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The operation is performed with the patient in the supine position, in reverse Trendelemburg (45 degrees inclined position), with the surgeon stands between the legs, the 1st assistant on his right with the camera and the auxiliary grasp, and the 2nd assistant on the left for liver retraction.
A disposable orogastric tube (36-Fr) is routinely placed. The pneumoperitoneum is performed by Veress needle in the left upper quadrant, in proximity of the costal margin, at a pressure of 14 mmHg. The surgery initiates by the placement of the first 12 mm optical trocar for introduction of 30 degrees camera placed at the mesogastrium, between 12-15 cm below the xiphoid process and 3 cm to the left of the midline. Others 4 trocars are positioned under direct vision (2 of 5 mm, 1 of 12 and 1 of 15 mm. of diameter).
The procedure starts with the dissection of the esophagogastric angle and the opening of the left gastrophrenic ligament, so as to expose the left diaphragmatic crus. Then, the resection of the fat pad of the esophagogastric junction (Belsey’s fat) is performed. Then, the surgeon proceeds the section of the distal lesser sac, next to the insertion of the Latarjet nerve, using advanced energy system to expone the posterior gastric wall. A gastric pouch is then created using a first green cartridges to perform the horizontal section and others 4 gold cartridges with bioabsorable staple line reinforcement, to perform the vertical section. During all the procedure an articulating laparoscopic grasper (ArtiSential) was used alternatively on the left or on the right hand of the surgeon, combined with the scalpel, the stapler or either the needle holder, during dissection, traction and stapling manouvers.
The Treitz ligament is then identified, and the greater omentum is then completely divided at this level. The small bowel is counted until 180 cm from the Treitz angle, and this segment is then sutured to the pouch on a vertical omega-loop, isoperistaltic, antecolic, and side-to-side 40mm-gastrojejunostomy is performed using a blue cartridge. The suture of the orifice is performed by double continuous suture with 3-0 polydioxanone reinforced by a single oversewn suture with the same material. A blue test is performed by gastric tube and the procedure ends with the application of fibrin glue on the suture line.