Sleeve Gastrectomy: Exposure of the Left Pillar

Sleeve gastrectomy IS a bariatric surgery procedure approved by the French National Health Authority. Several techniques have been described. This surgery is not as straightforward as one might think, and requires meticulous dissection and a number of operation principles. The aim of this article is to describe the tip and trick for the exposure of the left pillar. Exposure of the left pillar is the key point in the sleeve gastrectomy. It is essential not only to visualize the left pillar but also to release the upper part of the posterior aspect of the fundus from the pillar.1 This part of the fundus lies beneath the peritoneum and is fixed to the left pillar by the gastrophrenic ligament. The pillar may be approached anteriorly (before dissecting Belsey’s fat pad) or posteriorly (the liver retractor is then used to raise the stomach), or a mixed approach may be used.2 Surgeons should be able to use either one or other or even both procedures, depending on the difficulty of surgery. The upper part of the fundus is released posteriorly by gentle up and down and left to right sweeping movements in contact with the pillar, to detach the upper posterior aspect of the fundus from the pillar. This release requires vessels in the region of the cardia to be divided (a procedure causing ischemia?).3 If it is not sufficiently released, a superior gastric pouch will be left which may dilate over time. It is important during the posterior dissection to take care not to divide the left gastric artery, which may look like a posterior gastric vessel. A 30-degree light beam (laparoscope) makes dissection more straightforward.1 The correct procedure for the final stapling is to move the stomach which has already been divided upward and to rotate the stapler to the left to clearly see and apply tension to the posterior aspect of the fundus. Point of Controversy