The lowest and camera port was inserted through a 15 mm incision to the left of the midline and above the umbilicus. The optiview was used and great care was used to identify each layer and to barely penetrate the peritoneum prior to insuflation. The carbon dioxide insufflator was then set to 15 mm mercury pressure. Once the abdomen was fully insuflated the port was carefully advance. Three 5 mm ports and two 12 mm ports were then inserted avoiding visceral contact and vessels.

The liver was retracted superiorly and to the right using a grasper as a retractor avoiding excessive pressure and injury. The angle of His was divided using LCS.

Injury to the stomach, esophagus, spleen and diaphragm was avoided. The lesser curvature was mobilized at the second vessel avoiding injury to the vagus nerve, stomach and pancreas. The stomach was then divided using the Ethicon 45mm 3.5 endocutter from the second lesser curvature vessel to the angle of His using the Bougie as a guide. Complete transection was obtained and confirmed. The staple line was thoroughly checked.

The omentum was then divided between the right and left leaves. The LCS was used and contact and injury of the transverse colon was avoided. The ligament of Treitz was identified and confirmed. The jejunum was then measured to 75 cm. The proximal end was marked blue then transected with the 45mm 2.5 endocutter. The proximal loop was retraced to the ligament of Treitz. The distal loop was opened through an antimesenteric enterotomy. Injury to the back wall was avoided. The gastric pouch was opened at its most dependent portion with the LCS. A gastrojejunostomy was then created with a 35mm 3.4 endocutter. The angles, posterior and anterior walls were reinforced with the 2-0 Ethibond endoknot suture. There was no tension. The angles were reinforce with the same suture and the enterotomy was closed. The Roux limb was then clamped with an atraumatic grasper. The anesthesia then removed the Bougie and inserted an OG tuve. The tube was advanced in to the Roux limb. The anastamosis was then pressure tested with air under saline until the pressure caused eructation and there was no leak.

The Roux limb was measured to 75 cm and an enterotomy was created in then of the afferent limb and the side of the Roux. These were antimesenteric. The second anastamosis was performed with a 45 mm 2.5 endocutter. The anastamosis was reinforce at the angles, posterior and anterior wall with the same suture. The enterotomy was also closed with the 2-0 Ethibond endoknot. Complete serosal coverage was obtained on both anastamosis'.

Both anastamosis were now clamped atraumatically and pressure tested using methylene blue. There were no leaks. The anastamosis had an oval symmetric configuration and good flow. The loops were checked for satisfactory positioning.

The staple lines and areas of dissection and handling of the intestins were checked for any bleeding or injury related to surgery. The CO2 was removed slowly as well as the NG tube. The port sites were check for the need for closure. All ports were removed. The skin was closed with 4-0 Vicryl subcuticular. Steri-Strips were applied. Dry dressings were applied.

The patient stood the procedure well and left the OR in good condition.