An Anatomical Point to Start Transection in Laparoscopic Sleeve Gastrectomy

Introduction: Laparoscopic Sleeve Gastrectomy (LSG) has become a preferred primary bariatric surgical approach. However, some technical aspects still lack standardization, including the distance from the pylorus at which the resection should start. The goal of this study was to identify an anatomical landmark to aid surgeons in identifying a reference point. Materials and methods: Patients undergoing bariatric surgery were enrolled prospectively. Inclusion criteria were age over 18, BMI > 35 kg/m2, and the absence of any prior upper abdominal surgery. After liver retraction, an imaginary line was drawn from the right side of the esophagus through the incisura angularis to the greater curvature, and the distance from this point to the pylorus was recorded. The measure and its correlations with gender, BMI and height were analyzed. Results: Out of 129 patients, 101 (78.3%) were female. Mean BMI was 45.4 kg/m2. The average distance measured was 6.95 cm (5-9, SD=0.75). There was no correlation between this distance and either BMI (r=0.06) or height (r=0.2). There was a 0.4 cm difference between men and women (7.3 vs. 6.9 cm), p=0.03. In 93.8% of the cases, the distance was between 6 and 8 cm. Conclusion: A line starting on the right side of the esophagus through the incisura angularis to the intersection with the greater curvature establishes a point that can be used reliably as a reference to start transection for LSG. It also may be useful when the pylorus is difficult to visualize, as in patients who are super obese or have adhesions.