Same setup as for gastric bypass with lithotomy split leg. 

Port placements: One 15mm port as right hand instrument (RUQ), 5mm ports in RUQ x2 (left hand instrument and liver retractor), LUQ laterally (assistant).

Steps:

1. Insert a liver retractor

2a. Create the angle of His by dividing peritoneum (but a small amount so as not to aid slippage) and sweeping down with Yohans (doesn’t use gold-finger). Get to the upper most edge of the peritoneal connection and divide caudally. Imagine where the yohan’s going to be coming out and clear that area. 

2b. Divide the gastric fat pad off the stomach. 

3. Pars flacida technique: divide through transparent window then get assistant to hold the fat on the posterior side of the stomach laterally. This shows the border of the right crus. AT ITS LOWER MOST ASPECT, divide the peritoneum just next to it to create a posterior window and pass the Yohans through it. This should now be visible on the lateral side when you medialise the fundus. MAKE SURE THE YOHANS IS ABOVE THE SPLEEN!.

Ensure the Yohans doesn’t come back out..get someone to hold it in place if in doubt. 

Make sure the band has been prepped by the scrub nurse – filled with saline and the flange put on. 

5. Insert the band by holding the tip of the uncurled band (WITH THE BALLOON FACING THE INSTRUMENT – so that its not damaged on insertion) with a Marylands and place into the abdomen through the 15mm port, including all the tubing. (To make it slick, grab the flange at the very end of the tube with the right hand and pass it in, straight to the Yohan’s in the posterior gastric tunnel)

6. With the Yohans through the posterior window, grab the tip of the tube and pull it through until the band wraps around the stomach in place. The tube can then be passed through the catch and clicked into place (with the Allergan band, the appearance of the black area in the window shows its correctly placed). 

7. This band will now appear correctly placed, lying diagonally. Jim places a couple of sutures to prevent slippage (no evidence, mostly for medicolegal purpose) which unfortunately will displace it. For the first suture, place it as highly as possible on the fundus (2-0 Ethibond, slip knot), then the second one slightly lower down. DO NOT PUT THE CATCH IN THE GASTRIC TUNNEL, THIS WILL CAUSE EROSION. 

8. Pull the tubing out through the 15 mm port and cut it shorter to size. Connect to the access port. A subcutaneous pouch fairly superficially in the fat allows it to lie flat- make this with a pair of scissors Close the fat with a couple of vircyl sutures and then close skin. 

First fill in 2 weeks time.