A Delphi consensus on the surgical technique of laparoscopic sleeve gastrectomy: An obesity and metabolic surgery society of India initiative

Introduction: Laparoscopic sleeve gastrectomy (LSG) is the commonest bariatric operation being performed in India and worldwide. There are many technical variations that are being practiced. This Delphi consensus was an Obesity and Metabolic Surgery Society of India (OSSI) initiative to standardize the surgical technique of LSG. Methods: Twenty bariatric surgeons were selected as experts based on their years of experience in LSG, overall patient volumes, publications, and the recommendations of the executive committee of OSSI, to vote on 26 statements regarding the surgical steps of LSG. The minimum cutoff for consensus was taken as 70%. Results: The committee achieved a consensus on 19 out of 26 statements in the first round. One question was sent for reconsideration and 3 were resent after modification. Finally, consensus was reached on 22 statements. The consensus was reached regarding the use of preoperative upper gastrointestinal endoscopy. 85.7% agreed on an antral length of 3–5 cm. 85.7% were in favor of dissecting the left crus of the diaphragm completely and 100% agreed on Roux-en y gastric bypass to be the procedure of choice in the presence of medically refractory gastroesophageal reflux disease with hiatus hernia. Most experts agreed that a calibration tube must be used during LSG and the recommended size was between 36 and 40 Fr. Ninety-five percent agreed that care must be taken to avoid narrowing at the incisura and also to stay away from the angle of His. 71.4% did not recommend any kind of staple line reinforcement and 71.4% recommended a postoperative leak test. Conclusion: This Delphi consensus is a step toward improving the quality of surgical outcomes of LSG in India. This document has attempted to establish technical specifications of performing LSG. This will in turn help to maximize the reliability, standardization, and safety of the procedure until more robust studies are published.