Obesity is a worldwide problem, and the most effective solution is bariatric surgery. LSG is the most frequently performed bariatric surgical procedure, at nearly 61% of all bariatric surgery in the USA [1, 2, 4].

Almost all the steps of sleeve gastrectomy are standardized, and LSG is performed by each surgeon in the same manner, but there is currently no consensus on the best methods for reinforcing the sleeve line to decrease bleeding and leakage rates. Some surgeons do not use any reinforcement method, but most surgeons opt for one of several methods that include imbrication with suture, oversewing with suture, using bovine pericardium, and using an absorbable membrane. Due to the ease of the procedure, omentopexy is one of the most commonly used reinforcement methods [1, 2, 10].

In addition to preventing postoperative complications, omentopexy is also used to improve gastrointestinal symptoms, such as nausea and vomiting and gastroesophageal reflux symptoms, during early postoperative recovery. Some surgeons have also suggested that omentopexy decreases the rate of staple line twisting and thoracic herniation of the stomach over the long term [17, 18, 19].

The aim of this study was to reveal the effect of omentopexy on the imbricated staple line of LSG patients and to evaluate its relationship with early postoperative complications.

Different surgeons describe omentopexy using different techniques. Some surgeons prefer continuous stitches, while others prefer separate stitches. Some surgeons complete the omentopexy with three separate stitches, and some with five stitches. The common goal of all these surgeons is to reduce bleeding and leakage risks while affixing the stomach to the greater omentum [18, 19, 20, 21].

A meta-analysis of 17 studies suggested that reinforcing the staple line with oversewing decreased postoperative bleeding significantly when compared to the absence of reinforcement (0.86% versus 4.83%) [22]. In a study of 98,142 patients, Zafar found a postoperative bleeding rate of 0.80% with no reinforcement, 0.60% with suture oversewing, and 0.56% with buttressing material. Reinforcement of the staple line significantly reduces postoperative bleeding [8]. Our study identified a postoperative bleeding rate of 1%, which aligns with the rates indicated in the literature (Table 1).

Most published studies have compared omentopexy with reinforced staple lines to omentopexy with unreinforced staple lines. One study of 2000 patients, 1000 with omentopexy and 1000 with no reinforcement, suggested the positive effects of omentopexy on early postoperative complications. Another study of 3942 patients, divided into three groups (no reinforcement, reinforcement with fibrin glue, and reinforcement with omentopexy), found that omentopexy decreased postoperative bleeding and leakage [17]. Our study compared two reinforced staple lines and is, to the best of our knowledge, the first study to compare LSG with imbrication and LSG with imbrication plus omentopexy. Aside from the omentopexy group showing a higher postoperative bleeding rate (1.3%) than the control group (0.7%), there were no significant statistical differences between the two groups.

Different studies have suggested that the post-LSG leakage rate ranges from 1.1 to 5.4% and that the resulting overall mortality rate is 0.4%. The high rate of this serious complication makes LSG leakage the most dangerous [10, 23, 24]. The post-LSG leakage rate in our study was 0.2% for both the omentopexy and control groups (Table 1). The lower leakage rate may be explained by sleeve staple-line imbrication, which is a safe and reliable method. Our findings suggest that when staple-line imbrication is used for reinforcement, omentopexy is not required to prevent leakage.

Regarding post-LSG reoperation, a single-center study of 664 patients found that only 0.5% required reoperation, while 2% of the patients experienced postoperative bleeding (3 patients in 13 bleeding cases). Only three patients required reoperation and the most preferred conservative management [25]. Another study of 612 LSG patients found a post-LSG reoperation rate of 0.4%. In this study, seven patients required an additional laparoscopy due to leakage (5 cases), twisting (1 case), or bleeding at the staple line (1 case). All laparoscopic operations were completed safely [26]. Another study of 1860 LSG patients showed that 20 (1.1%) experienced post-LSG hemorrhaging and 11 required reoperation (0.6%) [9]. In our study, the postoperative bleeding rate was 1%, and the reoperation rate was 0.6% (Table 1). The high reoperation rate may be due to conservatism and avoiding the risk of abscess formation due to hematomas accumulating near the stomach staple line. Regarding hemorrhage, there is no consensus in the literature, and our approach was to reoperate if CT scans of a hemodynamically stable patient revealed a hematoma near the stomach staple line.

A consensus on surgeries performed at the same time as LSG is also absent from the literature. Despite some surgeons making decisions based on the presence of a hiatal hernia and preferring bypass surgeries when a hiatal hernia is observed via endoscopy, the tendency of some bariatric surgeons is to perform LSG with hiatal hernia repair during the same operation. Few studies have evaluated whether laparoscopic cholecystectomy is safe when performed at the same time, and although hiatal hernia repair is safe, there is controversy about its long-term effects on gastroesophageal reflux [27, 28, 29, 30, 31]. In our study, laparoscopic cholecystectomy was performed simultaneously with LSG in 3.6% of patients, hiatal hernia repair was performed simultaneously with LSG in 4.2% of patients, and both methods were performed simultaneously with LSG in 0.2% of patients (Table 3). Despite increasing the surgical dissection area, no excessive bleeding was encountered. In one leakage case, the patient underwent hiatal hernia repair and omentopexy. No abnormal steps that might cause leakage due to hiatal hernia repair were observed during the repeated review of the surgical video. Based on our professional experience, we recommended that patients with BMIs below 50 kg/m2 undergo simultaneous surgery when a preoperative endoscopic examination revealed a hiatal hernia or asymptomatic gallstones.