Comparison of Stapled and Hand-Sewn Sleeve Gastrectomy, Retrospective Study
Phase: NA
Conditions: Morbid Obesity
Sponsor: Inonu University

Comparison of Stapled and Hand-Sewn 
Sleeve Gastrectomy 
(NCT number has not been assigned yet) 
Document date: 26 May, 2019 
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Abstract 
Background: Sleeve gastrectomy is a stapler dependent bariatric procedure. A hand-sewn 
sleeve gastrectomy can be necessary under certain circumstances. Here, we aimed to compare 
the outcomes of hand-sewn and stapled sleeve gastrectomies for the first time. 
Materials and Methods: In the hand-sewn group, no staplers were used and after vertical re-
section of the stomach by energy devices, the remnant stomach was closed by two rows intra-
corporeal sutures. In the stapler group, sleeve gastrectomy was done in the usual way. 
Results: Total of 13 patients were compared (hand-sewn:6 and stapled:7). All the sleeve gas-
trectomies completed laparoscopically. The operating time was longer  200 (100-300) minutes 
vs. 135 (60-220)  minutes, p:0.07) and amount of bleeding was higher 105 (50-190) vs. 35 
(10-45) ml., p:0.004) in the hand-sewn group.  Leakage and gastrointestinal bleeding were 
seen in the hand-sewn group but no complications were found in the stapler group. No statis-
tically significant difference was found between metabolic outcomes of the two groups three 
years after the operation (p>0.05). Excess of body mass index loss (EBMIL) of hand-sewn 
group and stapler group following three years (52.9% and 60%, respectively) were similar.   
Conclusion: Laparoscopic hand-sewn sleeve gastrectomy can be an alternative procedure to 
stapled sleeve gastrectomy in certain circumstances. Longer procedure time and more blood 
loss were associated with hand-sewn sleeve gastrectomy.  
Keywords: morbid obesity, surgical stapling, suture techniques, natural orifice surgery, transo-
ral, mini-laparoscopy. 
Introduction 
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Nowadays, morbid obesity is a major health problem that we face in every age groups. In the 
treatment of morbid obesity, sleeve gastrectomy is applied more and more frequently. Howev-
er, sleeve gastrectomy is a stapler dependent operation and sleeve gastrectomy without the use 
of staplers was very limited in the literature [1]. Hand-sewn sleeve gastrectomy can rarely be 
necessary in some special conditions such as technical defects of the staplers, patients aller-
gies to titanium clips or sometimes when staplers were unusable [1]. As far as we know, there 
was no study that compare the results of stapled and hand-sewn sleeve gastrectomies so far. 
The purpose of this study was to compare the hand-sewn and stapled sleeve gastrectomies in a 
small case series. 
Materials and methods 
In June 2013, we launched a natural orifice surgery program including several procedures. In 
this context, we planned natural orifice (transoral) extraction of sleeve gastrectomy speci-
mens. Patients who were eligible and agree with participation to the hand-sewn sleeve gastec-
tomy combine with transoral specimen extraction study were accepted to two group. This 
study is conducted according to the STROCSS criteria. Total six morbidly obese patients 
(body mass index more than 40 kg/m2) who had undergone hand-sewn sleeve gastrectomy 
between the dates May-2014 and December 2014, were investigated retrospectively. In the 
same time period, seven another morbidly obese patients included in the control group were 
treated with stapled sleeve gastrectomies. Grouping was done by the acceptance of the pa-
tients. The hand-sewn sleeve gastrectomy group combined with natural orifice surgery. Pa-
tients who do not participate the hand-sewn group were treated by the stapled sleeve gastrec-
tomy and the specimens were extracted through the trocar site. In both groups, patients' age, 
gender, height, weight, body mass index, comorbidity, and lifestyle properties were recorded. 
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Intraoperative blood loss, operating time, length of hospital stay, postoperative complications, 
and the metabolic/bariatric results of the two groups in one and three years were evaluated. 
Statistical comparisons were performed with nonparametric statistical tests (Mann-Whitney 
U-test and Wilcoxon Signed Rank Test to analyze numerical data, and Fisher exact test to ana-
lyze cathegorical data). Numerical data expressed as median and range. P<0.05 was consid-
ered as significant. 
Surgical Technique 
In the hand-sewn group, following pneumoperitoneum with a Veres needle, the first 5 mm 
trocar was entered 14 cm down and 4 cm left from the xyphoid process. Other two 5 mm tro-
cars were applied to the left and right upper quadrant. Last two 5 mm trocars were placed just 
below the xyphoid process for automatic liver retractor and through the epigastrium as a 
working port. A 5 mm 300  optic camera was used and the intraabdominal pressure was set to 
14 mmHg. Gastrocolic and gastrosplenic ligaments were divided by 5 mm Ligasure (Force 
Triad, Covidien, Boulder, CO, USA) starting from 4-6 cm to pylorus till the angle of His. The 
greater curvature was liberated up to the left crus of the diaphragm. The anterior and posterior 
wall of the stomach were transected with  a 5 mm Ligasure device under the guidance of a 36 
F bougie, starting 4-6 cm away from the pylorus and division of both gatric leaves headed 
vertically in the direction of angle of His. After completion of the gastric division, the resect-
ed specimen was removed through the mouth with the help of an intraoperative peroral en-
doscopy using an endoscopic snare. The remaining open anterior and posterior walls of the 
stomach was continiously sutured each other by 3/0 polypropylene sutures. The suture length 
was 20 cm. 
