A new technical approach in sleeve gastrectomy: The SA-FAS (fundic anchor sleeve)

Sleeve gastrectomy is the most commonly performed bariatric procedure but remains limited by high proximal staple-line leak rates and post-operative reflux, largely due to disruption of the angle of His and loss of fundic support. This study describes a technical modification designed to strengthen the proximal sleeve, preserve key anti-reflux anatomy and optimise gastric flow. The procedure uses a 40 Fr bougie and preserves a small, well-vascularised fundic remnant by positioning the final staple firing 2 cm lateral to the native angle of His. The proximal staple line is reinforced with oversewn sutures, and the fundic remnant is anchored to the left diaphragmatic crus to restore the physiological flap-valve mechanism. In patients with a 2-5 cm hiatal hernia, posterior or anterior cruroplasty is performed prior to anchoring. This modification aims to reduce leak risk, enhance sleeve geometry and improve post-operative reflux control by re-establishing a more competent gastro-oesophageal junction.