*3.1.7 Bleeding control and staple line reinforcement*

Staple line bleeding (SLB) is a common intraoperative complication following resection in LSG [16]. A hemostatic clip (10 mm) is a quick and simple tool for controlling bleeding, particularly oozing. Clips are also used at stapler transition points as they are considered potentially vulnerable areas, though this has not been proven.

#### **Figure 10.**

*(a, b) (a) shows a straight and smooth staple line that should be aimed. The false stapling technique results in an irregular staple line that is prone to complications (b).*

*Laparoscopic Sleeve Gastrectomy – Technical Tips and Pitfalls DOI: http://dx.doi.org/10.5772/intechopen.108997*

Staple line reinforcement is a controversial step of the procedure. Although it has not been demonstrated that routine reinforcement of the staple line is necessary, we usually reinforce the staple line with sutures in our practice. During this process, we prefer to sew the dissected omentum majus line to the stapler line. With this reinforcement, we hope to reduce complications including leakage and stenosis (due to the formation of a twist or kink) and most notably, bleeding. The decision to reinforce should be based on the stapler used and the patient's condition. According to recent studies on bariatric surgery, the following risk factors for postoperative bleeding are stated: male sex, >45 years of age, body mass index <40 kg/m2 , cardiovascular disease, and current procedure of LSG, bougie size, prior cardiac procedure, hypertension, renal insufficiency, therapeutic anticoagulation, diabetes, obstructive sleep apnea, and operative length [17, 18].

Perioperative control of blood pressure is another important measure to prevent bleeding. Because it is assumed that some of the bleeding is due to the sudden increase in blood pressure during the operation or in the post-anesthesia care unit [19] (**Figure 11**). It should be ensured that the blood pressure is kept below a certain level, especially from the firing stage to the early postoperative period. Karaman et al. found that keeping the systolic blood pressure below 120 mm Hg during surgery reduced staple line bleeding [9]. In our practice, we keep our systolic blood pressure target around 100–110 mm Hg throughout the surgery. Blood pressure control is achieved by titration of remifentanil infusion and, if necessary, glyceryl trinitrate infusion is started (**Figure 12**).

#### *3.1.8 Drain placement*

We routinely place a soft drain to take early measures for bleeding, but it is known that many surgeons have recently abandoned the use of drains (**Figure 13**).

#### *3.1.9 Resected stomach (specimen) extraction*

The specimen is extracted with jaws grasper through the-15 mm trocar incision under direct visualization.

**Pitfall:** Specimen removal can be quite difficult, especially in large stomachs, and will result in a rupture if the correct gentle maneuvers are not performed with patience.

**Tip:** To prevent this situation, the specimen should be removed by pulling the greater curvature, not the staple line, because the staple line is weaker (**Figure 14**).

#### **Figure 11.**

*a,b Clips to the staple line. A hemostatic clip is a straightforward tool for bleeding and also can be used at staple transition points for reinforcement.*

**Figure 12.** *Omentopexy and sewing.*

**Figure 13.** *Drain.*
