Sleeve Gastrectomy for Morbid Obesity

This video shows a stapling first technique, which is used in about 10% of cases. Gastro-colic space is entered too distally, as posterior adhesions may hinder further progression and risk injury to the pancreas, it is better to enter on the left side in my opinion. When stapling, bleeding initially is due to not having mobilized the greater curvature distal to the first stapler application which results in getting into some vascular branches of the gastroepiploic (or the vessel itself). The major problem with the stapling first technique is the inability to evaluate the adhesions posterior which means the stapler can get too lateral from the lesser curvature. The esophagogastric junction is not really identified, and a blue cartridge (3.5mm) maybe too thin to divide this area, as gastric tissue will usually get thicker near the EG junction. The admirable advantage of this technique is the ease of the greater curvature mobilization, especially near the upper part of the spleen. Suturing of the staple line should be done to decrease the risk of leakage and bleeding, especially if staple line reinforcement has not been used, tissue sealants has not been shown to decrease leaks, are expensive and may potentially increase the risk of intrabadominal infections. It is even more important in high risk patients, where leakage will not be tolerated. Extraction is better at the umbilicus, so facial defects are easier to close in the thinnest portion of the abdomen, in higher BMI patients.