Postoperative nausea and vomiting (PONV) remains a significant concern following sleeve gastrectomy. With a multifactorial etiology involving anatomical, physiological, and pharmacological factors, PONV presents unique challenges in this patient population. This chapter delves into the pathophysiology underlying the heightened incidence of PONV post-sleeve gastrectomy, including changes in gastric anatomy, hormonal alterations, and individual patient risk factors. We review evidence-based strategies for prevention and management, emphasizing the importance of preoperative risk stratification, intraoperative anesthetic techniques, and multimodal therapy. Emerging therapies and future directions are also explored, providing a comprehensive overview for clinicians aiming to optimize outcomes. By understanding and addressing the nuances of PONV in sleeve gastrectomy patients, healthcare providers can significantly reduce morbidity, improve recovery, and elevate the standard of care in bariatric surgery.