Objective: create 15ml gastric pouch by separating the stomach with linear staplers

Position: Steep Reverse Trendelenberg
 
Instruments:
     
Surgeon:  Harmonic and alligator grasper
Linear staplers
Roticulating grasper
      
Assistant:  2 alligator graspers

1. Make sure that the OG tube is removed by the anesthesiology staff.  Confirm that it has been removed.
 
2. Create a window in the gastrohepatic ligament (filmy portion). Identify the left gastric artery and create a posterior gastric tunnel inferior to the left gastric artery
 
3. Stapler 60mm white load x 1 to divide the omentum up to the gastric lesser curvature below 2nd branch of left gastric artery
 
4. Stapler 60mm blue load x 4-5 to divide the stomach and create a 15ml gastric pouch
 
5. The assistant should pull away the omentum and pull the fundus inferiorly with an alligator
 
6. When approaching the greater curvature and before the last blue load, use the suction to create a window in the gastro-splenic ligament
 
7. Place the stapler with the jaws side by side so the metal jaw can be inserted into the window. Rotate the wheel on the stapler 90 degrees counterclockwise so the markings are on top.

8. The assistant lifts the gastric remnant and the back of the stomach is cleaned from adhesions with the harmonic scalpel to create a free retrogastric space.

Gianluca Bonanomi, MD

Perils to avoid
• Grasping the gastrohepatic omentum with a grasper
• Injuring pancreas, splenic vessels, liver, spleen
• Making pouch too small or too large
• Tearing stomach with grasper