Laparoscopic Sleeve Gastrectomy in Lucknow

Overview of Laparoscopic Sleeve Gastrectomy

Laparoscopic sleeve gastrectomy (LSG) is a bariatric procedure in which approximately 75–80% of the stomach is removed along the greater curvature, leaving a vertical tubular sleeve of stomach approximately the size and shape of a banana. The operation is performed laparoscopically through 4–5 small port incisions and typically takes 60–90 minutes.

Since approximately 2014, LSG has been the most commonly performed bariatric operation worldwide, overtaking Roux-en-Y gastric bypass — driven by its technical simplicity, strong weight loss outcomes, low rate of long-term nutritional complications and good acceptability to patients. It is endorsed as a standalone primary bariatric procedure by the International Federation for the Surgery of Obesity (IFSO), the American Society for Metabolic and Bariatric Surgery (ASMBS) and the Obesity and Metabolic Surgery Society of India (OSSI).

How Sleeve Gastrectomy Works

Sleeve gastrectomy produces durable weight loss through three concurrent mechanisms:

• Restriction: the much smaller residual stomach volume (typically 100–150 mL vs the normal 1500 mL) restricts the volume of food that can be eaten at a sitting.
• Reduction in ghrelin: the gastric fundus, which is removed during the operation, is the principal site of ghrelin secretion. Ghrelin is a hormone that drives hunger; its reduction after sleeve produces a sustained decrease in appetite, particularly in the first 12–18 months.
• Altered gut hormone signalling and accelerated gastric emptying: changes in GLP-1, PYY and other hormones improve satiety and have direct metabolic effects that benefit type 2 diabetes and other obesity-related disease.

Who Is Suitable for Sleeve Gastrectomy?

Indian eligibility thresholds, per IFSO-APC and OSSI:

• BMI ≥ 37.5 kg/m² without comorbidity
• BMI ≥ 32.5 kg/m² with at least one significant comorbidity (T2DM, hypertension, OSA, NASH, dyslipidaemia, severe joint disease)
• BMI ≥ 27.5 kg/m² with poorly controlled type 2 diabetes — metabolic surgery indication

Patients with significant pre-operative GERD, large symptomatic hiatal hernia, or Barrett's oesophagus are usually counselled towards Roux-en-Y gastric bypass instead.

Sleeve vs Gastric Bypass — Choosing Between Them

Both are excellent bariatric procedures, each with strengths:

Sleeve gastrectomy is generally favoured for:

• Younger patients with primary obesity and no significant reflux
• Patients preferring a technically simpler, lower-risk first operation
• Patients with iron-deficiency anaemia or malabsorptive concerns
• Patients with active inflammatory bowel disease
• Patients on chronic NSAIDs (less risk of marginal ulcer than bypass)

Gastric bypass is generally favoured for:

• Significant pre-operative GERD or large hiatal hernia
• Long-standing type 2 diabetes — stronger metabolic effect
• Very high BMI (≥50) — better long-term weight loss
• Severe NASH or fatty liver — somewhat stronger metabolic effect

The decision is made together with the patient after multidisciplinary review.

Pre-operative Work-up

• Multidisciplinary evaluation — bariatric surgeon, dietitian, endocrinologist, psychologist, anaesthetist
• Routine blood investigations including HbA1c, lipid profile, liver function, vitamin B12, vitamin D, iron studies, electrolytes
• Upper GI endoscopy to assess for hiatal hernia, GERD, H. pylori and ulcer disease
• Ultrasound (gallstone screening) and abdominal evaluation
• Cardiac evaluation (ECG, echocardiogram as indicated)
• Pulmonary evaluation, polysomnography if OSA suspected
• Psychological and behavioural assessment
• Pre-operative low-calorie / very-low-calorie diet for 2–4 weeks to reduce liver size and ease surgical exposure

Surgical Technique

1. General anaesthesia. Patient positioned supine or in the French (split-leg) position with reverse Trendelenburg.
2. 4–5 laparoscopic port incisions of 5–12 mm.
3. The greater omentum is detached from the greater curvature of the stomach using an energy device, working from approximately 4–6 cm proximal to the pylorus up to the angle of His.
4. A calibration bougie (typically 36–40 Fr) is passed orally and positioned along the lesser curvature to standardise sleeve diameter and avoid stenosis.
5. The stomach is sequentially stapled with linear endoscopic staplers parallel to the bougie, beginning from a point 4–6 cm proximal to the pylorus and continuing up to the angle of His.
6. The resected greater curvature stomach is removed through a port site.
7. Staple-line reinforcement and methylene blue/air leak test are performed where indicated.
8. Drain placement is selective.
9. Ports are closed and skin sutured.

