastric bypass,
bypassing the leak with a bowel limb and even with a total
gastrectomy.

STRICTURES

Early strictures are symptomatic in first

6 weeks after surgery

The smaller the bougie size, the tighter

the sleeve, the greater stricture rate

e now better understand the technical aspects that can

cause strictures after a laparoscopic sleeve gastrectomy.
The SG consensus expert panel agreed with other
published data that the incisura angularis is the site with the
greatest potential for strictures, but we should not forget that
strictures can occur elsewhere in the sleeve. The consensus panel
also agreed that maintaining symmetric lateral traction, while
stapling, will reduce the potential for strictures. The symptoms of
stricture usually start in the first six weeks after surgery, so
aggressive but nonsurgical management should be implemented.
Management includes close observation followed by endoscopic
dilation up to six weeks. The option of using stents to keep the
lumen open was not presented to the panel but is occasionally
necessary in our experience.

EXPERT COMMENTARY
Natan Zundel, MD, FACS

Florida International University College of Medicine,

Miami, Florida

The consensus panel agreed largely (88%) that laparoscopic

Roux-en-Y gastric bypass (RYGB) is the treatment of choice after
failed interventions for strictures. On the other hand, even though
seromyotomy was mentioned as an option, it did not reach
consensus (69%) as a valid option for failed endoscopic treatment.
We need to learn more about this complication, especially
because it often appears at the same time as leaks and we cannot
treat one without treating the other.

[JUNE 2012, SUPPLEMENT B]

Bariatric Times

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CHECKLIST IN LAPAROSCOPIC SLEEVE GASTRECTOMY

Part 3: CONSIDERATIONS

HIATAL HERNIA

Aggressive identification of hiatal hernia
intraoperatively

Repair hiatal hernia if found

X-ray image of
a patient who
developed a
hiatal hernia
after
undergoing
sleeve
gastrectomy.

Close the diaphragmatic defect after the

sleeve procedure is completed

EXPERT COMMENTARY
Kelvin Higa, MD, FACS, FASMBS

University of California, San Francisco; Fresno Heart and

Surgical Hospital; Advanced Laparoscopic Surgery
Associates, Fresno, California

he recommendations of the SG consensus panel of experts on hernia repair are important because weight recidivism,
proximal leaks, and late gastroesophageal reflux disease (GERD) can be related to imprecise proximal dissection and
underestimating the importance of undiagnosed hiatal hernia at the time of performing a sleeve gastrectomy. It is
clear that endoscopy and contrast studies are not reliable at predicting the presence of hiatal hernias preoperatively;
therefore, aggressive hiatal dissection with subsequent repair is recommended

Ninh T. Nguyen, MD

University of California Irvine Medical Center,

Irvine, California

iatal hernia is commonly present in the morbidly obese. It is well known that up to 40 percent of patients
undergoing bariatric surgery have a hiatal hernia identified on preoperative studies, such as upper gastrointestinal
contrast studies or endoscopy. It is also well known that hiatal hernia contributes to the development of GERD. The
SG consensus reports that GERD is the most prevalent complication observed after SG and is likely due to it being a highpressure system. Therefore, a hiatal hernia should be repaired concomitantly with a sleeve gastrectomy. In my experience,
small hiatal hernias can be closed with primary repair, while moderate and large hiatal hernias can be repaired posteriorly
with an absorbable or biologic mesh in an effort to reduce postoperative hernia recurrence.

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[Bariatric Times JUNE 2012, SUPPLEMENT B]

CHECKLIST IN LAPAROSCOPIC SLEEVE GASTRECTOMY

Part 3: CONSIDERATIONS

GASTROESAPHOGEAL REFLUX DISEASE (GERD)

The first line of treatment in patients with GERD = proton pump inhibitors
EXPERT COMMENTARY
Randal S. Baker MD, FACS

Grand Health Partners, Grand Rapids Michigan

number of studies and the SG expert panel have

indicated that sleeve gastrectomy can lead to new
onset or increased GERD. Discussion of the panel
revealed that many were concerned about performing the
sleeve in patients with significant pre-operative GERD not
caused by hiatal hernia (as worsening GERD and bile
reflux has been reported after SG), but no consensus vote
was taken regarding this issue. The panel agreed that
Barretts esophagus is a definite contraindication to
performing a sleeve. In addition, we felt that during
surgery the phreno-esophageal membrane must be
explored to help identify, and subsequently repair, any
hiatal hernias. It is easier to perform this after the sleeve
is created and the excluded stomach is out of the way. To
avoid retching and injury to the crural repair, sleeve
patients, especially those with hiatal hernias, should wait
at least two weeks after surgery to start solid food. GERD
after a sleeve should first be treated with proton pump
inhibitor medications and, during the panel meeting,
many voiced the consideration of revision to Roux-en-Y
gastric bypass if severe GERD is not responsive to
conservative treatment.

REVISIONS

Last firing = green
or greater

Gregg H. Jossart, MD, FACS

California Pacific Medical Center, San Francisco, California

eflux and hiatal hernias are common in the morbidly

obese and often, as noted in the SG consensus
statement, exacerbated by a sleeve gastrectomy
without a hiatal hernia repair. It is well known that
preoperative studies, such as endoscopy and upper
gastrointestinal (GI) contrast, can fail to diagnose a hiatal
hernia. Hence, the recommendation of intraoperative
examination of the hiatus anteriorly and along the left crus
in all patients undergoing a sleeve gastrectomy. I think that
opening the pars flaccida to probe for a hernia along the
right crus may be the most sensitive technique. In my
experience, hiatal hernia repair should always include
circumferential dissection and mobilization of the distal
esophagus, suture approximation of the posterior and
anterior crus, as well as attachment of the cardia to the
insertion point of the left phrenoesophageal ligament on
the left diaphragm. This may restore the Angle of His and
reduces recurrence rate.

LSG is acceptable to

convert a successful, but

complicated, gastric band

evisions continue to be controversial, as evidenced by the

lack of consensus reached by the SG panel on the topic of
what to do after a laparoscopic sleeve gastrectomy fails. I
think this most likely represents the heterogenous nature of the
SG patient rather than ignorance of outcomes. For example, a
patient with initial body mass index (BMI) of 65 kg/m2 might be
best served by conversion to duodenal switch for inadequate
weight loss; whereas, a patient with 80-percent excess weight loss
(EWL) with intractable gastroesophageal reflux disease (GERD),
would be better off converted to gastric bypass.

When converting from gastric

banding to LSG, the operation

can be done in 1 or 2 steps

EXPERT COMMENTARY
Kelvin Higa, MD, FACS, FASMBS

University of California, San Francisco; Fresno Heart and

Surgical Hospital; Advanced Laparoscopic Surgery
Associates, Fresno, California

[JUNE 2012, SUPPLEMENT B]

Bariatric Times

B7

Volume 9 Number 6 June 2012 Supplement B

FOR THE FULL, ORIGINAL ARTICLE

International Sleeve Gastrectomy Expert Panel Consensus Statement:
best practice guidelines based on experience of >12,000 cases,
published in Surgery for Obesity and Related Diseases (Surg Obes Relat Dis), visit
http://www.soard.org/article/S1550-7289%2811%2900764-7/fulltext

To view a video of the sleeve gastrectomy procedure by Dr. Raul J. Rosenthal, visit
EES.com/SleeveSolution
DSL# 12-0173

For a direct link to the DIGITAL EDITION of this supplement,

scan the QR code below with your smart device.

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