Once the stomach is freed, we place a 36 Fr bougie down to the antrum ensuring that it is ush with the lesser curve of the stomach. The Cadiere forceps in arm 2 is substituted for a robotic stapler, and our sleeve gastrectomy is performed along the bougie. It is important to ensure that the incisura is not narrowed to avoid strictures. Different staple loads can be used depending on the tissue thickness and the sur­geon’s experience. We do not use buttressing material, though the staple line is imbricated with a running 2-0 Vicryl suture. It is important not to create a tight sleeve during stapling as oversewing can narrow the lumen further.

We replace arm 4 with a vessel sealer and place the patient in the reverse Trendelenburg between 15° and 20°. We then carry out dissecting the greater omentum off the stomach distally beyond the sleeve staple line and approximately 2–3cm past the pylorus. Dissection is kept in proximity to the gastric wall to avoid injuring the gastroepiploic vessels. This approach allows us to lift the stom­ach and dissect off the rst portion of the duodenum under direct visualization in a retrogastric fashion. A window is then created in the gastrohepatic ligament close to the superior border of the duodenum. Dissection is carried out for 2–3cm distal to the pylorus, care is taken to avoid injuring the gastroduodenal artery that can be visualized when lifting the duodenum. The perforating small branches sup­plying the duodenum posteriorly is our landmark to stop our dissection. We then place a robotic white-loaded stapler in arm 2 and re across the rst portion of the duodenum, ensuring that we are distal to the pylorus. This transection straightens out the stomach and allows for easier maneuverability for our duodenoileostomy. This maneuver also allows us to push the bougie further into the pylorus, which helps us create our anastomosis.

We switch out the scissors for a Suture cut in arm 4, and for our inner layer, we use two 2-0 Vicryl running sutures. We start by performing the inner layer with a 9-inch suture. We start from the corner on the patient’s left, internalizing the knot by going in-to-out on the duodenum and out-to-in on the bowel (Fig.18.4). We then complete the posterior inner layer in-to-out on the duodenum and out-to-in on the ileum while ensuring visualization of full-thickness bites of the duodenum and ileum (Fig.18.5). We carry this running suture anteriorly and stop it midway with the suture on the duodenal side. We then run a 7-inch suture starting from the same corner externalizing the knot by going out-to-in on the duodenum and in-to-out on the bowel. We then complete the anterior inner layer out-to-in on the duodenum and in-to-out on the bowel, leaving the last few sutures loose. This allows passage of the bougie through the anastomosis with the purpose of avoiding any narrowing when tying out sutures. Once the bougie has been pushed through, we can sinch down on the loose sutures and tie our two running sutures together to close our inner layer (Fig.18.6). It is important to ensure there are no air knots when anchoring the run­ning sutures, as this can be a site for enteric leak. Keeping the bougie in place, we then complete our outer layer with a running 2-0 absorbable V lock in a horizontal mattress fashion. It is easy to take large bites while running a horizontal mattress. This can cause the anastomosis to narrow and should be avoided.

Antiglycemics, antihypertensive agents, and diuretics are held postopera­tively, and patients are instructed to follow up with their PCPs at discharge to evaluate whether these medications need to be resumed. If patients are on mul­tiple medications, an inpatient consultation to internal medicine can be helpful in calibrating what needs to be resumed or held in the immediate postopera­tive period.