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Sleeve Gastrectomy

Listed below is the step by step procedure of sleeve gastrectomy:

  1. What is sleeve gastrectomy ?
  2. Why is sleeve gastrectomy Required?
  3. Pre-operative Preparation
  4. Day Before Surgery
  5. Procedure Day
  6. Methods/Techniques of sleeve gastrectomy
  7. Post-operation Procedure
  8. Risks and Complications

What is sleeve gastrectomy?

Sleeve gastrectomy, gastric sleeve surgery or laprascopic sleeve gastrectomy (LSG) is a procedure in which the stomach is reduced to about 2/3rd of its original size. As a result, what we get is a tube or sleeve like structure. It is a kind of restrictive surgery, where the structure of the stomach is altered to restrict food intake.

It is done in those patients who are obese and need surgical aid to reduce their weight. Reduced size of stomach causes less intake of food, resulting in subsequent weight loss. It is a gradual procedure and, instant.

Why is sleeve gastrectomy Required?

Indications -

  • Your body mass index (BMI) is 40kg/square meter.
  • You are overweight by approximately 45 kilograms or more.
  • A body mass index 35kg/square meter or more. Along with this, at least two obesity related disorders such as Type II diabetes mellitus, high blood pressure, sleep apnea (interrupted breathing during sleep), cardiac disease, disorders of lipid metabolism, osteoarthritis, gastroininal diseases, non-alcoholic fatty liver disease, etc.
  • Your efforts to maintaining a healthy weight are not successful even with exercise and supervised diet changes.
  • Heartburn (in cases of severe acid reflux) coupled with a very high BMI.
  • A healthy state of mind

Contraindications -

  • BMI is less than 35kg/square meter.
  • If you are pregnant, the surgery can most certainly be postponed.
  • The presence of any severe psychological disorder.
  • An addiction to drugs or alcohol
  • Esophagitis (inflammation or irritation of the food pipe)
  • If you are suffering from Gastro-esphageal refulx disease (GERD) and have a Barret's esophagus (altered epithelium of food pipe due to constant acidity), it will not be allowed. But gastric bypass surgery is a better option.

Pre-Operative Procedure

If the indications give a green signal to surgery, your doctor will ask you to undergo some tests to ensure an uneventful and successful procedure.

An important thing to keep in mind is that the tests should be performed within 30 days of the sleeve gastrectomy procedure. Tests advised will include the routine blood workup & imaging tests plus those which are particular to your present health condition.

The diagnostic tests are as follows :

  • Routine blood workup:This includes complete blood count, creatinine, blood-urea nitrogen (BUN), electrolyte count, thyroid stimulating hormone, cortisol, etc.
  • Urinalysis:Urine is checked for presence of sugar, protein, pus cells, changes in turbidity, etc.
  • Imaging tests:An abdominal ultrasound is mandatory. Along with this, colonoscopy (studying the lining of intestines using a colonoscope), pelvic ultrasound and chest X-rays are also done. This is done to rule out any other abnormality present in the body at that time. Chest X-ray helps in studying respiratory disorders.
  • Heart check-up: Your heart will be examined with tests like treadmill stress test, cardiac catherization (evaluate heart musculature, valves or coronary arteries), electrocardiogram (ECG), echocardiogram, etc.
  • Sleep study:Sleep apnea is abnormal, interrupted breathing when asleep. This is because the airway muscles tend to relax when in slumber. It is important that your surgeon has a knowledge of this condition because you will be given certain sedative drugs & anesthesia, which again depress our breathing.
  • Gastrointestinal evaluation: Many patients before undergoing sleeve gastrectomy complain of abdominal pain, severe heartburn, belching & sour taste in the mouth. These symptoms are indicative of peptic ulcers and gastro-esophageal reflux disease.
  • Psychiatric evaluation: This is carried out to see if the patient is mentally fit to undergo surgery and is able to understand the risks and complications associated with the sleeve gastrectomy procedure.
You would be advised to stop smoking at least a month before surgery in order to minimise any further risk. There are a few other things which you would like to consider before the date of surgery finally comes -
  • Have a sensible diet:You can devote the time before an LSG to start the good habit of eating judiciously. A healthy diet will give you nutrition and prevent you from any untoward weight gain. Practice chewing slowly. This checks the urge to eat uncontrollably. A diet rich in proteins and vegetables but with minimum carbohydrate is considered best.
  • Exercise:After consulting your doctor, you can go for simple exercises like walking, bicycling, aerobics and yoga. Not only do they add to your health, they help in better post-op recovery. It is easy to get back back to a familiar routine rather than starting a new one.
  • Nutritional supplements:Take your supply of multivitamins and minerals for better post-op healing.
  • Drink plenty of water:Aids in weight loss and fat metabolism
  • Avoid eating too many sweets, even as a stress buster. Simple sugars have a tendency to attract us whenever we feel low.
As far as medications are concerned, following guidelines may help -
  • If you are on blood-thinners, stop taking them at least five days before surgery. Consult your doctor for specific instructions.
  • Aspirin is to be discontinued 10 days before surgery.
  • Oral contraceptives should be stopped a month before because they increase the risk of blood clots. You can resume these a month after surgery.

