A nasogastric tube is inserted to decompress the stomach. The patient and the robot are draped in a sterile fashion. Importantly, the patient should be draped without the anesthesia drape barrier so that the robot can be docked from the patient’s left shoulder.

Once positioning is complete, an optical entry is obtained into the abdomen at Palmer’s Point and the abdomen is insufflated to 15 mm Hg. Alternatively, Veress entry can be utilized as appropriate depending on body habitus and surgeon comfort. All ports are placed after obtaining pneumoperitoneum, as port site placement prior to insufflation may be inaccurate. The camera port is placed 15–20 cm below the xiphoid process and slightly to the left of midline. This port is inserted into the abdominal cavity under direct visualization using a 0-degree, 10-mm laparoscope, after which four subsequent ports are placed, all under direct visualization. We prefer to use the laparoscopic stapler via a 12-mm assistant port instead of the robotic stapler for two reasons. First, the laparoscopic staple cartridges are longer (60 mm vs. 45 mm) and thus fewer staple cartridges are required to complete the operation and the risk of staple line cross-over is reduced. Secondly, we routinely buttress our staple line which is not a feature of the robotic stapler at this time.

A 12-mm working port (R1) is placed along the left-mid-clavicular line, just above the level of the camera port. The port is “double docked” with a robotic port inside in the event that we need to use this port for the laparoscopic stapler to achieve the desired angle on the sleeve, typically as we approach the Angle of His. A second 12-mm working port (R2) is placed along the right mid-clavicular line, several centimeters above the level of R1. Care must be taken to place this port below the liver margin but it is appropriate to move it more lateral toward the anterior axillary line should spacing between trocars be a concern. The angle between the camera port, R1 and R2 should be approximately 120 degrees. A third 12-mm port (R3) is placed along the left anterior axillary line at the level of the camera port (this too can be lateralized to aid in spacing; however, care must be taken to stay about the level of viscera to prevent bowel injury, particularly as this trocar can be obscured from the abdominal view in the reverse Trendelenburg position). A 12-mm assistant port is then placed halfway between the camera port and R2. A 5-mm subxiphoid incision is made to accommodate the liver retractor. Of note, in obese patients with insufflated abdomens, intra-abdominal distance is less than one would expect based on the location of the skin incisions. Thus it is critical that all ports are placed at least 10 cm apart (8 cm on the Xi) in order to prevent the robotic arms from colliding with one another (Fig. 9.2).

When docking, the robot must be positioned such that the angle between the robot column (which is at the patient’s left shoulder) and the camera port is at 10°. The target anatomy, the stomach, should fall on the axis between the camera port and the robot column. The patient is placed in reverse Trendelenburg of a minimum of 20°. It is our practice to tilt the patient as much as tolerated such that we can clearly see the hiatus. The camera arm is docked first and a 30° scope is inserted into the abdomen in the 30° down position. Robotic arms 1–3 are aligned parallel to their respective ports, the target anatomy (the stomach) is identified, and the arms are docked. The essential equipment is inserted into the abdomen under direct visualization, which includes either a vessel sealer or ultrasonic shears (to R1), a fenestrated bipolar forcep (to R2) and a Cadiere grasper (to R3). The assistant typically uses an atraumatic grasper to aid in retraction or insertion of sponges or needles as necessary. All instruments are inserted into the abdomen under direct visualization. The surgery begins by first identifying the pylorus. Using the fenestrated bipolar forcep, the console surgeon grasps the greater curvature approximately 5 cm proximal to the pylorus and gently elevates it while applying medial traction. The Crow’s foot can be seen penetrating the lesser curvature at this level and serves as a landmark for beginning the dissection. The atraumatic grasper (R3) is used to retract the gastrocolic ligament laterally in order to provide counter traction. We use the ultrasonic shears to divide the gastrocolic ligament at the level of the Crow’s foot until the plane of the lesser sac is entered. Entering the correct plane before proceeding ensures that the posterior stomach is not inadvertently injured as the dissection is carried superiorly toward the Angle of His (Fig. 9.3). Care is taken to divide the ligament close to the greater curvature in order to avoid injury to the colon as well as excessive bleeding from the short gastric vessels. Once the lesser sac is entered, the surgeon can tuck the left grasper into the lesser sac and elevate the stomach in order to improve exposure. Posterior gastric adhesions must be completely divided to prevent inadvertent injury to the pancreas. Cephalad, the greater omentum and redundant gastrocolic ligament, may obstruct the console surgeon’s view of the greater curvature. To reduce the impact of these structures, the surgeon can insert a sponge into the abdomen and using R3, pack the sponge into the lesser sac while applying lateral force so that the greater omentum and the gastrocolic ligament are retracted laterally toward the spleen. As the console surgeon continues to mobilize the stomach superiorly, the sponge should similarly be advanced to maintain exposure. If there is excessive omental fat, the assistant can aid with retraction.

