Procedure

The operation is commenced by using energy devices to take down the greater curvature of the stomach from the antrum to the Angle of His. This includes dividing various branches of the gastroepiploic vessels, close to the gastric wall of the greater curvature. Most operators will fully mobilized the fundus posteriorly, lysing the adhesions in the lesser sac and anterior to the pancreas (more so behind the antrum). The left crus is also exposed to investigate the presence of a hiatal hernia. Most surgeons will selectively close hiatal hernias when identified. Some surgeons will also mobilize the fat pad near the gastro-esophageal junction to better identify this area and staple accordingly. A bougie is introduced trans orally (32-40Fr) and positioned abutting the lesser curvature. The stapling begins 1-6 cm proximal to the pylorus and aiming lateral to the bougie. Strictures are avoided at the incisura angularis by avoiding stapling too close (or tight) to the bougie. One also has to avoid stapling the esophagus near the GE junction, as most leaks occur distal or near the GE junction. Choosing the appropriate staple height depends on gastric tissue thickness and varies according to the sex, BMI and stomach site. Wall thickness tends to decrease from distal to proximal. Appropriate compression time is necessary, especially in thick tissue. Most surgeons will reinforce the staple line in order to decrease bleeding and leaks. Reinforcement options include suturing or buttressing. Drainage and leak testing is left to the discretion of the surgeon.