Sleeve gastrectomy (SG) has emerged as the most commonly performed bariatric procedure worldwide due to its favorable weight loss and metabolic outcomes. Originally a part of biliopancreatic diversion with duodenal switch (BPD-DS), SG evolved into a standalone procedure as patients achieved weight loss results without requiring a second-stage bypass. This chapter describes a surgical technique that aims to preserve physiologic alignment and anatomical preservation to optimize outcomes and reduce complications. Key features include routine preoperative endoscopy with selective esophagram, creation of the sleeve 4–5 cm from the pylorus, and stapling along the Magenstrasse line rather than using bougie size alone. The hiatus is not routinely dissected, and both Belsey’s fat and the gastrophrenic ligament are preserved to minimize leak risk and maintain revisional options. This approach aims to balance effectiveness and preserve future surgical options in managing postoperative complications such as GERD, weight recurrence, or hiatal hernia.