*3.1.1 Trocar placement and Pneumoperitoneum*

Pneumoperitoneum can be established with a variety of techniques (open, visualizing trocars or Veress needle), but we prefer the direct entry method. Although the direct entry method has a long learning curve and requires experience, it is a fast and safe method when performed by experienced surgeons. Only five patients in our series had lacerations in the gastric serosa, and one patient with extensive intraabdominal adhesions had full-thickness colon injury, which was noticed and repaired during the surgery (**Figure 2**).

The first trocar for a 10-mm camera is placed 10–12 cm below the xiphoid, and CO2 is insufflated up to 14–16 mm Hg. A laparoscope with 30° camera is introduced, and the abdominal cavity is inspected to rule out injury from the trocar and any other anatomic abnormalities such as adhesions. Three more trocars and a retractor are placed as shown in **Figure 3**:


#### **Figure 2.**

*Direct entry of the camera trocar (left-handed surgeon). The surgeon grasps the fascia with a towel clamp and lifts it upward to avoid any intraabdominal injury.*

**Figure 3.** *(a, b) Trocar placement.*

With the surgeon's command, the orogastric tube is placed to evacuate the stomach and should be taken to 30–35 cm of the esophagus.

**Tip**: The entry point of the camera trocar should not be adjusted to the umbilicus, but to the xiphoid, which is a more reliable and stable mark. The location of the umbilicus may vary depending on the patient's BMI and anatomical features. Also, the location of the umbilicus has changed in patients who have undergone abdominoplasty. If the camera trocar is inserted lower than it should be, fundus dissection will be difficult, especially in patients with high BMI.

**Tip:** Adequate aspiration of the stomach provides serious convenience, especially during fundus and left crus dissection. Dissection can be difficult while the tube is in the stomach.

**Pitfall:** To avoid any injury, a nasogastric or orogastric tube should not be inserted without the knowledge of the surgeon. In case of carelessness or miscommunication, the tube is fired between the staplers.

#### *3.1.2 Gastrocolic omentum dissection*

Dissection begins from the corpus-antrum junction of the greater curvature. The gastrocolic omentum is divided off the greater curvature of the stomach with the energy device on the surgeon's right hand, beginning approximately 3–4 cm proximal to the pylorus and proceeding to the angle of His, completely mobilizing the greater curve (**Figure 4**).

**Tip:** The surgeon's left hand pulls the stomach to the upside while the assistant catches the gastrocolic ligament and pulls gently to the downside. It allows working close to the great curvature, which reduces the risk of bleeding from gastroepiploic vessels and facilitates specimen extraction at the end of the operation (**Figure 5**).

**Pitfall:** If a dissection close to the stomach is not performed, bleeding from the gastroepiploic vessels may occur and take time to stop .

#### *3.1.3 Posterior adhesions dissection*

All posterior attachments to the pancreas must be divided, taking care not to injure the lesser curvature and left gastric vessels because the blood supply to the sleeve originates solely from the lesser curvature vasculature.

**Figure 4.**

*(a-c) Gastrocolic Omentum Dissection (a) shows the first movement to enter the lesser sac via stomach traction and omentum contra-traction. Surgeon separates the omentum up to 3 cm proximal to the pylorus in (b). Dissection is continued close to the stomach, along the greater curvature to the angle of His in (c).*

**Tip**: The most efficient maneuver to achieve adequate exposure for the posterior dissection is to retract the posterior aspect of the stomach upward with two graspers.

**Pitfall**: It is important to divide these attachments before stapling because these attachments can tear and create bleeding. However, left gastric and splenic vessels should be preserved (**Figure 6**).

**Figure 5.** *Bleeding from the gastrocolic omentum.*

**Figure 6.** *Posterior Dissection (Retracting the stomach upwards with two graspers provides an adequate exposure).*
