Sleeve gastrectomy (SG) is the most commonly performed metabolic and bariatric surgery worldwide. Sleeve gastrectomy has been gaining popularity among patients with class IV and V obesity due to its efficacy and technical and safety profiles. Patients with such severe obesity are at higher risk of complications; thus, the need for pre- and perioperative management to optimize surgical outcomes arises. This optimization includes but is not limited to screening and controlling comorbidities, preoperative weight loss with diet, medications, or a combination of both, and minimizing postoperative risks such as thromboembolism and hypoxemia. Postoperative outcomes regarding weight loss and resolution of comorbidities must also be monitored and assessed over the long term to evaluate for the next best steps involved in a patient’s healthcare journey, such as a second-stage procedure or revision surgery, if ever needed.