Sleeve Gastrectomy: A Procedure in a State of Flux

Originally, sleeve gastrectomy (SG) was part of biliopancreatic diversion (BPD), which is the most effective bariatric procedure for super obese patients. As BPD is a complex procedure with substantial morbidity and mortality, attempts were undertaken to split the procedure into two steps. SG became the first step in a staged BPD procedure assuming that this less-invasive operation would reduce the surgical risk in super obese patients. The second step - the duodenal switch - was thus postponed until after a major weight loss. Several studies have since been published showing data that, besides the successful weight loss, the procedure itself had a positive effect on obesity-associated comorbidities. Sleeve gastrectomy has gained widespread acceptance as a primary and definite bariatric procedure. SG has become an innovative tool in the battle against obesity. Although several variations of SG have been described, standardization is paramount for optimal results. Of particular interest are: the minimally invasive access, the dissection, preservation of the antrum, position of staple-line and buttress material, as well as the size of the bougie and the extent of fundal resection. This article describes the different procedural and technical aspects of the operation. In addition, it will line out how we transferred our skills and experience in single incision laparoscopic surgery (SILS) from cholecystectomy and sigmoid resection to sleeve gastrectomy.