Pneumoperitoneum can be established via a variety of established techniques (open, visualizing trocars or Veress needle). We place trocars as shown (Fig. 1): a 15 mm trocar at the umbilicus, a 5 mm trocar in the right upper quadrant, a 5 mm trocar in the epigastrium, a 5 mm trocar in the left upper quadrant, and a 5 mm trocar in the lateral left upper quadrant. The Nathanson^® liver retractor is placed via an additional 5 mm incision in the superior epigastrium. If necessary, additional 15 mm stapling trocars can be placed in the right and left upper quadrants.

If the stomach appears dilated (and difficult to maneuver), a nasogastric tube may be placed to evacuate the stomach. The nasogastric tube should be removed after the stomach has been emptied.

The left lobe of the liver is elevated with the Nathanson^® retractor, exposing pars flaccida and the vagus nerves.

Using an ultrasonic scalpel, the gastrocolic omentum is divided off the greater curvature of the stomach, beginning approximately 5–6 cm proximal to the pylorus and proceeding to the angle of His at the hiatal orifice, completely mobilizing the greater curve. The entire fundus is freed posteriorly from the left crus (Fig. 2). Posterior attachments to the pancreas are also divided such that the stomach is only attached via its lesser curvature blood supply. The most efficient maneuver to achieve adequate exposure for the posterior dissection is to retract the posterior aspect of the stomach to the right with a grasper and dissect with the harmonic scalpel beneath the grasper. If present, a hiatal hernia should be reduced to ensure complete mobilization of the fundus; the hernia is then repaired (preferably by posterior apposition of the crus). A large gastric fat pad (seen especially on males) can be resected.

Prior to transection of the stomach, an additional 5 mm port is placed in the midline superior to the 15 mm trocar. The camera is now placed in this position as the 15 mm port in the umbilicus will serve for introduction of the stapling device.

Transection of the stomach begins on the antrum 5–6 cm proximal to the pylorus with a 60 mm long, articulating stapler using Endo GIA™ Black Reload with Tri-Staple™ Technology cartridges. The transection is oriented such that the stomach is not narrowed at the incisura (Fig. 3).

After the first staple firing, a 40 F Maloney or Hurst-type bougie is placed by the anesthesia team and directed towards the pylorus along the lesser curvature. The surgeon can guide proper placement of the bougie using graspers.

The remainder of the stomach transection is performed aligning the bougie against the lesser curvature to guide the resection as it proceeds towards the angle of His. Seamguard® (W.L. Gore & Associates, Inc., Flagstaff, AZ) is used for each firing after the initial of the stapling device. The Endo GIA™ Black Reload with Tri-Staple™ Technology (Covidien) cartridge can be used for the entire resection with the addition of commercially available buttress materials. Alternatively, 3.5 mm-height (blue) staples can be used in the thinner, more proximal portions of the stomach. Generally, 4–5 cartridges are necessary to complete the sleeve.

The bougie is withdrawn once the sleeve is complete. A nasogastric tube is advanced into the stomach and a methylene blue leak test is performed. The pylorus is occluded using a previously fired stapling device or grasper to compress the area. If there are any areas of leakage, then additional absorbable sutures can be placed to reinforce the area and the leak test can be repeated.