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All procedures were performed by the same surgical team. The patient is placed in a modified lithotomy position with the surgeon standing between the patient’s legs, the camera operator on the right side, and an assistant on the left. Five 12 mm trocars are normally used. The first step consists of locating the Treitz ligament and measuring the jejunal loop to be bypassed which initially was ∼180 cm.
The patient is then placed in a 30° anti-Trendelenburg position. The angle of His is identified and the fat pad at the esophago-gastric (EG) junction explicitly dissected in order to visualize the diaphragm’s left crus for optimal endostapler positioning at this critical location. With associated hiatal hernia (very common in MO), this step includes section of periesophageal adhesions and phreno-esophageal ligament to reduce the hernia. Ultrasound shears are used to section the lesser gastric curvature’s fat and blood vessels at the level of the crow’s foot to enter the lesser sac.
An endoscopic stapler loaded with a 60-mm/3.5-mm cartridge is inserted through the created opening and applied, sectioning the stomach horizontally. A 36-Fr double-lumen orogastric tube is inserted to calibrate the gastric reservoir. Fatty tissue and fibrous adhesions between the posterior gastric wall and pancreas are dissected. Then, an endoscopic stapler loaded with 60- mm/3.5-mm cartridges is consecutively applied (usually five times), sectioning the stomach vertically and completing the gastric reservoir. The latter should be long, narrow, well vascularized, and easy to move caudally.
The orogastric tube is removed and the previously chosen SB mobilized upward placing it without tension in an antecolic, antegastric position. Bivalving of omentum is especially required in superobese patients and those with central obesity. A uncontinuous reabsorbable no. 2-0 suture is sewn in a latero-lateral position, securing the SB loop to the gastric reservoir’s staple line along ∼2–4 cm. Enterotomy and gastrotomy (distal reservoir) are done with monopolar hook. An endoscopic stapler loaded with a 35-mm/3.5- mm cartridge is partially inserted (∼75 %) and applied between both, thus creating a gastroenteric anastomosis ∼2–2.5 cm long. Incisions on the anterior anastomotic wall are sutured with reabsorbable no. 2-0 interrupted stitches. These measures unload anastomotic tension, improve its orientation, and reinforce the antireflux mechanism. Anastomosis integrity is verified with a idropneumatic test. The greater omentum is tucked and adhered to them. Lastly, a drain is positioned under the left hepatic lobe and brought out through the right subcostal incision.