Since laparoscopic SG and bypass surgery are commonly performed types of bariatric surgery, different techniques reduce staple line-related complications such as SLB and leakage. However, there is no consensus regarding the best technique. Several systematic reviews of staple line leakage after SG, comparing different reinforcement techniques, found a similar result. The leakage rate was significantly lower when using the absorbable polymer membrane (APM) staple line reinforcement than oversewing, fibrin sealant, bovine pericardial strips (BPS), and no reinforcement[10, 11]. However, using the APM, BPS, or other expensive commercial products may be a financial burden for patients .
As for SLB control, monopolar cautery is not always recommended because it may weaken the staple line, although it is a simple and rapid method for reaching hemostasis. However, Gundogan et al. recently investigated the efficacy of monopolar cautery versus clips for SLB control in RYGB . Sağlam et al. used only monopolar cautery for SLB control in 187 patients undergoing SG . Both studies found monopolar cautery to be a safe, effective, and inexpensive approach for SLB control. However, they did not describe the number and duration of attempts while using monopolar cautery; this technique might be difficult to apply in clinics. In this study, the controlled monopolar cautery was defined precisely in terms of duration and frequency. Postoperative outcomes revealed no intraabdominal or gastrointestinal bleeding. The only staple line leakage was over the EGJ, and this was considered a thermal injury due to the LigaSure during a concomitant hiatal hernia repair.
Postoperative gastric stricture is a rare but serious complication following bariatric surgery. The routine complete oversewing of the staple line may prevent SLB, but this is time-consuming and must be performed by experienced surgeons to avoid gastric stricture . A study conducted by Fort et al. compared complete and partial oversewing of the staple line . They found that operative time was significantly longer, and the need for revision surgery was significantly higher in the complete oversewing group. In this study, we only performed complete oversewing in patients with more than six bleeding sites of the staple line. Partial oversewing was applied to the bleeding site in patients with failed hemostasis by monopolar cautery. In our opinion, partial oversewing may help overcome the shortcomings of complete oversewing and achieve satisfactory hemostasis. We noted a case of gastric stricture after SG in our study, but oversewing was not performed in this case. Upon reviewing the surgical video of this patient, the stricture appeared to be due to excessive traction of the stomach during gastric stapling.
In conclusion, SLB is a crucial issue in laparoscopic bariatric surgery, involving gastric stapling procedure. There are various SLB control methods. In this study, we found controlled monopolar cautery to be a safe, effective, and easy method to achieve hemostasis in cases of SLB. In cases when this technique failed, partial oversewing was applied to overcome the shortcomings of complete oversewing and achieve satisfactory hemostasis. Therefore, our proposed strategy of controlled monopolar cautery with/without oversewing can be a feasible option for SLB control.