Surgical Technique The patient is evaluated by a multidisciplinary team of bariatric specialists and preoperative preparation is done before surgery. This includes gastroscopy (H. pylori positive needs to be treated), control of comorbidities, dietary modification, and respiratory-related tests. The patient is placed in a supine position with legs apart (French position) and head high and feet low (reverse Trendelenburg position). The operating table is tilted slightly to the right to facilitate visualization of the gastroesophageal junction. This position requires that the patient be well secured to the table so that it does not slip out of place. The use of antithrombotic stockings and intermittent compression devices are also required to prevent venous thrombosis. The author currently performs LSG procedures usually using 5 or 6 puncture holes, the distribution of which is shown in Figure 17.1. the first 10-12 mm trocar is located in the umbilicus and is placed into the abdominal cavity using an open technique. two 5-mm or 12-mm trocar are placed in the supraumbilical region, one under the glabella and the other in the right upper abdomen. two 15-mm trocar (for placement of the largest diameter anastomosis) placed in the mid-clavicular line on both sides. A 5-mm trocar is placed in the left upper abdomen with the assistance of a traction assistant, which needs to be high enough to reach the fundus. The gastric diaphragmatic ligament is freed and the angle of His is revealed to determine the presence of diaphragmatic hernia. The left diaphragmatic angle is fully revealed and the perigastric freeing is concluded. If a diaphragmatic hernia is found, the attachment of the distal esophagus to the mediastinum needs to be completely freed, the stomach is returned into the abdominal cavity, and the diaphragmatic fissure is closed with non-absorbable sutures. Cutting of the stomach is started 100px from the pylorus to preserve partial emptying of the sinus portion of the stomach. A 34-40 Fr orthodontic tube is placed with the assistance of an anesthesiologist to guide the cut and maintain the proper gastric lumen. The surgeon and anesthesiologist need to communicate with each other at all times during the placement of the correction tube to ensure that it is safely placed in the proper position. The orthodontic tube needs to be placed prior to cutting the stomach to guide it into the pylorus, placing it close to the lesser curvature. Gagner uses a green (4.8 mm) or black (5 mm) staple position with additional absorbable reinforcement material. If no absorbable reinforcement is available, the first two strokes require a green or black staple compartment, and the rest are made with a blue staple compartment (Zundel). All cuts require the use of 60 mm nail bins and the need to avoid twisting of the remaining stomach during the cut. To achieve this, an assistant is needed to pull the stomach from the left side so that the anterior and posterior walls to the lesser curvature are at the same distance. The distance from the anterior wall of the remaining stomach to the lesser curvature should not be less than the posterior wall. In addition, the anastomosis should be placed at the same angle as the previous stroke to avoid a “dog-ear” cut that could lead to ischemia of the remaining stomach. After each stroke, the anesthesiologist swings the orthodontic tube to confirm that the remaining stomach is not too tight and that the orthodontic tube is not cut. A 10 mm diameter 30 degree laparoscope was selected. The left outer lobe of the liver is retracted to expose the gastroesophageal junction and the lesser curvature of the stomach. The surgical operation starts with freeing the greater gastric omentum and opening the lesser omental sac. An ultrasonic knife or an advanced bipolar cutting device is used to free the greater curvature of the stomach, paying attention to the gastric wall and disconnecting the branches of the vessels leading to the stomach until the short gastric vessels are disconnected. The assistant pulls the omental tissue to one side to maintain a good view and instrument position to prevent bleeding. The distal end is freed to 50 px of the pylorus. The purpose of freeing along the greater curvature of the stomach is to minimize the fat attached to the stomach so that it will be easier to remove the specimen at the end of the procedure. The stomach is turned upward to expose the posterior wall and free the adhesions between the stomach and the small omental sac. This helps to keep the cutting line in place and to avoid bleeding. When freeing these adhesions, care also needs to be taken to prevent damage to the left gastric artery branch, which, if damaged, can interfere with blood flow to the remaining stomach. The surgeon also needs to pay attention to the