Warm Saline Irrigation Before Omentopexy to Reduce Early Bleeding After Laparoscopic Sleeve Gastrectomy

Study Design and Rationale:

This study is a prospective, randomized, controlled clinical trial conducted at two high-volume tertiary bariatric centers. The aim is to evaluate whether irrigation of the gastric staple line with physiologically warm saline (37-40 °C) before performing omentopexy improves intraoperative hemostasis and reduces early postoperative bleeding following laparoscopic sleeve gastrectomy (LSG).

Irrigation of the operative field is standard practice during laparoscopic surgery to clear blood and enhance visualization. However, the effect of irrigation temperature on staple-line hemostasis in bariatric surgery has not been previously studied. Warm irrigation has demonstrated hemostatic and recovery benefits in other surgical specialties. This trial compares two clinically relevant strategies: warm saline versus conventional room-temperature saline.

Participants:

A total of 200 adult patients (18-60 years) undergoing primary LSG were enrolled. Inclusion criteria included BMI ≥ 40 kg/m² or ≥ 35 kg/m² with obesity-related comorbidities. Patients with coagulopathy, recent anticoagulant use, prior major upper abdominal surgery, advanced organ failure, pregnancy, or inability to complete follow-up were excluded.

Randomization and Allocation:

Patients were randomized in a 1:1 ratio using a computer-generated sequence with allocation concealment via sealed opaque envelopes. Surgeons were aware of the irrigation temperature, while postoperative assessors and patients were blinded to group allocation.

Intervention:

After completion of gastric transection using a 36-French bougie calibration, patients received:

• Warm Irrigation Group: 400 mL sterile saline at 37-40 °C applied along the staple line.
• Control Group: 400 mL sterile saline at 22-24 °C applied identically.

After irrigation and complete suctioning, the staple line was inspected and any active bleeding was controlled using bipolar cautery or clips. Standardized omentopexy was then performed in all patients using interrupted 2-0 PDS sutures spaced 2 cm apart.

No buttressing material, sealants, or additional reinforcement techniques were used in either group.

Primary Outcome:

Early postoperative bleeding within 48 hours, defined as any of the following:

• Hemoglobin drop ≥ 2 g/dL
• Drain output ≥ 150 mL sanguineous fluid within 24 hours
• Clinical signs of bleeding
• Need for endoscopic or surgical hemostasis

Secondary Outcomes:

• Hemostasis-phase duration
• Hemoglobin drop (continuous variable)
• 24-hour drain output
• Additional intraoperative hemostatic maneuvers
• Postoperative pain scores
• Postoperative nausea and vomiting
• Length of hospital stay
• 30-day complications (Clavien-Dindo classification)
• Reoperation or readmission

Follow-up:

Patients were evaluated during hospitalization and followed at 1 week, 1 month, and 3 months postoperatively. All randomized patients completed follow-up and were included in intention-to-treat analysis.

Statistical Considerations:

Sample size was calculated to detect reduction in bleeding incidence from 15% to 5% with 80% power. Statistical significance was defined as p < 0.05.

This study evaluates a safe, inexpensive, and easily reproducible intraoperative modification that may improve staple-line hemostasis and early recovery after LSG.

Inclusion criteria

• Age between 18 and 60 years
• BMI ≥ 40 kg/m², or BMI ≥ 35 kg/m² with at least one obesity-related comorbidity (e.g., type 2 diabetes, hypertension, obstructive sleep apnea)
• Eligible for primary laparoscopic sleeve gastrectomy
• Provided written informed consent

Exclusion criteria

• Previous major upper abdominal surgery with expected adhesions
• Known bleeding disorders
• Use of anticoagulant or antiplatelet therapy within 7 days before surgery
• Advanced hepatic or renal disease
• Unstable cardiac conditions
• Pregnancy
• Immunosuppression
• Active systemic infection
• Inability to comply with follow-up schedule