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

● The patient is positioned in a 30˚ reverse trendelenburg position, without lateralization;

● The abdominal cavity is 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;

● A 0.5 cm whitesh, round, subserosal lesion is identified on the anterior wall of the antrum, in between the greater and lesser curvature, 3 cm proximal to the pylorus (Figure 6);

● The left hepatic lobe is withdrawal using a straight cylindric retractor, inserted through the 5 mm trocar, 5 cm bellow the xiphoid process;

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

● The dissection of the vessels of the greater curvature of the antrum starts 7 cm proximal to the pylorus, opening a small retrogastric window;

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

● The gastric vessels from the right and left gastroepiploic arcade and the short gastric vessels 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 then positioned over the right hepatic lobe;

● 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 Polypropylene thread;

● The lesion in the antrum is resected circumferentially, addressing all the layers of the gastric wall, with a 2 cm safety margin, starting approximately 1cm proximally to the pylorus. A 4 to 5 cm hole is created in the anterior wall of the antrum (Figure 7);

● A 300 cm of common channel is warranted, counting it from the Ileocecal Valve (ICV);

● The Treitz angle is identified;

● A 200 cm jejunal segment (Biliopancreatic Limb, BPL) is counted and brought up to be anastomosed at this level with the antrum opening;

● A 4cm longitudinal opening is made in the antimesenteric side of the jejunum, using harmonic scalpel (Figure 8);

● An antrojejunal anastomosis is done, starting with a running posterior full-layer 3-0 PDS thread suture (Figure 8 and Figure 9);

● An antrojejunal anterior full-layer 3-0 PDS thread running suture is done, tying it up with the posterior layer thread suture (Figure 10);

● A little hole is made in the mesentery of the afferent jejunum, just coincident to the distal end of the gastric staple line;

● A 60 mm staple is inserted open in the mesenteric hole, using a white cartridge to transect the jejunum;

● The jejunum is transected at this level, separating the alimentary limb from the biliopancreatic one (Figure 11 and Figure 12);

● A 50 cm alimentary limb is measured and a 3 cm longitudinal linear opening is made at this level, in it is antimesenteric border, using harmonic scalpel;

● A 3cm longitudinal linear opening is made in the antimesenteric border of the biliopancreatic limb, starting 1 cm proximal to the staple line, running proximally, using harmonic scalpel;

● A side-to-side enteroenteric, 3 cm manual, extramucosal running suture, is done between these two jejunum openings, creating a Roux-en-Y configuration (Figure 13);

● The mesenteric space between the alimentary and the biliopancreatic limbs is closed with a 3-0 polypropylene running suture;

● The mesenteric space between the mesentery of the alimentary limb and the transverse mesocolon (Petersen space) is closed with a 3-0 polypropylene running suture;

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

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

● 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;

● Cavity drainage is not performed;

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