Obesity is a global health concern associated with significant morbidity and mortality, contributing to diabetes, hypertension, cardiovascular disease, sleep apnea, and joint problems. Bariatric surgery has emerged as the most effective treatment for morbid obesity, providing sustainable weight loss and improvement in obesity-related comorbidities. Among bariatric procedures, Laparoscopic Sleeve Gastrectomy (LSG) has gained worldwide popularity due to its simplicity, efficacy, and favorable safety profile.

Dr. R. K. Mishra, a pioneer in minimally invasive and bariatric surgery, has produced a detailed step-by-step instructional video demonstrating LSG, making it an invaluable resource for surgeons and trainees.

Indications for Laparoscopic Sleeve Gastrectomy

LSG is indicated in patients with:

Morbid obesity: Body Mass Index (BMI) ≥ 40 kg/m²

Severe obesity with comorbidities: BMI ≥ 35 kg/m² with conditions like type 2 diabetes, hypertension, or sleep apnea

Failed previous conservative measures such as diet, exercise, or pharmacotherapy

As the first stage in two-stage bariatric procedures for extremely high-risk patients

LSG is also preferred for patients who require restrictive procedures without significant malabsorption and for those seeking minimally invasive treatment with low complication rates.

Preoperative Preparation

Dr. R. K. Mishra emphasizes that preoperative preparation is critical for surgical safety and optimal outcomes:

Medical Evaluation – Comprehensive assessment including cardiac, pulmonary, hepatic, and renal function.

Nutritional Counseling – Preoperative diet to reduce liver size, improve surgical access, and optimize nutrition.

Psychological Assessment – Screening for eating disorders, depression, and unrealistic expectations.

Imaging – Abdominal ultrasound or CT scan to evaluate liver size and gastric anatomy.

Anesthesia Planning – General anesthesia with endotracheal intubation is required.

Step-by-Step Surgical Technique
Patient Positioning and Port Placement

The patient is placed in supine reverse Trendelenburg position to allow gravitational retraction of the intestines.

Typically, five laparoscopic ports are inserted:

One 12 mm camera port near the umbilicus

Four working ports for the surgeon’s instruments and assistant manipulation

Inspection of Abdominal Cavity

A laparoscope is introduced to inspect the liver, stomach, and adjacent organs.

Any adhesions are lysed to create a safe working space.

Liver Retraction

The left lobe of the liver is retracted using a liver retractor to expose the gastroesophageal junction and upper stomach.

Mobilization of Greater Curvature

The greater curvature of the stomach is dissected from the omentum and short gastric vessels using energy devices.

Dissection extends from the antrum to the fundus, ensuring complete mobilization.

Gastric Calibration and Sleeve Creation

A bougie (usually 36–40 Fr) is inserted along the lesser curvature to guide sleeve formation.

Sequential stapler firings are used to divide the stomach vertically along the bougie, creating a tubular gastric sleeve.

Care is taken to avoid narrowing at the incisura angularis and preserve the gastroesophageal junction.

Reinforcement and Hemostasis

Staple line is inspected for bleeding or leaks.

Reinforcement techniques may include suture oversewing or buttressing to reduce postoperative bleeding and leak risk.

Leak Test

A meth blue or air leak test is performed by insufflating the stomach with methylene blue or air to ensure staple line integrity.

Sleeve Extraction and Closure

The excised gastric portion is removed via the port.

Ports are removed, and incisions closed with absorbable sutures.

Postoperative Care

Diet: Clear liquids are introduced gradually, advancing to soft foods over several weeks.

Pain Management: Usually mild, controlled with oral analgesics.

Early Ambulation: Encouraged to reduce risk of deep vein thrombosis.

Follow-Up: Regular monitoring for nutritional deficiencies, weight loss progress, and management of comorbidities.

Outcomes

Dr. Mishra’s videos highlight that LSG offers:

Significant weight loss: Average excess weight loss of 60–70% within one year.

Improvement of comorbidities: Especially type 2 diabetes, hypertension, and sleep apnea.

Minimally invasive benefits: Reduced pain, short hospital stay, and faster return to normal activity.

Low complication rates: Staple line leaks are rare with careful technique.

Conclusion

Laparoscopic Sleeve Gastrectomy is a highly effective bariatric procedure for managing morbid obesity and related comorbidities. Dr. R. K. Mishra’s step-by-step video serves as a comprehensive guide for surgeons, illustrating meticulous surgical planning, safe dissection, precise sleeve creation, and postoperative care. Mastery of these steps ensures optimal outcomes, minimal complications, and improved patient quality of life, reinforcing the pivotal role of minimally invasive bariatric surgery in modern medicine.