Hiatal hernia repair (cruroplasty) is performed at the same operation if a hiatal hernia is identified, per IFSO recommendations.

Recovery & Staged Diet

Hospital course:

• Day 0: clear liquids 6 hours after surgery, mobilisation, DVT prophylaxis
• Day 1: full liquids, mobilisation, drain removal if placed
• Day 2–3: discharge home on PPI, multivitamins, analgesia

Staged dietary progression (under dietitian supervision):

• Weeks 1–2: clear and full liquids
• Weeks 3–4: puréed foods (high-protein)
• Weeks 5–6: soft foods
• Week 7 onwards: gradual return to regular textures

Return to desk-based work in 1–2 weeks. Full physical activity at 4–6 weeks. Multivitamin and calcium supplementation begin from day 1 and continue lifelong.

Expected Weight Loss

Typical sleeve gastrectomy outcomes reported by international bariatric registries (IFSO, ASMBS BSAQIP):

• 60–70% excess weight loss at 1–2 years
• 50–60% excess weight loss at 5 years
• Some weight regain (5–10%) after year 2 is common; addressed through structured follow-up

Results depend strongly on adherence to diet, exercise, follow-up and behavioural support.

Comorbidity Outcomes

• Type 2 diabetes: substantial improvement or remission in a large proportion of patients
• Hypertension: improvement or resolution in many patients
• OSA: improvement in CPAP requirements in most
• NASH / fatty liver: meaningful improvement in steatosis, inflammation, fibrosis
• Dyslipidaemia, PCOS, joint pain, mobility, quality of life: consistently improve

Long-term Follow-up

• Reviews at 1, 3, 6, 12 months and annually thereafter
• Lifelong multivitamin, calcium, vitamin D supplementation
• Annual blood tests — iron, vitamin B12, vitamin D, calcium, folate, protein
• Dietary review with the bariatric dietitian
• PPI continuation as indicated
• Behavioural support as needed

Risks & Complications

• 30-day mortality: under 0.3% in experienced laparoscopic bariatric centres
• Staple-line bleed: 1–2%; usually self-limiting
• Staple-line leak: under 1–2%; the most feared complication. Managed by endoscopic stenting, drainage and selective surgical revision.
• DVT / PE: mitigated by chemical and mechanical prophylaxis
• Sleeve stenosis or stricture: uncommon; managed by endoscopic dilation or revision
• New-onset or worsened GERD: 15–25% in long-term follow-up; mostly medication-controlled; revision rarely needed
• Long-term nutritional deficiencies: iron, vitamin B12, vitamin D — mitigated by lifelong supplementation
• Weight regain: possible after year 2; addressed through structured follow-up and behavioural support

Why Choose Dr A K Bansal for Sleeve Gastrectomy

Dr A K Bansal trained in surgical gastroenterology at SGPGI Lucknow with All India Rank 1 in the M.Ch entrance examination. He is Ex Senior Consultant in the Department of Gastrosciences at Medanta Hospital and currently heads the Department of GI Surgery at Myra City Hospital. His bariatric practice covers sleeve gastrectomy, Roux-en-Y gastric bypass and OAGB-MGB, with structured multidisciplinary care.

• Multidisciplinary pre-operative evaluation including dietitian, endocrinologist, psychologist
• Standardised technique with calibration bougie and intra-operative leak testing
• Hiatal hernia repair at the same operation where indicated
• Structured staged dietary progression under bariatric dietitian guidance
• Lifelong nutritional monitoring and follow-up

Frequently Asked Questions