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All the trocars were 5 mm in size in the hand-sewn group. The surgical technique of the sta-
pled group has been defined in detail before (2). In short, vertical gastrectomy was applied 
with a 60 mm. lineer stapler (Endo GIATM Ultra, Covidien) under the guidance of  36 F 
bougie. These procedures were done through three 12 mm and two 5 mm trocars, that were 
placed to the same locations with the hand-sewn group. The specimen in the stapler group 
were extracted from the left upper quadrant trocar site. No supportive material or suture was 
use to the staple lines. Methylene blue test was done and a drain was place in all case. 
After 6-8 hours postoperatively, the patients were mobilized, thromboembolic stockings were 
kept for five days. A liquid diet was started on day one. Prophylaxis of deep vein thrombosis 
was continued for 15 days. 
Results 
There was no difference between the two groups in terms of demographic characteristics and 
concomitant diseases (Table 1). All the procedures were completed laparoscopically and no 
additioanl port placement was required. Duration of surgery for hand-sewn operations was 65 
minutes longer than stapled ones 200 (100-300) vs.135 (60-220), p=0.08). Total amount of 
bleeding was significantly higher in the hand-sewn group 105 (50-190) ml, 35 (10-45) ml, p: 
0.003). Intraoperative complications were seen in two of the hand-sewn cases. A mucosal in-
jury was observed in the esophagus during the sending of the 36 F bougie into the stomach. 
The intact esophagus wall was confirmed by intraoperative endoscopy and postoperative con-
trast radiography. No complication occurred in this case postoperatively. This complication 
was not related with the selected sleeve gastrectomy technique. On the other case, the remnant 
posterior gastric wall was narrower than the anterior wall. However, after suturing both walls 
of the stomach each other , no stenosis was seen. In the early postoperative period, there was 
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no complications in both groups and patients were discharged uneventfully. However, there 
were two re-admission and both were in the hand-sewn group. One was due to upper gastroin-
testinal bleeding and treated succesfully by conservative methods for five days. Another one 
had peritonitis findings 3 days after discharge. She required a laparotomy and a suture line 
leak was found out. Leak point was repaired by sutures again. Postoperative course was un-
eventful and she was discharged smootly without any other complications 13 days after sec-
ond hospitalization. There was no mortality in this study. 
The mean follow-up period was 39 (34-43) months in the stapler group. It was 34 (20-46) 
months in the hand-sewn group. Decrease in BMI at similar rates was observed in  3rd postop-
erative year (hand-sewn group: 34 (29-38) kg/m2 vs. stapled  group: 33 (30-34) kg/m2, 
p>0.05).  No significant difference were found between metabolic outcomes of the two 
groups three years after the operation. Excess of body mass index loss (EBMIL) of hand-sewn 
group and stapler group (52.9% and 60%, respectively) were similar on the 3rd follow-up year. 
In the hand-sewn group there was only one patient with glucose intolerance and her glucose 
intolerance was completely reliefed. In the stapled group, three patients were diabetic and one 
patient had glucose intolerance. Two of them completely stopped using oral antidiabetics, and 
one of them continued to use oral tablet at the same dose. Sleep apnea in both groups was re-
covered completely. Preoperative and postoperative levels of low density lipoprotein (LDL), 
high density lipoprotein (HDL), triglycerides, cholesterol, and HbA1c levels were similar in 
both groups (Table 2). 
Discussion 
The popularity of sleeve gastrectomy is increasing among the patients and the surgeons. The 
operation constitutes more than one third of bariatric processes now performed all over the 
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world and more than half in the United States [3]. Sleeve gastrectomy is a stapler dependent 
procedure like Roux-en-Y gastric bypass, biliopancreatic diversion and duodenal switch and 
very limited number of data is available in the literature for sleeve gastrectomy operations 
without use of staplers. Himpens et al. had reported two cases of the sleeve gastrectomies 
without using staplers, but they did not mention the details of these cases [4]. In case of tech-
nical problems of the staplers, sometimes, hand-sewn suturing can be inevitable during sleeve 
gastrectomies. For example, El Geidie et al. have indicated that stapler was locked in la-
pararoscopic sleeve gastrectomy after third firing of the stapler [5]. In such cases, hand-sewn 
surgery is inevitable. In 2013, Rezvani, et al. was described a robotic sleeve gastrectomy 
without staplers in a patient who was allergic to metallic materials. They concluded that hand-
sewn sleeve gastrectomy with the robot had an advantages in terms of suturation, but also 
stated that the cost has increased [6].  
Sleeve gastrectomy can be regarded as a restrictive process and the weight loss is compatible 
with the the volume of the stomach that is removed. Removal of the gastrectomy specimen by 
expansion of the entrance of trocar is a routine process. We were able to find only one study 
that remove sleeve gastrectomy specimen transorally. Gunkova et al. removed sleeve gastrec-
tomy specimen transorally in 21 patients with the aim of decreased risk of  wound related 
complications [7]. In our cases that we did not use staplers, opening of the stomach gave us 
the oppurtunity to extract the specimen through the esophagus and mouth by endoscopy. We 
did not need any extension of skin incision to remove the specimens and no complications 
were observed related with the oral specimen extraction. 
Laparoscopic hand-sewn sleeve gastrectomy is a challanging process that requires experience 
and patience. Despite the limited number of the patients, this first comperative study of both 
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hand-sewn and stapled sleeve gastrectomies demonstrated that hand-sewn technique is a fea-
sible surgical process and particularly can be an alternative procedure to the stapled sleeve 
gastrectomy in certain circumstances. Longer procedure time and more blood loss were asso-
ciated with hand-sewn sleeve gastrectomy.  
Disclosure Statement: Authors have no conflict of interest. 
Sources of funding: This research did not receive any specific grant from funding agencies in 
the public, commercial, or not-for-profit sectors. 
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