The surgery may be performed using the commercially available single-port devices or conventional trocars [27–32]. The former devices provide less sufficient space between the instruments and hence necessitate the use of curved or articulating instruments [30, 32]. Because of their large size, they require the creation of an equivalent fascial defect which, if not closed properly, can increase the risk of incisional hernia. Moreover, these devices add considerable cost to the procedure. In SITU method, placement of all three operating trocars within a small umbilical incision would cause excessive crowding and hamper manipulation. This could be overcome by the technique we developed, omega umblicoplasty [31]. The initial umbilical incision was around 6 cm in length along the superior border of the umbilicus, allowing for comfortable placement of the three trocars with a gap of 4 cm between each trocar. The instrument clashing was overcome by using low profile trocars and instruments of different lengths, allowing adequate space between the surgeon’s hands. The trocars are all angled to the area of interest and not perpendicular to the abdominal wall, reducing the torque and shoulder strain for the surgeon.

The initial dissection of the subcutaneous space for trocar placement weakens the grip of the abdominal wall on the trocars and may result in gas leakage. The repeated instrument exchanges and excessive torque forces add to this problem and enlarge the existing fascial defect, necessitating the use of threaded trocars or skin suture for anchoring the ports. It is preferable to use a 30 ° 10 mm long telescope for creating good endovision. The light cable of the telescope is a frequent cause of interference. This is counteracted by using a light cable adapter that allows the light source to exit at an acute angle from the scope. Some authors have used semi-flexible scopes with integrated light and camera cables to make the procedure more comfortable, albeit at a higher cost.

Liver retraction is essential in bariatric surgery to perform dissection near the hiatus as the left lobe is usually bulky and friable and usually obscures this area if there is insufficient exposure. Earlier reports described the use of the conventional Nathanson liver retractor during RPL-RYGB [26]. Tacchino et al. performed the surgery without using any form of the liver retraction and managed to use the articulating stapler to push up the left liver lobe during pouch creation [30]. With this technique, the mean length of the gastric pouch was as large as 8 cm to avoid the technical difficulties that would have been encountered by big left liver, during the creation of a pouch and the subsequent higher gastrojejunal anastomosis. The liver suspension tape [31] that we developed can be easily prepared before the procedure, and multiple tapes can be used in the situation when one is not enough to retract liver well. The concern about the safety of liver suspension and its effect on postoperative liver function has been allayed by a prospective randomized trial wherein the three different methods of liver retraction were compared with respect to the time required for placement, postoperative pain, and liver function tests. Surprisingly, we found that the Nathanson liver retractor caused more pain and liver dysfunction compared to our liver suspension techniques [33].

The successful performance of SITU-LRYGB requires that the dissection and anastomosis be confined to a single abdominal quadrant. Long instruments and harmonic shears (43 cm) are required to reach hiatus. Several authors have reported the use of articulating instruments like the endograsp for creating artificial triangulation within the abdomen. However, this requires crossing of the surgeon’s hands, creating confusion and sword fighting during the procedure. The success of using straight instruments mostly depends on the surgical steps we performed. After creating the pouch, we brought the uncut loop of jejunum to the gastric pouch for creation of the gastrojejunal anastomosis. Some authors then measure the foot of the Roux limb, create the jejunojejunostomy, and transect between the two anastomoses to finally separate the biliary and alimentary limbs [30]. In our technique, we transected the biliary limb after gastrojejunal anastomoses to avoid excessive tension. In both approaches, the entire manipulation and suturing is confined to the supracolic compartment and avoids excessive torque forces and change of position to the infracolic region which would make this step extremely difficult. We used instruments with curved opposing tips to create angles required for intracorporeal looping and knot tying. A to-and-fro movement of the instruments helps create loops especially using a monofilament suture material with a strong memory.