**3.2 Preoperative workup**

It is essential to evaluate the pre-LSG weight and how much weight was lost during the patient's interview. Evaluating a patient's perspective about the reasons for bariatric surgery failure is crucial. If bad dietary habits were the main reason, consulting a dietician for education will help lose weight and maintain the loss after revisional surgery.

#### **Figure 7.** *Suggested pathway decision for sleeve gastrectomy revision.*

All patients should undergo an upper GI contrast study to evaluate the status of the sleeve, if dilatation is present, remnant fundus or if there is a twist. Reflux symptoms (heartburn, frequent cough/choking, and using proton pump inhibitors) will require EGD. If there is a consequence of the reflux in the form of esophagitis, then offering RYGB is a safe option. In case of hiatal hernia discovery that can explain the reflux, OAGB can be offered but with a risk of reflux up to 30% in the postoperative period. If the patient is eligible for OAGB, it is essential to mention that reflux can occur after OAGB that can be controlled by avoiding reflux aggravators (large meals, spicy foods, and lying down after meals) and healthy eating habits. In case of biliary reflux, the safest option is RYGB. **Figure 5** provides a suggested management plan for the revision of LSG.

#### **3.3 The operation**

Preoperative preparations are followed similar to the previous section. After safe entry to the abdomen, we start counting the bowel, first starting from the duodenojejunal junction. If the patient's BMI is less than 40 kg/m<sup>2</sup> , 150 cm of the bowel is bypassed. If the BMI is more than 40 kg/m2 , 180 cm of the bowel is bypassed. That point is labeled with clips. Adhesions are released from the area of previous stapling till the GEJ. The assessment for any hiatal hernia is critical. Repair of hiatal hernia is accomplished by anterior and posterior nonabsorbable monofilament sutures. At the incisura and below the crow's feet, we recommend the horizontal transection of the stomach with the highest stapling available (i.e., black reload) (**Figure 8**). A 36F bougie is introduced, and the pouch should be resized when applicable, avoiding narrowing the lumen (**Figure 9**). In preparation for the anastomosis, an enterotomy and gastrotomy are made. The gastrotomy should be made at the posterior aspect of the stomach to prevent bile reflux (**Figure 10**). An ante-colic gastrojejunostomy is constructed by a stapler fired at the 3 cm point joining the two lumens, then closing the defect with a 3-0 continuous absorbable suture in a double layer fashion (**Figure 11**). We highly recommend fixing the gastric pouch by omentopexy. Alignment stitches should be utilized to align and fix the anastomosis to prevent any kink or twist.

**Figure 8.** *Horizontal division of the sleeved stomach.*

**Figure 9.** *Resizing the gastric pouch under the guidance of 36Fr bougie.*

**Figure 10.** *A gastrotomy is made at the posterior aspect of the gastric pouch.*

If the decision is to convert to RYGB, we highly recommend counting the whole bowel first. After forming the gastric pouch, a 120 cm alimentary limb is anastomosed to the pouch with a gastrojejunostomy technique similar to what was mentioned previously. A side-to-side jejunojejunostomy is made with 80–100 cm biliopancreatic limb. It is vital to allow an adequate common channel length to lower the risk of malabsorption. All mesenteric defects must be closed to prevent internal hernias. In case of a twist or stricture, and the decision to go for a bypass, it is important to make the GJ anastomosis above the stricture because the blood supply to that segment might be insufficient, which might threaten the anastomosis viability (**Figures 12** and **13**).

**Figure 11.** *A gastrojejunostomy is constructed at the 30 mm mark using a 60 mm stapler.*

**Figure 12.** *Twist of the stomach after sleeve gastrectomy.*