Day Before sleeve gastrectomy

  • Stay on a diet of clear liquids. You can have juices, water, decaffeinated tea or coffee, clear popsicles and gelatin.
  • After midnight, you would not be able to take anything through the mouth, because an empty stomach is needed.
  • Only medicines prescribed by the anesthesiologist are to be taken before the surgery.
  • Your blood tests will be repeated before the procedure.
  • Keep your jewelery or ornaments which you wear at home. It wont be a distraction during the surgery.
  • Bring comfortable clothing along as you will stay at least one day after surgery.

Procedure Day

Have a nice bath on this day. On reaching the hospital, the staff will record your details for the admission procedure. Again your blood and urine tests will be conducted. A nurse will inject a medicine that will prevent your blood from clotting (heparin) and ask you wear compression stockings to prevent the risk of deep vein thrombosis.

After settling down, your surgeon and anesthetist will visit you and you can clarify all doubts with them. Then a consent form will be given to you which explains all the details of the surgery, underlining the risks and complications as well. If you are satisfied with the details and wish to continue further, you will have to sign the form. Then you are taken to the operation theater.

All the equipment is sterilized and the operation theater is disinfected. You will be draped in a clean patient drape and made to lie down on the operation table.

Methods/Techniques of sleeve gastrectomy

The aim of sleeve gastrectomy is to reduce the stomach size. An advantage of this technique is that the important anatomic structures and connections are preserved. Most of the procedure inside the abdominal cavity is carried out using a laparascope, which makes this surgery minimally invasive.

Anesthetic considerations:

You will be assessed for the possibility of difficult intubation. General anesthesia is used in most of the cases. It is given either intravenously or by inhalation of gas.

While giving anesthesia, a few pillows are kept under your head to elevate your upper body well above the chest level. This is to improve visualisation during laryngoscopy.

The patient is positioned so that he/she lies flat on the back. Abdominal skin is shaved and cleaned with an antiseptic solution. Suitable incisions are made over the abdominal skin, to gain access to stomach. After the muscles have been dissected, the surgeon proceeds to operate upon the stomach. The stomach is a J shaped pouch which is to be reduced in volume. The J shaped side of the stomach is folded and stitched together to leave behind what looks like a cylindrical tube. If the surgeon feels, the extra flap of stomach is surgically removed.

The abdominal muscles are then placed in their former position and abdominal skin is sutured. The patient is then transferred to a recovery room, till effects of anesthesia wear off.

Post-Operative Procedure

Following sleeve gastrectomy, these guidelines may be of some help -

Recovery :

Day one-

In the initial few hours after surgery, you may not feel anything. This is the effect of anesthesia and pain medications given during the procedure.

Once the anesthesia starts wearing off, you will start to feel pain for sometime. This will be felt in places where the doctor has given sutures (stitches) and most importantly the part from where the large portion of stomach was removed. Just let the nursing staff know, they will give the pain medications as and when required.

