A Foley catheter is inserted into the bladder. The patient is positioned supine on the table with the right arm tucked to the side. The left arm is positioned on an arm board. A foot board is applied to the end of the table to facilitate placement of the patient in reverse Trendelenburg position to aid exposure in the upper abdomen.

The surgeon stands on the patients right, the assistant and scope holder on the patients left. Elevate the umbilical plate with two Allis clamps and insert a Veress needle into the abdomen approximately 15 cm below the xiphoid and 2 to 3 cm to the left of the midline. Do not use the umbilicus as a landmark because it is displaced inferiorly in many morbidly obese patients. Insufflate the abdomen with a high flow insufflator to an intraabdominal pressure of 15 cm water. Next insert a 5-mm trocar in the left upper quadrant and place a 5-mm, 30-degree scope to guide insertion of the other trocars. The next trocar is a 5-mm trocar inserted in the right upper quadrant laterally to allow liver retraction. Insert a 10-mm trocar into the midepigastrium to the patient’s left. Its position should generally be just below the level at which the ligamentum teres begins. This trocar will be used for the 10-mm, 45-degree scope throughout the procedure. Insert a 12-mm port at the same level in the right epigastrium; this will serve as one of the surgeons’ operating ports. Take care not to place this port too inferior because this may compromise the ability of the instruments to reach the operating area. Next place the liver retractor. Retract the liver superiorly and fix the retractor to the table with a retractor holder to provide stable exposure. Insert another 5-mm trocar into the right upper quadrant as the second operating port. Take care to place this port below the liver retractor and free of the round ligament. Inserting a long needle through the abdominal wall in the proposed trocar site may help prevent misplacement of this trocar. Finally, place a fourth 5-mm trocar in the left upper quadrant as a second port for the assistant.

Place the patient in reverse Trendelenburg position. The assistant retracts the omentum as well as the fundus inferiorly. A fat pad known as the gastroesophageal fat pad, or Belsey’s fat pad, overlies and in many cases obscures the gastroesophageal junction and the cardial notch (angle of His). Excise this pad with an ultrasonic shears to expose the cardial notch (angle of His) (Fig. 60.2A). Incise the peritoneum in this area with the ultrasonic shears and gently dissect the area behind the cardial notch (angle of His) with an articulating angled dissector (Fig. 60.2B).