Assessing variation in technique for sleeve gastrectomy based on outcomes of surgeons ranked by safety and efficacy: a video-based study

Surg Endosc. 2019 Mar;33(3):895-903. doi: 10.1007/s00464-018-6382-y. Epub 2018 Aug 15.


Background: Considerable technical variation exists when performing laparoscopic sleeve gastrectomy (LSG). However, little is known about which techniques are associated with optimal outcomes.

Objective: To compare technical variation among surgeons with the lowest complication rates and whose patients achieved the most weight loss.

Methods: Practicing bariatric surgeons (n = 30) voluntarily submitted a video of a typical LSG performed between 2015 and 2016. Technique-specific data captured from videos and a questionnaire included bougie size, stapler vendor, number of staple loads, use of staple line reinforcement, fibrin sealant, intraoperative leak test, endoscopy, and drain placement. Surgeon-specific outcomes were obtained from cases performed by surgeons during the study period (n = 7023) using a state-wide bariatric-specific data registry. Surgeons were ranked based on 30-day risk-adjusted surgical complication rates ("safety") and excess body weight loss (EBWL) % ("efficacy") at 1 year after surgery. Technique-specific variables were compared between surgeons ranked in the top and bottom quartile for both safety and efficacy.

Results: Surgical complication rates ranged from 0 to 4.32% while EBWL varied from 45.3 to 65.3%. There was no correlation between surgeon rankings for safety and efficacy (Pearson's r = 0.063, p = 0.741). Surgeons ranked in the top quartile for safety and efficacy had significantly shorter mean operative times than surgeons ranked in the bottom quartile (65 min vs. 69 min, p < 0.0001). Surgeons with the highest leak rates were more likely to use buttressing (85.7% vs 40.0%, p = 0.032), otherwise operative techniques varied considerably.

Conclusions: Technical variation appears to have minimal effect on the safety or efficacy of sleeve gastrectomy among surgeons participating in a state-wide quality improvement collaborative. Top ranked surgeons did have faster mean operative times indicating that there may be other metrics of technical quality that correlate to optimal outcomes.

Keywords: Bariatric surgery; Complications; Outcomes; Sleeve gastrectomy; Technique; Video assessment.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Attitude of Health Personnel
  • Bariatric Surgery / standards*
  • Comparative Effectiveness Research
  • Female
  • Gastrectomy* / adverse effects
  • Gastrectomy* / methods
  • Gastrectomy* / standards
  • Humans
  • Laparoscopy* / adverse effects
  • Laparoscopy* / methods
  • Laparoscopy* / standards
  • Male
  • Middle Aged
  • Obesity, Morbid / surgery*
  • Outcome Assessment, Health Care* / methods
  • Outcome Assessment, Health Care* / statistics & numerical data
  • Postoperative Complications / epidemiology*
  • Quality Improvement
  • Surgeons
  • Video Recording / methods