Mini gastric bypass / omega loop gastric bypass

Position the camera trocar in the left epigastrium, approximately 2-3 fingerbreadths caudal to the left costal arch in the midclavicular line.

Access is by means through an optical trocar (12 mm Xcel trocar) under camera view. During insertion, ensure that the individual tissue layers can be viewed. During insertion, optical trocars ensure a clear view of the individual tissue layers. Place the additional trocars under camera view and after placement the patient into the anti-Trendelenburg position.

Then place three more 12 mm trocars in the following order: First trocar about 1.5 hand widths inferior to the xiphoid process paramedian on the left (far supraumbilical) and the second trocar roughly in the midclavicular line immediately at the right costal arch, guiding the trocar tip in the direction of the patient's left leg. Finally insert the third 12 mm trocar about one hand’s width caudal to the right costal arch medial to the midclavicular line in the right upper quadrant. Then and finally insert an additional 5 mm trocar at the left costal arch somewhat cranial to the first 12 mm trocar.

Note: A liver retractor is needed only for extremely large livers, which is the case in less than 5% of patients.

Between the angle of His (without freely dissecting it completely) and somewhat medial to the upper pole of the spleen, detach the physiological adhesions between the gastric fundus and diaphragm or retroperitoneal space as much as possible using ultrasonic dissection. By ultrasonic dissection, take down the physiological adhesions between the gastric fundus and diaphragm/retroperitoneal space as much as possible from the cardial notch (without freeing it completely) to somewhat medial to the superior pole of the spleen. This defines the superior end of the stapled suture line.

Note: Hiatal revision is not routinely done, but only in exceptional cases, e.g., in relatively low-weight patients and substantial reflux problems. The surgery procedure results in creation of a low-pressure system by bypassing the pylorus and simultaneously applying tension on the pouch, thereby resulting in a quasi-prophylactic measure against reflux. 

After exposing the pylorus, enter the lesser bursa sac at the superior edge of the gastric antrum about 2–3  cm distal to the inferior aspect of the so-called “crow’s foot.” (branches of the vagi to the antropylorus). On the lesser curvature aspect, visualize the posterior wall of the stomach proximally and detach adhesions to the pancreas. Expose the posterior gastric wall proximally along the lesser curvature and take down adhesions with the pancreas.

From the lesser curvature extending into the lesser sac, now fashion a long, tubular gastric pouch (around 20 cm) under calibration with a 30 French gastric tube, but keep the staples relatively far away.  First cut into the antrum with an Echelon 60 mm black (because of the thick wall in this region) oblique/transverse to the organ axis around 2-3 cm distal to the crow’s food/angular incisure. 

Note: The pouch does not have to be as narrow as with a gastric sleeve because this is not a highly restrictive procedure.

Now fashion the tubular pouch by vertical dissection along the gastric (calibration) tube, first with green, further above with gold, and then with blue cartridges, in the direction of the angle of His, thereby separating it from the gastric remnant, so there is no longer a connection with it.  

As the dissection progresses, continue to take down adhesions of the posterior gastric wall until the gastric fundus is completely transected vertically about 1 to 2 cm lateral to the cardial notch. 

Note: Complete transection of the stomach is a deciding factor in avoiding gastric-gastric fistulas.