Ÿ The surgery starts with a pneumoperitoneum confection, using a Veress needle introduced bellow the left costal margin (Palmer point);

Ÿ The patient is positioned in a 30˚ reverse Trendelemburg position without lateralization;

Ÿ The abdominal cavity checked, with the surgeon positioning between the patient’s legs , the first assistant, on the patient’s left and the camera assistant, on the patient’s right;

Ÿ The left hepatic lobe is withdrawal using a straight cylindric retractor, inserted through the 5 mm trocar, close to the xiphoid process;

Ÿ Intraoperative endoscopy is performed, with prior clamping of the jejunal limb, 10 cm distally to the angle of Treitz;

Ÿ Through intra-op endoscopy, the major and minor duodenal papillae are identified and are laparoscopically marked with a 3-0 PDS seromuscular stitches, on a contralateral wall; the endoscope is removed, with previous gastric aspiration, followed by jejunal clamp release;

Ÿ A 32Fr Fouchet tube is introduced down to the stomach;

Ÿ The dissection of the vessels of the greater curvature of the antrum starts 6 cm proximal to the pylorus, opening a small retrogastric window;

Ÿ Longitudinal gastric stapling begins at this level, shaped loosely by a 32Fr Fouchet tube, stapling with 60 mm J & J Echelon GST (6 to 7 shots), up to the His angle, septating the stomach longitudinally; for this, 1 green, 1 gold and 4 to 5 blue cartridges are used, from distal to proximal stomach;

Ÿ The gastric vessels from the right and left gastro-epiploic arcade are sealed, near the stomach wall, with ultrasonic scalpel, from the level of the distal gastric septation until the angle of His, releasing the entire septated stomach, which is positioned over the right hepatic lobe;

Ÿ Oversuture of the staple line is performed with 3-0 PDS;

Ÿ The posterior wall of the gastric tube is fixed to the base of the transverse mesocolon, at the level of the incisura angularis, up to the distal edge of the gastric staple line, with 3-0 Polipropilene thread;

Ÿ The bulb dissection started, but a huge umpredictable fibrosis was found in this region, making it difficult to continue the dissection;

Ÿ A distal dissection is chosen, to avoid fibrous tissue;

Ÿ An intraoperative endoscopy is done to locate both papillae, which are marked with seromuscular stay sutures;

Ÿ The duodenal dissection starts on both margins, above the papillae, 3 to 4 cm distal to the cross line between the choledochus and the superior edge of duodenum, approximately 7 to 8 cm distally to the pylorus;

Ÿ A retroduodenal tunnel is created, just enough for the passage of the stapler;

Ÿ The right gastric artery and the entire antrum-duodenal vascular and neural arcade are preserved, from the distal level of the gastric septation until the duodenal transection level;

Ÿ After dissecting the posterior duodenal wall, a tape is passed behind and pulled up, to expose this region (Figure 4);

Ÿ The duodenum is stapled and sectioned, under direct vision, using a 60 mm J & J Echelon GST blue cartridge, entering through the 12 mm trocar of the left abdomen (Figure 5 and Figure 6);

Ÿ A pre-tied 3-0 PDS thread is used to transfix the proximal duodenal stump staple line, at the contralateral pancreatic side, to help bringing up the ileum;

Ÿ The table is positioned in 20˚ Trendelenburg with 30˚ left lateralization;

Ÿ The surgeon moves to the left side of the patient, the camera holder positions himself between the patient legs and the first assistant moves to the patient’s right;

Ÿ The cecum is identified and 300 cm of the ileal limb is counted, proximally, from the cecum; The ileal limb is marked at this point in its mesentery, with 1 clip in its proximal portion and 2 clips in its distal portion; the rest of the intestine is counted;

Ÿ The previous 3-0 PDS thread attached to the proximal duodenum stump is used to transfix the seromuscular layer of the ileum (at 300 cm from the ICV), in the mesenteric border. By pulling up this thread, the ileum is brought up and rests over the proximal duodenum stump, thus being ready to be anastomosed with it;

Ÿ At this point, all surgical team return to the previous position, as well as the patient;

Ÿ The correct positioning of the proximal and distal segments of the ileum is confirmed by observing the endoclips attached to ileal meso;

Ÿ The first posterior anastomotic layer is constructed with the 3-0 PDS thread previously passed, in an uninterrupted way, addressing the staple line of duodenum and mesenteric seromuscular layer of ileum;

Ÿ The anterior duodenal wall and the lateral ileum wall are opened by an extension of 2 cm, using ultrasonic scalpel (J & J);

Ÿ The second duodeno-ileal total posterior layer suture is done in uninterrupted way, with a 3-0 PDS thread;

Ÿ The anterior layer of duodenum-ileum anastomoses is closed in one plane, by a continuing full-layer stitchs, using 3-0 PDS (Figure 7);

Ÿ The mesenteric space between the colon and the ileal limbs is not closed;

Ÿ The integrity of the anastomosis is tested with methylene blue, infused through the Fouchet tube, removing it afterwards;

Ÿ The resected stomach segment is placed in an endobag and extracted through the 12 mm trocar incision, in the left abdomen;

Ÿ The hepatic retractor and the trocars are removed, with closure of the aponeurosis at the sites of the 12 mm trocars with 2-0 Vicryl transparietal sutures;

Ÿ Cavity drainage is not performed;

Ÿ The wounds are closed with intradermic sutures, using 3-0 Monocryl thread.