The Nissen Sleeve Gastrectomy: Technical Considerations.

Background: Laparoscopic sleeve gastrectomy (LSG) is currently the most performed bariatric procedure worldwide. We have developed a modification to the usual surgical technique of LSG by adding a Nissen fundoplication. Objectives: Provide the technical details of this new bariatric procedure. Materials and Methods: The first step of the N-sleeve technique involves dissection and reduction within the abdominal cavity of a possible hiatal hernia and closure of the hiatal orifice. A short 3 cm Nissen valve is created to maintain a gastric fundus as small and functional as possible. After that, the stapling process begins and continues in a standard pattern until the level of the previously created valve. Stapling the stomach around the valve must maintain its natural position and preserve vascularization. Results: The following are the five major technical tips: avoid thermic injuries of the gastric wall during short gastric vessel dissection; gently handle the gastric fundus during fundoplication; take the anterior and superior part of the fundus to create the wrap 4 cm from the His angle to avoid a wrong pathway for the food (the food should not go through the wrap); check the good pathway for the food at the end of the operation with the tube by moving it through the esophagogastric junction. Conclusion: N-sleeve is a new procedure, technically more challenging than standard LSG, but in our experience, it seems to show similar outcomes in terms of weight loss, effects on comorbidities, and lower rate of leak and gastroesophageal reflux disease.