Mini Gastric Bypass / Omega loop gastric bypass

The position of the camera trocar is in the left upper abdomen, approximately 2-3 fingerbreadths below the left costal margin in the midclavicular line.

Access is achieved using an optical trocar (12mm Xcel trocar) under camera view. During insertion, visualization of the individual tissue layers is ensured. Further trocar placement is performed under camera view and after positioning in the anti-Trendelenburg position.

Three additional 12mm trocars are then placed in the following order. First, approximately 1.5 handbreadths below the xiphoid process paramedian left (far supraumbilical), then approximately in the midclavicular line immediately at the right costal margin, with the trocar tip directed towards the patient's left lower extremity. The third 12mm trocar is finally inserted approximately one handbreadth below the right costal margin medial to the midclavicular line in the right upper abdomen, and lastly, an additional 5mm trocar at the left costal margin slightly cranial to the first 12mm trocar.

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

Between the angle of His (without completely dissecting it) and slightly medial to the upper pole of the spleen, the physiological adhesions between the gastric fundus and diaphragm or retroperitoneal space are loosened as much as possible using ultrasonic dissection. This defines the cranial end of the staple line.

Note: A hiatus revision is never performed routinely, but only exceptionally, e.g., in relatively low-weight patients with significant reflux problems. The operation acts prophylactically against reflux by creating a low-pressure system by bypassing the pylorus and simultaneously pulling on the pouch.

After visualizing the pylorus, the omental bursa is accessed at the upper edge of the gastric antrum approximately 2-3 cm distal to the lower boundary of the so-called "crow's foot." On the lesser curvature side, the posterior wall of the stomach is displayed proximally, and adhesions to the pancreas are released.

A long, tubular gastric pouch (approximately 20 cm) will now be modeled from the lesser curvature into the omental bursa, calibrated with a 30-French gastric tube, while staying relatively far away with the staple line. For this, the antrum is first incised transversely/obliquely to the organ axis about 2-3 cm distal from the crow's foot/incisura angularis using an Echelon 60mm Black (due to the thick wall in this area).

Note: The pouch does not need to be as tight as in a gastric sleeve, as this is not a highly restrictive procedure.