This chapter traces the evolution of laparoscopic sleeve gastrectomy (LSG) over 25 years, highlighting its rise as the most performed bariatric procedure globally due to improved safety and effectiveness. Initially part of a two-step approach in super-obese patients, LSG is now considered a standalone operation, with ongoing challenges like weight regain and GERD. Combining LSG with anti-reflux techniques, such as fundoplication, shows promising results in reducing postoperative GERD without compromising weight loss. The procedure’s reversibility and potential for conversion to malabsorptive surgeries offer additional benefits. Emerging technological innovations, including advanced staplers, aim to decrease complications. As a metabolic procedure, LSG is increasingly used early in type 2 diabetes management. Future developments include minimally invasive, reversible sleeve procedures like BariClip, aligning with conservative treatment ideals and personalized care.