Laparoscopic sleeve gastrectomy - general and visceral surgery

Position the camera trocar in the left upper quadrant, ensuring it is at least 15 cm away from the xiphoid.

Insert another two 12 mm trocars in the median epigastrium inferior to the rib cage. Place a 5 mm trocar high up in the median epigastrium.

Skeletonize the greater curvature of stomach by transecting the gastrocolic ligament close to the gastric wall, while preserving the gastroepiploic arteries. Start the distad dissection with the Ultracision at the inferior gastric body, ending 3-5 cm proximal of the pylorus. Open the lesser sac and take down any adhesions to the pancreas.

In this way, release the entire greater curvature of stomach. Divide the connection to the spleen, the gastrosplenic ligament, and clip the short gastric vessels. Carry the skeletonizaton through to the angle of His.

Note: Expose the angle of His with the left diaphragmatic crus to rule out any hiatal hernia and parts of the stomach displaced into the mediastinum.

Now introduce a 32 French calibration bougie transorally into the stomach and, with grasping forceps, place it at the lesser curvature. 

Note 1: This measure is intended to avoid stenosis or an excessively wide gastric sleeve.

Note 2: Bougies <34 French are associated with a higher fistula rate. However, better restriction is achieved with a narrower gastric sleeve and, accordingly, a better treatment outcome.

Note 3: Charrière (Ch) is a measure of the outer diameter of tubes / cannulas, etc. Three Charrière corresponds exactly to one millimeter (1 Ch = 1/3 mm).  This is an eponymous term named after Joseph-Frédéric-Benoît Charrière. In the English-speaking world, this unit is simply known as French (Fr) (because of its French origin).