A 10-mm, 30° scope is used. The left lobe of the liver is retracted to expose the entire GE junction and the lesser curve. The procedure starts by cutting the small branches of the gastroepiploic arcade and opening the lesser sac. Then, dissection is carried out along the greater curve, staying very close to it, dividing the branches of both gastroepiploic arteries, until short gastric vessels are divided using an advanced bipolar cutting device or the ultrasonic scalpel. The assistant retracts the omentum laterally during the maneuver and keeps repositioning the instrument superiorly to improve exposure of the vessels and avoid bleeding. The remainder of the gastrocolic ligament (without gastroepiploic vessels transection) is severed distally up to 2 cm proximal to the pylorus. The objective of cutting the omentum right by the edge of the greater curve is to minimize the amount of fat attached to the stomach, to make its extraction from the abdomen easier at the end of the operation. The stomach is then lifted to expose its posterior aspect, and all lesser sac attachments of the stomach are freed. This will allow the appropriate positioning of the mechanical suture and avoid bleeding. When cutting these adhesions, it is necessary to be aware of the presence of the branches of the left gastric artery. If the left gastric branches were cut, the blood supply to the sleeve would be compromised. Other anatomic relations the surgeon needs to be aware of are the splenic artery and vein, running along the superior edge of the pancreas. Splenic artery in older patients may be redundant and therefore may be in harms way during the posterior dissection.

The gastrophrenic ligament is divided and the angle of His is exposed to determine the presence of a hiatal hernia, adding the full exposure of the left crus to complete the dissection. In case a hiatal hernia is discovered, the distal esophagus is freed of mediastinal attachments and brought down into the abdomen and a posterior crural approximation is conducted to close the gap, using nonabsorbable suture. Stomach division starts 4 cm proximal to the pylorus, to preserve a part of the gastric emptying mechanism of the antrum. Prior to the creation of the sleeve, the anesthetist introduces a 34–40-Fr bougie to guide the stapling and maintain an adequate lumen of the gastric sleeve. Continuous communication between surgeon and anesthetist is paramount to ensure adequate positioning of the bougie in a safe fashion. The bougie should be placed prior to stapling, guiding it to reach the pylorus, and positioned close to the lesser curve. Care is taken not to divide the stomach too close to the incisura angularis to avoid kinking or stenosis at this level. Green (4.8 mm) or black (5 mm) stapler cartridges are used with absorbable buttress material (Gagner). Green or black for the first two firings and blue for the rest if no absorbable buttressing materials are used (Zundel). In any case, all of them are 60 mm in length. Stapling is performed in a way that no kinking or twisting of the sleeve is produced at any level. To achieve this, the stomach is held by the assistant stretching it to the patient’s left, while the surgeon places the stapler making sure that anterior and posterior edges are at the same distance from the lesser curve. In other words, the distance of the anterior aspect of the remaining stomach should not be shorter than its posterior counterpart. Additionally, a stapler should be placed right at the angle of the previous one, avoiding “dog-ears” created on the edge of the stomach that may produce ischemia. After each firing, the anesthetist is asked to wiggle the bougie to ensure the sleeve is not too tight or that the bougie has not been stapled or cut.

Although the senior author recommended in the past to cut the fundus at least 1 cm from the gastroesophageal junction, his current practice is to divide it as close as the GE junction as possible, without actually compromising the esophagus.

The other authors still cut the fundus 0.5 cm away from the GE junction and imbricate the staple line with absorbable suture in an effort to reduce leak rates. This is done without the presence of buttressing material.

The senior author’s intention is to create a sleeve that goes in straight line from the GE junction down into the stomach, since a funnel-shaped sleeve may be more likely to produce gastroesophageal reflux by dilatation and stretching of the lower esophageal sphincter. Additionally, the perigastric fat is mobilized, permitting better identification of the esophagogastric junction, and this may be used to buttress the staple line. In this technique, the staple line is reinforced only at the GE junction, where leaks are more frequent, and at the bottom of the staple line on the antrum, the thickest part of the stomach. This is done using through-and-through figure-eight stitches with 3–0 absorbable monofilament sutures.

The other authors (Zundel and Hernandez) do not routinely use absorbable buttressing material; conversely, with the bougie in place, the full length of the staple line is oversewn with a running suture of 3–0 absorbable suture.

The anesthetist removes the bougie under direct vision to check the final shape of the sleeve. The stomach is removed through one of the 12-mm ports. The integrity of the staple line is tested with the instillation of 50–100 ml of methylene blue in saline solution. No drains are left.