Upper GI

Sleeve Gastrectomy (Laparoscopic) (Variant)

OPERATION: Laparoscopic Sleeve Gastrectomy
ANAESTHETIC: General anaesthesia
ANTIBIOTICS: IV antibiotics at induction
POSITION: Supine. Surgeon on patient's right. Steep reverse Trendelenburg. Footboard applied. VTE prophylaxis.

INDICATION:
Morbid obesity. BMI [value]. [Comorbidities]. Standard bariatric criteria met. Preoperative multidisciplinary assessment including dietitian and psychological review completed.

PROCEDURE:
WHO Checklist performed. Abdomen prepared and draped.

PORT PLACEMENT:
Initial 12/15 mm working port placed at the umbilicus or in the region immediately superior and to the right. 5 mm camera port placed left upper paramedian. Sub-xiphoid Nathanson liver retractor inserted. 5 mm right upper paramedian port for surgeon's left hand. 5 mm left anterior axillary line port for assistant. Pneumoperitoneum maintained at 12-15 mmHg. Liver retractor positioned. Diagnostic laparoscopy performed — [hiatal hernia present / absent]. [Liver biopsy taken if abnormal hepatic appearance].

GASTRIC MOBILISATION:
Pylorus identified and marked with a suture / clip. Dissection commenced along the greater curvature opening the lesser sac between the gastric wall and the gastroepiploic arcade, beginning 3-6 cm proximal to the pylorus. Short gastric vessels divided sequentially with an energy device directly on the gastric serosa, proceeding superiorly towards the fundus. Mobilisation carried to the angle of His and left crus. Posterior attachments between the stomach and pancreas divided. Anterior fat pad mobilised to expose the gastro-oesophageal junction.

[HIATAL HERNIA REPAIR: Hiatal dissection performed. Posterior cruroplasty with [number] x 0-braided permanent sutures placed. Anterior hiatus closed with single suture. Cardiopexy performed to recreate angle of His.]

SLEEVE FORMATION:
[32-38 Fr] bougie passed transorally by the anaesthetist and positioned against the lesser curve to the pylorus. Gastric sleeve commenced with a [green / purple / black] cartridge load 2-3 cm proximal to the pylorus. Successive firings of the linear stapler directed along the lesser curve adjacent to the bougie towards the angle of His, forming a tubular gastric sleeve. Total [number] stapler firings used. Staple line oversewn with a running absorbable suture [and/or reinforced with buttress material]. Bougie removed.

Staple line inspected for haemostasis and integrity. [Leak test: air insufflation via orogastric tube / flexible endoscopy under saline — no leak identified.]

Resected stomach placed in retrieval bag and removed through the 12/15 mm port site.

CLOSURE:
Haemostasis confirmed. All ports removed under direct vision. 12/15 mm port fascial defect closed. Skin closed with subcuticular absorbable sutures.

FINDINGS:
Hiatal hernia: [present — repaired / absent]. Liver: [normal / steatotic — biopsy taken]. Sleeve fashioned over [bougie size] Fr bougie from [distance] cm from pylorus to angle of His. Staple line intact and haemostatic.

SPECIMEN: Gastric sleeve to histopathology.
EBL: Minimal. COMPLICATIONS: None.

POST-OPERATIVE INSTRUCTIONS:
Liquid diet for 2 weeks then pureed diet. Vitamin and mineral supplementation commenced. Avoid NSAIDs. Follow-up at 1, 3, 6, 12 months. Upper GI contrast study if any concern about staple line integrity postoperatively.