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Mortality during the first year after bariatric surgery is currently below 0.25%, compared to 3-4.5% two decades ago. Multiple factors, such as the laparoscopic approach, the specific training programs of the different scientific societies, and the advances in the perioperative management of these patients, seem to be involved in this significant improvement in results. In this talk, we will discuss the technical aspects to take into account to avoid intraoperative complications during the most frequently performed procedures in bariatric surgery: sleeve gastrectomy and gastric bypass.
Starting with the creation of pneumoperitoneum and trocar placement, you must aim to achieve optimal surgical field exposure, always avoiding inadvertent injuries to solid organ injuries, vascular structures, or the small bowel.
Regarding sleeve gastrectomy, it is important to avoid hemorrhagic complications by performing an adequate dissection of the greater curvature and a correct hemostasis. Optimal dissection of the hiatal region to avoid leaving a remnant fundus and dissection of adhesions in the posterior gastric aspect will allow for optimal gastric mobilization to achieve the desired shape of the sleeve when performing the vertical gastrectomy. To minimize the likelihood of staple line leaks it is important to select the adequate linear staplers to avoid tension, performing leak tests when deemed necessary. To avoid potential torsion of the sleeve, it is recommended to fix it to the omentum with stitches.
When performing a gastric bypass it is important to start by achieving an optimal dissection of the hiatal region to design the gastric pouch. There are different techniques to perform a gastrojejunal anastomosis (circular vs linear), and the different incidence rates of stenosis and leaks for each of them have to be taken into account. It is also important to close mesenteric defects to prevent future internal hernias.
