**2.3 The operation**

All patients should receive preoperative antibiotics and prophylaxis for the venous thromboembolic event (VTE). After anesthesia induction, the site of the port should be marked. The abdomen is accessed using a 5 mm visiport at the left upper quadrant 5 cm from the umbilicus. Another 5 mm port in the left upper quadrant is placed at a planned incision site for port removal. A superior epigastric incision is used for Nathanson's retractor to assist with left hepatic lobe retraction. A 12 mm port is placed 5 cm to the right and superior to the umbilicus. Another 5 mm port is placed in the right upper quadrant. The adhesions of the band should be dissected thoroughly, making sure not to injure the stomach. Complete circumferential dissection is needed to remove the band (**Figure 2**). Then the tube can be divided near its insertion into the band. It is advisable to separate any fibrous tissue adherent to the stomach wall to

**Figure 2.** *Circumferential dissection around the band.*

**Figure 3.** *Resection of fibrous tissue.*

apply the stapler safely (**Figures 3** and **4**). Then laparoscopic sleeve gastrectomy is done by dividing the greater omentum to the gastroesophageal junction. It is crucial to assess for hiatal hernia. If present, complete mobilization of 2–3 cm intraabdominal esophagus should be accomplished with a posterior and anterior nonabsorbable suture repair (**Figures 5** and **6**). Creating the sleeve is started by applying staplers along a 36Fr bougie. We prefer to apply clips long the sleeve but not a full deployment to control bleeding. Reinforcement of the staple line with sutures is advisable. The procedure is completed by exteriorizing the band and the resected stomach, removing the port, and closing the skin.

**Figure 4.** *Fine dissection of reactive tissue caused by the band before applying the stapler.*

**Figure 5.** *Hiatal hernia dissection.*

**Figure 6.** *Repaired hiatal hernia.*
