Laparoscopic Sleeve Gastrectomy
Patient phenotype
BMI ≥ 40 (or ≥ 35 with comorbidity). Often: T2DM, OSA (frequently undiagnosed), HTN, hypercholesterolemia, GERD, hypothyroidism. Age 30-60 typical.
Procedure
Laparoscopic creation of a vertical 'sleeve' stomach by stapling along a bougie. Reverse Trendelenburg, CO₂ insufflation. Outpatient or 1-night stay common. Surgical time 60-90 min.
Anesthetic plan
GETA, ramped position for intubation, RSI vs modified RSI based on GERD severity. Multimodal opioid-sparing analgesia. TAP block or surgeon-injected local. Aggressive PONV prophylaxis. Aim to extubate awake.
Setup
- ·Ramp positioning device (HELP pillow or stacked blankets — meatus aligned with sternal notch)
- ·Bariatric BP cuff
- ·Two PIVs (one with adequate access for the BMI)
- ·OG tube to decompress + place over bougie (surgeon directs)
- ·Forced air warmer
- ·Foley if anticipated > 90 min
- ·BIS for accurate depth in obesity (drug PK altered)
Biggest concerns by phase
OSA — STOP-BANG screen, plan for postop
STOP-BANG ≥ 5 = high risk for OSA. CPAP at home? Bring it for postop. Plan: minimal sedation premed, opioid-sparing technique, postop monitored bed if home CPAP not strict, multimodal pain.
Difficult airway anticipated — ramp + video laryngoscope
Obese patients desat fast (FRC dramatically reduced). Pre-oxygenate to ETO₂ > 90% with HOB 25°. Ramped position aligns ear-meatus with sternal notch. Video laryngoscope first attempt. RSI if GERD; modified RSI otherwise. Backup LMA + plan for fiberoptic.
Ventilation strategy — protective + recruitment
TV 6-8 mL/kg ideal body weight (NOT total). PEEP 8-12. Recruitment maneuvers q15-30 min. FiO₂ 0.4-0.6 sufficient. Reverse Trendelenburg + insufflation = tough ventilation; may need pressure-control mode.
Drug dosing — TBW vs. IBW vs. LBW matters
Lipophilic drugs (propofol induction, fentanyl, midazolam): use LBW. Hydrophilic (sux, NMBs): TBW. Maintenance propofol: LBW. NSAIDs and acetaminophen: standard. Calculate before induction.
PONV — extremely high risk, multimodal prophylaxis
Female + non-smoker + abdominal surgery + opioid use = Apfel 4. Combine: dex 8 mg + ondansetron 4 mg + scopolamine patch + TIVA propofol-based maintenance + NK1 antagonist (aprepitant) if available.
Postop airway + pulmonary complication watch
Highest risk of post-extubation airway obstruction in OSA bariatric patients. Sit up 30°+, CPAP if home user, avoid lingering opioid, naloxone at bedside. Keep monitored at least overnight if any concern.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
Your sleeve gastrectomy patient: BMI 52, STOP-BANG 7, GERD on omeprazole, neck circumference 18 inches. You're about to induce. Walk me through your airway plan.
What an examiner probes for
- ▹Pre-O₂ to ETO₂ > 90% with HOB up + apneic O₂ via nasal cannula
- ▹Ramp position — meatus to sternal notch alignment
- ▹Video laryngoscope first attempt
- ▹RSI with cricoid + sux 1.5 mg/kg vs. roc 1.2 mg/kg
- ▹Backup: LMA, fiberoptic, surgical airway plan
Sources
- SAGES bariatric guidelines
- Miller's Ch 71
- ASA Practice Advisory: OSA
Anatomy reference
Sourced reference images. 4 matches for "stomach digestive abdominal".
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