• Pneumoperitoneum (set to 14 mmHg) is performed with a Veress needle, at Palmer’s point;

• The first trocar is inserted near the umbilicus; the others four trocars are inserted under optic view;

• The abdominal cavity is inspected;

• Adehisions are takendown.

• Some adhesions were found between left liver lobe, stomach and crura, which were released with scissors and energy dissection (Figure 15);

• A large crura space and moderate hiatal hernia was found (Figure 16);

• The hernia sac detachment was started, facing big lipomas and dense adherences in the mediastinum. The esophagus was stuck and difficult to release; To get enough esophagus in the abdominal cavity and facilitates its mobilization, it was opted for a truncal vagotomy, making it possible to pull the esophagus down to the abdomen, without tension;

• After reducing the hernia and removing the hernia sac, the crura was closed by approximating right and left pillars with three figures of eight 2-0 ethibond sutures.

• After total gastric release from adherences, dilated gastric pouches were confirmed;

• A 32Fr Fouchet bougie was introduced down to the stomach;

• Longitudinal gastric stapling began 3 cm proximal to the pylorus, over a 32Fr Fouchet tube, positioned in the small gastric curvature until the level of pylorus. It was used 60 mm J&J Echelon GST (7 shots), separating the dilated part of the previous gastric sleeve, longitudinally; for this, one black, two greens, one gold and three blues cartridges were used, from distal to proximal stomach, finalizing the stapling 1 cm to the left of His angle (Figure 17);

• The staple lines were oversewn with 3-0 polypropylene continuous suture;

• The posterior wall of gastric tube was fixed to the base of the transverse mesocolon, at the level of the incisura angularis, with three separate 3-0 polypropylene sutures;

• The entire small bowel was measured, using both trocars positioned in the left abdomen, starting the counting from ileocecal valve (ICV) and putting a mark with a clip at a point 3 meters proximal to the ICV (to ensure at least this minimum length of common channel);

• The Treitz angle was identified;

• A 150 cm jejunal segment (biliopancreatic limb—BPL) was counted distally from the Treitz ligament and transected with a 60 mm staple, loaded with a white cartridge, separating the alimentary limb (distal) from the biliopancreatic one (proximal);

• The mesentery between these two limbs was opened vertically 4 cm long, in direction to its root, with ultrasonic scalpel;

• The alimentary limb was brought up to be anastomosed with the antrum, manually. A 4 cm antrojejunal anastomosis was done on the greater curvature of the antrum, just proximal to the pylorus, after removing a semilunar specimen of the anterior gastric wall, 1 cm large, with a curved convex shape. This anastomosis was done with total layer running suture, using two 3-0 PDS thread;

• An 80 cm long alimentary limb was measured distally, from the antrojejunal anastomosis and an 3 cm longitudinal linear opening was made at this level, in it is antimesenteric border;

• The staple line of the biliopancreatic limb was resected, leaving an 3 cm wide opening;

• An end-side entero-enteric, seromuscular running suture was done between these two jejunal limbs, creating a Roux-en-Y configuration;

• The mesenteric space between jejunal limbs (alimentary and biliopancreatic) was closed with a 3-0 polypropylene running suture;

• The mesenteric space between the alimentary limb and the transverse colon (Petersen space) was closed with a 3-0 polypropylene running suture;

• The integrity of both anastomoses was tested with methylene blue;

• The Fouchet bougie was removed;

• The resected stomach segment was placed inside an endobag and extracted through the 12 mm incision on the left side of the abdomen;

• The trocars were removed, with aponeurosis closure at the 12 mm trocars sites, with 2-0 Vicryl thread;

• The skin wounds were closed with intradermic sutures, using 3-0 Monocryl thread;

• The schematic final aspect of the surgery is represented on Figure 18.