A generalised soreness in the body may be felt.

  • Diet: Endotracheal intubation will make your throat sore and it will be difficult to consume food initially. Mouth swabs and ice cubes are the only way to keep you hydrated.

  • Exercise: The doctor will ask you to do a little bit of physical activity, such as walking. It will be difficult, but it will help to decrease the post operative soreness.

    Recovery in the following days

    - The next day the radiologist will conduct a gastrograffin swallow test to make sure there are no leaks in the GIT (gastro intestinal tract) and then give a green signal. You can finally consume fluids!

  • Diet:

    For the first week you will need to stay on a liquid or soft diet. You can have broths, soups, mashed food. Slowly you can progress to complex foods. Avoid carbonated drinks such as soda. You would’nt want any extra gas entering your stomach. Don’t use straws either. The structure of your diet now changes to a low calorie (500 Kcal everyday), high protein 70gm/day), low fat (30g/day) and a low carbohydrate (40gm/day) one. You should have small meals everyday, instead of the usual 2-3 large meals. Chew food slowly. If you consume alcohol, avoid it in the initial days after surgery, since alcohol gets quickly absorbed in the body. Eat a lot of fibre to deal with the initial phase of irregular bowel movements that follows surgery. Return to your normal diet slowly and steadily. There is no rush.

  • Medication:

    Your doctor will give proper instructions about how and when should you take your medicines. If you are on blood thinners, aspirin, start taking them again only after you are given the go-ahead. Try not taking two medications at the same time. Follow your prescriptions exactly as directed. Complete the full course, do not leave it midway.

  • Activity and Exercise:

    It is advised not to take a bath for the first few days, or until the doctor tells you so. Take lots of rest as it will help you recover faster. Little by little, start doing something. Try walking, gradually increasing your capacity. It will help against constipation. Do not lift heavy loads and avoid any strenous physical activity. Resume aerobic exercise only when the doctor tells you so. Keep a pillow handy whenever you feel like coughing. This will avoid any undue strain on the stomach incisions.

  • Incisions:

    The incisions will be bandaged with a tape which will come off by itself a week after the surgery. Then keep the area clean by washing with water and mild soap and patting it dry.

Your quality of life will improve drastically, but the results should be maintained with a strict healthy diet and regular exercise

What to expect after sleeve gastrectomy?

In the long run, you will feel more energetic and the problems related to obesity will gradually disappear. You should be able to perform routine activities without much difficulty. Patients have experienced improvements in the conditions of morbidity (type II diabetes mellitus, high blood pressure, obstructive sleep apnea). Since the weight loss is quick, the overlying skin may sag a little. Do discuss this with your cosmetic surgeon for other treatment options.

Follow up-

Regualr visits to the doctor ensure that the healing is going well and monitoring of the diet and exercise regimen becomes easy.

However, if you find any of the following happening, contact your doctor as soon as possible -
  • Pain is increased
  • Swelling
  • Trouble passing urine or stool
  • Signs of formation of blood clots inside the body such as pain in calf, legs, near the groin, thighs.
  • Fever, swollen lymph nodes
  • Opening of incisions

Risks and Complications

Though a rare occurrence, some problems may arise – Bowel obstruction

  • Allergic reaction to drugs
  • Internal bleeding
  • Damage to important structures such as spleen, vagus nerve, etc.
  • Skin wound infection
  • Weight gain and no constructive weight loss
  • Metabolic deficiency
  • Anemia
  • Perforation of stomach causing buildup of pus in the body.
  • Nausea, vomiting
  • Low blood pressure
  • Specific organ system complications- myocardial infarction (heart attack), liver failure, stroke, hepatitis, kidney failure.

Any kind of bariatric surgery is a life-changing experience. It completely changes the way how we look after and care for our bodies. Indeed, it is a very quick way to lose weight, but it is possible to maintain its results only with a disciplined way of living, with lots of healthy food and exercise. As it is said, "the journey of a thousand miles begins with a single step.”