*3.1.6 Transection*

Transection of the stomach begins on the antrum 3–4 cm proximal to the pylorus with a black 60-mm-long cartridge with an articulating stapler. Transection of the

**Figure 8.** *Orogastric tube insertion (No excessive stretching of the stomach).*

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

stomach should begin no less than 3 cm proximal to the pylorus [7]. Then purple 60-mm-long cartridges are used for the remainder. The thickness of the stomach tissue becomes thinner from the antrum to the fundus. Therefore, surgeons choose the tallest cartridges (black, green) at the antrum level, and while going proximal in the stomach, shorter (purple, blue, and golden) cartridges are chosen. It is crucial to ensure adequate resection of the fundus. Approximately 75–80% of the stomach is resected.

**Tip**: The incisura angularis should not be narrowed during stapler placement, the stomach should be laid in its anatomical position with equal apposition of the anterior and posterior aspects of the sleeve, and the orogastric tube should not be approached with excessive traction. This technique creates a straight staple line resistant to strictures, kinks, twists, and leaks.

#### **Figure 9.**

*a-c Staplings (Surgeon avoids narrowing the incisura angularis during the first stapling as shown in (a) and makes control with a clamp to be sure during the second stapling in (b). Last staple that is not adjacent to the esophagus is shown in (c)).*

**Tip:** Gastric tissue thickens due to contractions in some cases, making transection difficult. In our experience, administering intravenous Hyoscine butylbromide (Scopolamine) before transection, which reduces contractions with its anticholinergic effect, may result in a straighter and smoother staple line in these patients. However, there are no clinical studies to back up this assertion (**Figure 9**).

**Pitfall**: The last fire has to be done 0.5–1 cm lateral to the His angle to avoid the risk of ischemia-related leak and fistulas (**Figure 10**).
