Sleeve Gastrectomy - Operation Steps

The operation is done with laparoscopy (keyhole). The outer 85% part of the stomach is removed, thus converting the stomach from a large bag to a banana shaped tube.
The stomach sits partially hidden by the left lobe of the liver which is elevated with a special retractor. The outer part of the stomach, the great curvature, is attached with many blood vessels to the omentum and the spleen. The omentum is a large broad fat apron that hangs from the outer border of the stomach and drapes over the intestine. 

Step 1

The outer border of the stomach is freed from its attachment to the omentum and the spleen using a special instrument called Ligasure. This instrument seals and divides the small blood vessels.The dissection is carried out all the way to oesophagus. If there is a hiatus hernia then this is dissected now and repaired at the end of the operation.  When this step is completed, the stomach outer border will be completely free.

Step 2

A sizing tube called Bougie (12 mm diameter) is inserted via the mouth into the stomach. Using the bougie as a guide for size the stomach is stapled and divided using a laproscopic stapler device starting 2-4 cm from the pylorus (where the stomach finishes and intestine begins).

The last top part of the stomach is much thinner than the rest of the stomach. I reinforce the stapler at that part with dissolving ribbon called Seam Guard. The bougie is then removed and the staple line is carefully inspected for any bleeding or deformed staples.    

The resected stomach is removed out of the abdomen through the port on the right side of the abdomen. This is done without enlarging the incision. This completes the sleeve gastrectomy operation. 

Step 3

In order to reduce the risk of staple line failure and leak and to prevent the stomach sleeve tube from twisting and kinking it is our routine practice to suture the omentum back to the staple line using a continuous suture. This additional step adds extra 15-20 minutes to the operation but it is well worth the extra time. 

Step 4 

The operation site is inspected one last time. If there are any bleeding spots then these are controlled with extra sutures.  

At the end of the operation, the liver retractor and ports are removed and the wounds are closed with a dissolving stitch.