In my previous post, I discussed how the gastric sleeve operation is not a standardized operation. This means there is not consensus on how the operation should be done to achieve the best possible patient outcomes.
Because of this lack of consensus, different surgeons do the gastric sleeve operation in different ways. Some make the sleeve smaller, some make the sleeve larger, some do a hiatal hernia repair frequently, some do a hiatal hernia repair infrequently, some make the sleeve narrow/medium/wide at the bottom, some make the sleeve narrow/medium/wide at the top, some make the sleeve one shape, some make the sleeve a very different shape, etc.
Gastric sleeve operations are not all the same
One would expect that this variation in surgical technique would result in variation in patient outcomes – weight loss results, complication rates – and it does. Some surgeons achieve much better weight loss results and much lower complication rates than other surgeons.*
Gastric sleeve outcomes vary between surgeons
When I started my bariatric surgery career in 2002, I recognized that patient outcomes were highly variable between different surgeons. As a patient, the #1 thing I would value in a surgeon would be the surgeon’s record of actual patient outcomes, so I decided that achieving excellent patient outcomes would be my #1 goal as a surgeon.
My strategy for achieving excellent outcomes was (and is) as follows: 1) be accountable by closely tracking my own patient outcomes, and 2) do what it takes to achieve excellent outcomes statistics.
Fast forward 16 years, and I now have data on >3000 weight loss operations. How have I performed? I am proud to report that for the outcome parameters that matter most (e.g. weight loss results, rate of serious complications), my statistics are better than the industry averages.*
Now let’s move on to the main topic of this post – how I do the gastric sleeve operation to achieve excellent patient outcomes.*
My gastric sleeve surgical technique is guided by the following simple rules:
- Prioritize careful and meticulous surgical technique
- Don’t cut corners
- Make a perfect staple line
- Don’t be overly aggressive with hiatal hernia repair
- Make a small sleeve (but not too small)
- BE EXACT!
Now let’s discuss each rule in more detail.
Prioritize Careful and Meticulous Surgical Technique
Surgery is a balance between carefulness and speed. On a very general level, more carefulness results in fewer complications but takes longer. More speed results in more surgeries (and therefore more money for the surgeon and the hospital) but increases complication rates. I come down very much on the carefulness side of the balance. My rule is to do each step of every operation as perfectly as possible, and I allocate the necessary surgical time to accomplish this.
Don’t Cut Corners
The same discussion as for rule #1 applies to rule #2. It is easy to cut corners when the priority is speed. My rule is to never compromise the quality of an operation in the interest of speed.
Make a Perfect Staple Line
Make a perfect staple line – what does this mean? It means make a staple line that is straight and on the exact side of the stomach (not more on the front or the back), without bends, kinks, twists, areas of narrowing/widening, etc.
It sounds easy to make a straight staple line on the side of the stomach, but it is not. The stomach is very stretchy, and when it is manipulated, like when the stomach is positioned for stapler firing, the normal stomach anatomy can very easily be distorted. Stapling across a distorted stomach results in a distorted, imperfect staple line.
To avoid ending up with a distorted, imperfect staple line, I have several sub rules that I follow: 1) measure and mark the planned line of stapling while the stomach is in its normal anatomy/position before any stomach manipulation is done, and 2) avoid lateral/inferior/superior traction on the stomach when positioning the stomach for stapling.
Don’t Be Overly Aggressive with Hiatal Hernia Repair
Heartburn (i.e. acid reflux, gerd) is the main potential long-term issue after gastric sleeve surgery. The presence of a hiatal hernia after gastric sleeve surgery is one of the main causes of heartburn. It is accepted that if a hiatal hernia is present, hiatal hernia repair should be performed at the same time as the sleeve gastrectomy operation.