anatomical relationship of the splenic artery and vein that travel along the superior margin of the pancreas. In elderly patients, the splenic artery will protrude from the surface of the pancreas and may be damaged during posterior wall dissection. Although some experts used to recommend separation of the fundus at least 25px from the gastroesophageal junction, in fact, it is now practice to separate close to the GE junction without avoiding the esophagus by a certain distance. It has also been suggested to separate the fundus 12.5px from the GE junction without reinforcing material and to reinforce the cutting line with absorbable sutures to reduce the occurrence of gastric leakage. The current view is to cut in a straight line downward from the GE union, because a funnel-like remaining stomach can appear to dilate or pull apart the lower esophageal sphincter, which is more likely to cause gastroesophageal reflux. In addition, removal of the perigastric fat can be more conducive to identifying the gastroesophageal junction and facilitate strengthening the cutting line. The authors concluded that since gastric leak mostly occurs at the GE junction, only that and the thickest gastric sinus cutting line need to be strengthened. The gastric cutting line can be reinforced with continuous sutures with 3-0 absorbable sutures. Other authors (Zundel and Hernandez) do not routinely use reinforcing material, but instead close the gastric cutting line with a full layer of 3-0 absorbable sutures when the correction tube is placed in the stomach. The corrective tube is slowly removed by the anesthesiologist under direct vision, at which point the shape of the remaining stomach can be examined. The excised specimen is removed through a 12 mm puncture hole. The stomach is filled with 50-100 ml of methylene blue saline solution to check the integrity of the gastric cutting line. Placement of drainage is usually not necessary. Postoperative care Postoperative treatment such as rehydration, analgesia and vomiting suppression should be given appropriately. Monitor closely for signs of gastric leakage and bleeding, such as fever, shortness of breath, and increased heart rate. Abdominal pain and left shoulder pain are not reliable symptoms, but they should not be considered normal. Antithrombotic compression stockings and lower extremity intermittent compression devices can be removed as soon as the patient is able to get out of bed. Upper gastrointestinal imaging should be routinely performed the day after surgery to rule out gastric leakage. If there is no sign of gastric leakage, the patient can be put on a liquid diet, get out of bed, and resume preoperative medication. LSG is usually discharged from the hospital 1 or 2 days after surgery. Discharge may be with fluid pain medication and on proton pump inhibitors for 6-8 weeks. Outcomes Weight loss and improvement in metabolic symptoms A growing number of studies with more than 5 years of follow-up have shown excellent clinical outcomes with LSG. It is worth pointing out, however, that it is difficult to determine comparable outcomes at this time due to the ever-changing surgical operating techniques. The bariatric surgery community is working to reach consensus on the major operational points of LSG. Since 2007, a number of meetings have been held to agree on the technical aspects of the procedure, which have made it possible to evaluate the results of the procedure. In the LSG Summit held in 2012, 130 bariatric surgeons with more than 1 year of experience pooled their experience in 46,133 LSG procedures. This study also included information from lesser surgical experience and short follow-up. Based on the information provided by the representatives, the mean excess weight loss rate (%EWL) after LSG was 59.3% at 1 year, 59% at 2 years, 54.7% at 3 years, 52.3% at 4-5 years, and 50.6% at 6 years [9]. The authors believe that when analyzing these data it is important to note that some authors provide information that should be left blank when there are no patients, but mark the %EWL change as 0. Since it is impossible to remove the 0% EWL option when doing statistics, instead of eliminating these numbers and adjusting the analysis for these deviations, the actual %EWL may be even higher. Summary It is clear that LSG is a safe, reproducible and effective treatment for morbid obesity. Its success rate is at least as good as that of Roux-en-Y gastric bypass. Attention to technical details is fundamental to avoid near- and long-term complications. Although there was skepticism until recently, its superiority is now being proven. If one considers that this technique has only been accepted in the last 5 or 6 years, one can assume that the results of future reported procedures will be better than those currently reported in the literature.