A Foley catheter is inserted into the bladder. A nasogastric tube is placed. Position the patient supine on the table with the right arm tucked to the side. Position the left arm on an arm board. Apply a footboard 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 patient’s right, the assistant and scope holder on the patient’s left. Elevate the umbilical plate with two penetrating towel 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 intra-abdominal pressure of 15 mm Hg.

The first 12-mm trocar, the camera port, is inserted 15 to 20 cm below the xiphoid process just to the left of midline using a Visiport technique. 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 surgeon’s 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 insert a 5-mm trocar in the left upper quadrant. The next trocar is a 5-mm trocar inserted in the right upper quadrant laterally to allow liver retraction. 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 the fourth 5-mm trocar in the left upper quadrant as a second port for the assistant.

Retract omentum and transverse colon superiorly into the upper abdomen where it is held by the assistant.

Identify the suspensory ligament of duodenum (ligament of Treitz) (see Figure 63.1D). Next, trace the jejunum 30 cm
(Fig. 69.2A) distal to the suspensory ligament of duodenum (ligament of Treitz) and divide it with a linear cutting stapler. Use a second firing of the linear stapler to divide small bowel mesentery further if necessary (Fig. 69.2B,C). Mark the distal bowel with a stitch to avoid confusion with the proximal end of the bowel.