As the dissection is carried cephalad, the fundus is mobilized away from the spleen by dividing the gastrosplenic ligament. The dissection should be taken to identify the left crus at the Angle of His and posterior attachments of the fundus need to be cleared. If necessary, dissection of the esophageal fat pad may aid with this mobilization of the fundus. Complete mobilization of the fundus is important for several reasons. First, it helps the surgeon avoid leaving a large sleeve fundus (neo-fundus), which decreases gastric restriction and could result in inadequate post-operative weight loss as well as reflux. Complete mobilization also provides adequate exposure of the gastroesophageal junction so that a staple load is not inadvertently fired across a portion of the esophagus. Lastly, it allows identification of a hiatal hernia should one be present. If a hiatal hernia is identified, it is repaired prior to proceeding with the sleeve gastrectomy in order to prevent trauma to the fresh sleeve staple line during hernia repair. We typically repair these hernias with a posterior horizontal mattress suture of 0-polyester. The hiatus is closed around a 52F bougie.

Mobilization of the stomach is complete once the lesser curvature vessels are visible from the posterior view. If the gastrocolic ligament needs to be divided further in the caudad direction, the Cadiere forcep in R3 is used to retract the greater curvature superiorly while R2 is used to retract the gastrocolic ligament laterally. The ultrasonic shears are used to complete the dissection along the greater curvature of the stomach.

Once mobilization is complete, the anesthetist advances a 40F bougie (Hurst dilator with a blunt tip) into the deflated stomach in order to assist with sleeve calibration. Once the bougie is visualized within the stomach, the surgeon assists with advancement of the bougie toward the pylorus under direct visualization, while ensuring that the bougie rests along the lesser curvature of the stomach. At this time, the assistant introduces a laparoscopic linear cutting stapler in order to fashion the gastric sleeve.

The staple height is determined based on a variety of patient factors, including BMI, gender, and the stomach thickness. The first staple load, typically a buttressed black load, is deployed across the gastric antrum, approximately 5 cm proximal to the pylorus, at a slight horizontal angle. It is our practice to make the sleeve approximately 4 cm wide opposite the incisura to minimize the possibility of distal obstruction, which may predispose the patient to leak or food intolerance. For the majority of patients, our second staple load is also a black cartridge, followed by green loads for the remainder of the stomach. In smaller patients, we may progress to reinforced gold loads as we march up the stomach. As the staples are being fired, the console surgeon should use the Cadiere grasper (R3) to retract the greater curvature laterally in order to prevent the stomach from spiraling. This helps ensure equal resection of the anterior and posterior stomach (Fig. 9.4). To prevent unintentional incorporation of the bougie into the staple line, the assistant should tighten the staple anvils around the target gastric tissue without deploying the stapler. With the staple anvils tightened, the anesthetist is asked to advance and withdraw the bougie. It is important to not “hug” the bougie in order to prevent over-pulling of the tissue which could yield stapler failure. If the bougie is freely mobile, the assistant surgeon deploys the stapler after a minimum of 15 s of tissue compression. The compression time is added in order to reduce tissue edema and allow the gastric tissue to lay flat within the tissue anvils. The assistant continues transecting the stomach along the lateral edge of the bougie, aiming toward the Angle of His. Some surgeons may opt to use the robot to oversew the staple line. The robot is well suited for this task, although the literature does not clearly delineate a benefit and there is even some literature to suggest a detrimental result. As such, it is our practice to use buttressed staples instead in order to minimize operative time.