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CHECKLIST IN LAPAROSCOPIC SLEEVE GASTRECTOMY Part 1: SURGICAL TECHNIQUE MOBILIZATION Completely mobilize the fundus before transection EXPERT COMMENTARY Michel Gagner, MD, FRCSC, FACS, FASMBS, FICS, AFC (Hon.) Florida International University School of Medicine, Miami, Florida C oncerning this particular aspect of the sleeve gastrectomy procedure, 96 percent of consensus panel experts agreed that complete mobilization of the fundus is necessary in order to perform an adequate transection of the stomach. In my opinion, this is best achieved by opening the lesser sac in the mid portion of the greater curvature with ultrasonic shears. Surgeons can progress cephalad, adjacent to the gastric serosa, until the left crus is exposed. In fact, the fundus mobilization is not a stomach dissection at this height, but rather a diaphragmatic dissection, dissecting the stomach and perigastric fat from the left diaphragmatic surfaces including the left crus until the right one is seen posteriorly. Therefore, experts agreed that all short gastric vessels needed to be taken down (82%), of which the specific methods are left to the operator. The complete mobilization of the fundus also permits better identification of the exact location of the esophagogastric junction, identification of a hiatal hernia (and its immediate repair), and elimination of the transthoracic migration of upper stomach. SIZING THE SLEEVE Use a bougie size: 32–36F Invaginating staple line reduces lumen size EXPERT COMMENTARY Raul J. Rosenthal, MD, FACS Cleveland Clinic Florida—Weston, Fort Lauderdale, Florida I B2 t is important for surgeons to remember that when performing a sleeve gastrectomy, we create a high-pressure system. Because of this, the likelihood of staple line disruptions is higher than in other circumstances. View of the antrum. Dissection of short gastric vessels on the greater curvature of the stomach starts 2–6cm from the pylorus. Take down of phreno- esophageal membrane and exposure of left crus Alfons Pomp, MD, FACS, FRCSC Weill Medical College of Cornell University, New York Presbyterian Hospital, New York, New York from the pylorus to start dissection is likely between 4 and 6cm. To my knowledge, there is no scientific evidence confirming that getting closer to the pylorus will result in better outcomes. T After the short gastric vessels have been taken down, advance the bougie transorally into the distal esophagus and slowly, under view, bring the bougie to the lesser curvature of the stomach. Lift the stomach in a ventral direction, in order to facilitate this maneuver, while you advance the bougie toward the lesser curvature of the stomach. It is recommended to use a bougie size 32–36F, as the consensus panel agreed. If you choose to use a bougie size under 32F or closer to 32F, you might see an increased number of complications, such as strictures and leaks. Before the division of the stomach is initiated, the surgeon should dissect the posterior wall of the stomach and check that all adhesions to the pancreas are taken down. While applying the stapler and transecting the stomach, the surgeon should also make sure that the assistant maintains symmetric traction and that the posterior and anterior walls of the stomach are maintained in an anatomical position without rolling them over each other. Otherwise, when stapling the gastric wall, you can create a corkscrew, which might lead to a higher incidence of strictures. Due to the elasticity of the gastric wall, if too much traction is applied, it might result in the stomach coming back together and cause a stricture. he SG consensus panel of experts agreed that transection should begin 2–6cm from the pylorus. In order to preserve antral motility, I believe the correct distance [Bariatric Times JUNE 2012, SUPPLEMENT B]