In the presented video, we show a primary BRnYGB in a 38-year-old woman. The operation is performed as a two-surgeon procedure. The patient is positioned in the lithotomic position and reversed Trendelenburg tilt. The surgeon stands between the patient’s legs and one assistant stands on the left side of the patient. After insufflation of the capnoperitoneum via a 12 mm separator trocar (Applied Medical, Rancho Santa Margerita, CA), four working trocars are placed under direct view as shown (Figure 4). After lifting the left lobe of the liver aside, the subcardiac region is exposed. As shown in the film, the dissection is now started in the area of the angle of His, using the LigaSure™ instrument (Covidien, Dublin, Ireland). Then, the dissection is continued at the lesser curvature, 7-8 cm below the cardia. Here the omentum minor is dissected, and preparation is continued towards the left crus of the diaphragm. After insertion of a 32 F gastric tube the dimension of the pouch is now marked, and the gastric pouch can be separated using 3 to 4 linear staplers (blue cartridge, Covidien, Dublin, Ireland). The 32 F gastric tube should be removed prior to stapling. The pouch volume should be 15 to 25 ml . The stapling line of the pouch is oversewn with a 3-0 resorbable running suture. Now the GaBP Ring is placed 2 cm from the distal end-point of the pouch. It is closed and fixed with two non-resorbable sutures. We usually use rings with a circumference of 6 to 6.5 cm. The alimentary limb is created by dividing the jejunum 50 cm below the ligament of Treitz. Here we use a 45 mm Endo-GIA stapler (Covidien, Dublin, Ireland) with a white cartridge. We perform the gastroenterostomy in an antecolic and antegastric manner. The anastomosis is performed with an Endo-Gia stapler (Covidien, Dublin, Ireland), The opening for the stapler is closed with suture and the anastomosis is oversewn with a running absorbable suture. The integrity of the anastomosis is tested using methylene blue. As the last step, the Roux anas-tomosis is created 150 cm below the gastroen-terostomy, side to side using a 45 mm Endo-Gia stapler and a running suture closing the openings for the stapler. A Blake drain is used if necessary, the capnoperitoneum is released and an absorbable skin suture performed. We do not drain the remnant stomach.
Source: Video Surgery