Figure 14.2 illustrates the position of trocars, which follow a “V” configuration. While the patient is in the supine position, a 12-mm optical port is placed to the left and just superior to the umbilicus, using a 0° laparoscope. The abdomen is insufflated, and the laparoscope is changed to a 45° laparoscope. The assistant places a 15-mm port very lateral just below the right costal margin as seen laparoscopically; this port will allow the placement of the EEA™ Stapler (Covidien; Minneapolis, MN). An additional 12-mm port is placed in the mid-upper right quadrant; another 12 mm port is placed between the 12 and 15 mm ports. The Nathanson retractor is inserted in the epigastrium to retract the lateral portion of the left lobe of the liver away from the hiatus; it is then secured to the operative table.

Figures 14.3, 14.4, 14.5, 14.6, 14.7, 14.8, 14.9, and 14.10 show the steps in creating the gastric pouch. The patient is placed in fully steep reverse Trendelenburg. The gastroesophageal fat pad is excised from the stomach until the left crus is visible. If a hernia is found, an anterior repair is performed at this time by stitching the apex of the left and right crus anteriorly with a 2-0 silk suture. At this time, the orogastric tube and the esophageal temperature probe are removed. The hepatogastric ligament is incised and access to the posterior gastric wall is gained by transecting the omentum of the lesser sac with a stapler. The dissection of the posterior wall of the stomach is continued and the pouch is created by firing one more load transversely and two more loads longitudinally towards the angle of His. At this time, the surgeon should make sure that there is not too much stomach posteriorly on the pouch.