Port Placement

The patient is placed in a severe reversed Trendeleberg tilt and an incision is made in the left subcostal region. A Veress needle is inserted. The abdomen is insufflated with CO2 to 15mm HG, and a 12mm port is inserted and secured with 2-0 silk
		Courtesy of Jennifer Dallal

A 45-degree laparoscope is inserted and the abdomen is inspected. Following this, a 10 mm port is placed in the left perimedian region. This port is used for the laparoscope, but in the beginning it is used for the AutoSonix* Ultra Shears* ultrasonic coagulator. It is also used to divide the falciform ligament to improve visualization.

To expose the esophagus and stomach, a 5mm liver retractor is placed through the inferior right subcostal port, and the left lateral segment of the liver is elevated.

Other ports are placed according to the diagram. The assistant is on the patient's left, and uses the 12mm grasper port (in some case this can be a 5mm port). Another working port can be placed for the assistant if a robotic system is manipulating the camera. The primary surgeon is on the patient's right and uses the two right ports, a 5mm working port for a graspers or dissectors, and a 12 or 15mm port for the stapler.

Port placement, particularly the 12mm stapler port, is extremely important. Placing the port too laterally leaves access to the final gastric division difficult; too medially, access to the initial gastric division may be difficult; too cephalad, then access to the jejunojejunostomy is compromised.

Creation of Gastric Pouch

To localize the esophagogastric junction and size the pouch, a Baker jejunostomy tube is inserted orally into the stomach, inflated with saline to 15 ml, and drawn up to the cardia. This can also be accomplished with a 30-34 French Bougie or NG tube, or an endoscope.
A window is created in the lesser omentum near the gastric wall at the lesser curvature (approximately 5 mm from the EG). The AutoSonix* Ultra Shears* is used to create this window, staying very close to the lesser curvature.
	Courtesy of Jennifer Dallal

Once the window is created, some of the short gastric vessels near the angle of His along the greater curvature are divided.

The Endo GIA* Universal stapler, 60mm length and 3.5mm staples or 45mm length and 3.5mm staples, is inserted and applied three or four times to staple and cut the gastric pouch with three rows of staples on each side. Staple lines are examined on both sides to make sure that they are intact. The Bougie, NG tube or endoscope can be used as a guide to form the 15 to 25ml pouch.

Creation of the Roux Limb

The patient is returned to the supine position to create the jejunojejunostomy. The greater omentum and transverse colon are passed to the upper abdomen to expose the ligament of Treitz. Here the ligament of Treitz is identified and is measured approximately 30 cm distally.
The jejunum is then transected with an Endo GIA* Universal stapler, 45mm length and 2.5mm staples, where a comfortable length of mesentery exists. The jejunal mesentery is then divided with two applications of Endo GIA* Universal stapler using the vascular cartridge (45-mm length, 2.0-mm staples). This increases the mobility of the Roux limb.
A 6-cm length of Penrose drain is sewn to the end of the Roux limb using the Endo Stitch* instrument or by hand using sutures designated by the surgeon. The Penrose drain enables the pulling of the Roux limb through the retrocolic/retrogastric tunnel up toward the gastric pouch.
	Courtesy of Jennifer Dallal

Measurement of the Roux Limb

The Roux limb is then measured 75 cm distally, or 150 cm distally for the superobese. A non-crushing Babcock clamp is used to measure the Roux limb in 5 cm increments.
	Courtesy of Jennifer Dallal

A stay suture is placed on the Roux limb side and then on the proximal jejunal segment side. This stay suture facilitates creation of the enterotomy site in both bowel limbs

Creation of the Jejunojejunostomy

The corner of the proximal segment is divided with electro-cautery to create the enterotomy site. Likewise, on the Roux limb side, the UltraShears* is used to create an enterotomy.
Each jaw of an Endo GIA* Universal (60mm length, 2.5 mm staples) is inserted into the enterotomy sites. A stapled side-to-side anastomosis is created with the proximal jejunal limb using one application of the Endo GIA* Universal stapler. The staple line is inspected internally to ensure there in no excessive bleeding.
The enterotomy site can be sutured closed using a running 2-0 Endo Stitch* or stapled closed. When using a stapled technique, a stay suture is placed to approximate the staple ends, and an Endo GIA* is fired across the enterotomy site. The divided end of the enterotomy is removed. Occasionally, bleeding at the staple line will occur and can be controlled with clips.
The residual jejunojejunostomy mesentery defect is sutured closed with either running or interrupted sutures. This is an important maneuver to prevent an internal bowel obstruction or internal hernia.
	Courtesy of Jennifer Dallal

Creation of the Mesenteric Window

A retrogastric-retrocolic tunnel is then created to facilitate passage of the Roux limb. Using ultrasonic dissection, a window is created immediately anterior and lateral to the ligament of Treitz to gain access to the lesser peritoneal sac.
The Roux limb is then passed through the window into the retrocolic retrogastric tunnel.
The Penrose is passed behind the colon, behind the stomach and up toward the gastric pouch.
	Courtesy of Jennifer Dallal

Creation of the End-to-Side Gastrojejunostomy

The Roux limb is advanced superiorly until adequate mesentery is exposed.
The end of the Roux limb is approximated to the posterior gastric pouch wall using the Endo Stitch* to form a running stitch or interrupted stitches.
Using the Ultra Shears*, small stab wounds are made in the gastric pouch and Roux limb to allow placement of the Endo GIA* Universal instrument.
After the posterior wall is created, The Endo GIA* Universal stapler (30mm length, 3.5mm staples) is then applied to create the anastomosis between the gastric pouch and Roux limb. Only 20 to 25mm of the Endo GIA* stapling cartridge is used.
A 30 French Bougie is passed trans-orally through the anastomotic site into the Roux Limb to ensure adequate lumen size.
The enterotomy sites can be stitched closed or stapled close. When stapling the enterotomy sites, 2 -3 stay sutures are placed using the Endo Stitch* instrument to stabilize the anastomosis location. The Endo GIA* Universal is used to complete the closure of the enterotomy.
Following closure of the enterotomy, an anterior suture layer is applied across the staple line, creating a two-layer anastomosis.
After this is completed, endosopy with insufflation is used to check for leaks. Methylene blue dye can also be used.
	Courtesy of Jennifer Dallal

Closing the Mesenteric Window

The window in the transverse mesocolon is closed to prevent internal herniation. Interupted or running sutures are used to approximate the Roux limb to the edge of the mesenteric window.
Typically, incision sites greater than 10mm are closed. A #10 Jackson-Pratt drain is placed posterior to the gastrojejunal anastomosis and brought out through a right subcostal port site.
	Courtesy of Jennifer Dallal