The challenge for surgeons is that it is not always straightforward to diagnose hiatal hernia. Preoperative tests (e.g. ugi, endoscopy) are not 100% accurate, and inspection during surgery is not always straightforward. The diagnosis of small/subtle hiatal hernias often comes down to a judgement call by the surgeon during surgery.
The challenge of knowing who needs hiatal hernia repair is illustrated by the fact that different surgeons do hiatal repair with different frequencies. Some surgeons do hiatal hernia repair in a high percentage of their patients (50% or more), and some surgeons do hiatal hernia repair in a low percentage of their patients (20% or less).
My hiatal hernia rule is to not do a hiatal hernia repair unless I can be 100% certain that a hiatal hernia exists. If I can’t be certain, then I don’t do it. This approach results in me doing a hiatal hernia repair in 10-15% of patients. This constitutes a conservative approach, and an evolution of my technique over the past ten years.
I used to be more aggressive about hiatal hernia diagnosis and repair. However, as we have learned more in the field, and as I have collected more long-term data on my own patients, I have come to believe that a more conservative approach is better.
Anytime a hiatal hernia repair is done, there is a risk for recurrence. Recurrence of hiatal hernia after the gastric sleeve operation will typically result in significant heartburn/gerd/reflux symptoms, and require a reoperation or a conversion to a gastric bypass. Therefore, it is important to not subject patients to this risk of recurrence (even if the risk is small) unless absolutely necessary.
Make a Small Sleeve (But Not Too Small)
Now for the fun final two rules! First, make the sleeve small, but not too small. In my experience, the smaller the sleeve, the better the weight loss. However, the smaller the sleeve, the higher the risk for complications and side effects (like dysphagia, heartburn/gerd, vomiting, stricture, etc.). The challenge as a surgeon is to get the perfect dimensions/shape/volume to maximize weight loss and minimize postoperative issues.
For many years I have very closely tracked my sleeve dimensions and patient outcomes to figure out the perfect sleeve dimensions/size/shape. Based on my data, I believe that a sleeve diameter of 2.5cm for the upper part of the sleeve, and 3.5-4cm for the lower part of the sleeve are ideal for most patients. I believe that the ideal entire sleeve volume for most patients should be 3-4 ounces.
I think this is an important one, hence the capital letters. Be EXACT! This means make the sleeve with the exact dimensions, size, and shape that I want. If I want the sleeve to be 2.5cm wide at the top, then that is how it needs to end up, not 2cm wide or 3cm wide.
Similar to rule #3 (make a perfect staple line), making an exact gastric sleeve is easier said than done. Because the stomach is very stretchy, any manipulation of the stomach can distort its normal anatomy. Stapling across a distorted stomach will result in a malformed, distorted, inexact sleeve.
The typical way to do the sleeve is by placing a sizing tube (bougie) into the stomach (typically 36Fr, which is 12mm in diameter), and then stapling along the bougie using the “eyeball” technique to judge stapler placement and sleeve width.
The problem with this approach in my experience is that manipulating the stomach by placing the sizing bougie, and by positioning the stomach for stapler firing while the bougie is in place, distorts the normal stomach anatomy. Stapling across a distorted stomach results in a distorted, inexact sleeve.
I used the “eyeball” technique when I first started doing the gastric sleeve operation, but I wasn’t happy with the resulting inexact sleeve dimensions and contour, and the significant variation in sleeve characteristics from patient to patient.
My gastric sleeve surgical technique has evolved over time to be more exact. Currently my approach is to carefully measure and mark the planned line of division on the stomach while the stomach is in its normal anatomic position, before any surgical manipulation takes place. I have found that taking the time to do this enables me to fashion a very exact sleeve, and this results in more consistent patient outcomes.
Gastric Sleeve Surgery Video
Watch Dr. Oliak do a gastric sleeve operation.
Learn more about Dr. Oliak and his Los Angeles and Orange County weight loss surgery program, visit www.OliakCenter.com.
* Outcomes vary after weight loss surgery. Past results may not be indicative of future results.
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