The vertical sleeve gastrectomy is an accepted primary or staged bariatric procedure with indications that follow current NIH guidelines. Body mass index (BMI) of greater than 40 kg/m², or greater than 35 kg/m² with significant comorbid conditions related to obesity, as well as, failure of conservative medical management needs to be documented. Other common requirements include medical, dietary, and psychological evaluations, and a history of past attempts at medical weight management. Informed consent should include a dietary and behavior modification educational program to ensure patients are aware of how the operation will impact their ability to eat and provide strategies for lifetime success. Sleeve gastrectomy may be chosen over other bariatric procedures for its minimal malabsorption due to normal gastrointestinal continuity, including access to the duodenum, its lower risk of marginal ulceration, and patient preference. Relative contraindications include severe gastroesophageal reflux disease.

As with all morbidly obese patients comorbidities should be evaluated and optimized before surgical intervention. This may include screening for and treating obstructive sleep apnea, an appropriate cardiac and pulmonary functional evaluation, airway evaluation, and optimizing glucose control in diabetics. It is suggested that these patients have an upper endoscopy to evaluate anatomy and diagnose functional or pathologic changes before resection. All patients receive preoperative antibiotics and prophylaxis for deep vein thrombosis (DVT) per institutional guidelines. In addition, there is some evidence that having patients on a “liver shrink” (low calorie, low fat) diet preoperatively can help make the operation technically easier by decreasing the volume of the liver and improving compliance of a thick abdominal wall.

The operation is performed with general endotracheal anesthesia. Difficulties are related to morbid obesity and may include a difficult airway, difficult venous access and challenges with monitoring, and positioning the patient due to their large body habitus. Communication with anesthesia is essential to the safe performance of this operation especially related to orogastric tube management, Bougie placement, fluid management, and medications to prevent postoperative nausea and emesis. Postextubation pathways should be in place related to obstructive sleep apnea (Continuous Positive Airway Pressure-CPAP and Bilevel Continuous Airway Pressure-BiPAP use) and pain management.

The operation is typically performed with the patient supine or in modified lithotomy with a split leg table (figure 1a). Morbidly obese patients should be secured well to the table to avoid movement when in steep reverse Trendelenburg, as well as, have pressure points well padded to avoid injury and risk of rhabdomyolysis. Knowledge of table capacities, foot rests, and table extenders are helpful and should be available in the operating room.