How I Do It Laparoscopic sleeve gastrectomy for morbid obesity Jason Moy, M.D., M.P.H., Alfons Pomp, M.D.*, Gregory Dakin, M.D., Manish Parikh, M.D., Michel Gagner, M.D. Weill Medical College of Cornell University, New York Presbyterian Hospital, 525 E 68th St., Box 294, New York, NY 10065, USA Abstract. The epidemic of obesity in the United States is a major public health issue and more than a third of adults are now considered obese (body mass index  30 kg/m 2 ). Surgery for morbid obesity, bariatric surgery, is the most durable treatment for this disease and about 140,000 cases are performed annually. Laparoscopic sleeve gastrectomy (LSG) has been advocated as the first of a 2-stage procedure for the high-risk, super-obese patient. More recently, LSG has been studied as a single-stage procedure for weight loss in the morbidly obese. LSG has been shown in initial studies to produce excellent excess weight loss comparable with laparoscopic Roux-en-Y gastric bypass in many series with a very low incidence of major complications and death. We describe our technique for LSG. © 2008 Elsevier Inc. All rights reserved. KEYWORDS: Bariatric surgery; Laparoscopic sleeve gastrectomy; Morbid obesity; Laparoscopy; Gastric bypass; High risk; Staged procedure Laparoscopic sleeve gastrectomy (LSG), in creating a narrow tube-like stomach, is a restrictive procedure de- signed to decrease appetite by reducing the ability of the stomach to distend and producing the sensation of fullness with minimal oral intake. 1–6 The procedure was first per- formed for the resection of gastric neoplasms but was adapted to bariatric surgery because of the significant weight loss it could induce. 7 Johnston et al 8 described a similar gastric division without resection for weight loss called the Magenstrasse and Mill surgery. As a weight loss procedure, LSG was first described by Hess and Marceau et al 9,10 as part of the biliopancreatic diversion– duodenal switch (BPD/DS) surgery. Ren et al 11 was the first to per- form this completely laparoscopically, and then later was the first to describe this procedure as the first of 2 stages for high-risk patients. 3,12 It is suggested that performance of the sleeve gastrectomy is easier, faster, and therefore safer in these high-risk patients than either gastric bypass or BPD/ DS. After a period of initial weight loss, the surgical risk would be improved and the second definitive surgery could be performed. Indeed, Ren et al 11 and Kim et al 13 found that the major complication rate in patients with a body mass index greater than 65 undergoing BPD/DS open or laparo- scopic can be as high as 38%. Currently, LSG is used as part of the BPD/DS and as the first of a 2-stage procedure. Its use as a primary procedure is still considered experimental, although 3-year data show it compares favorably with Roux en Y gastric bypass (RYGBP) and laparoscopic adjustable gastric band (LAGB). 14 There are many potential advantages of the LSG. Pres- ervation of gastric function including the pylorus eliminates dumping. It usually can be performed laparoscopically even in massively obese patients and requires only a short inpa- tient day. No adjustments are required as with the LAGB. Because there are no sequelae of malabsorption it can be used in patients with inflammatory bowel disease or in patients with chronic anemia. Disadvantages include poten- tial complications of the relatively long staple line and the irreversibility of the procedure. 7 Results of the procedure have been encouraging. Many series have reported excellent rates of resolution of comorbidities. In a study by Han et * Corresponding author. Tel.: +1-212-746-5294; fax: +1-212-746- 5236. E-mail address: jasmoy@gmail.com Manuscript received December 20, 2007; revised manuscript April 13, 2008 0002-9610/$ - see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2008.04.008 The American Journal of Surgery (2008) 196, e56 – e59