insufflation is then started using a veress needle at palmar’s space. After adequate gas insufflation an 11 mm bladeless trocar will be inserted at the supraumblical region, which will contain a 10 mm 30° scope which will be used for examination of the peritoneal cavity. The monitor is positioned at the patients’ right shoulder, while the surgeon stands between the patients’ legs, with the nursing assistant on the patients’ left side (mirror image of the typical positioning for a gastric sleeve). A 15 mm bladeless trocar is then inserted at the left upper quadrant, while a 12 mm bladeless trocar is inserted at the right upper quadrant, Iron med laparo­scopic liver retractor is then used to lift up the hepatic lobe (Fig. 1). Dissection is then started by taking down the gastrocolic ligament using the left sided trocar, just proximal to the pylorus, all the way up to the base of the right diaphragmatic crus, with meticulous dissection of the gastosplenic ligament. 1st stapling is done using an Endo GIA black articulating, while reload with Tri-staple Technology 60 mm (extrathick) is done just proximal to the pylorus. A 36F calibrating tube is then inserted orally by the anesthesiologist under direct vision all the way up to the pylorus, followed by stapling of the rest of the stomach using a purple Endo GIA articulating reload with Tri-staple Technology 60 mm and ending about 2 cm lateral to the GE Junction. Staple line reinforcement is recommended using 10 mm Endo clips at the overlap and bleeding areas, afterwards, the calibrating tube is pulled out to the level of the GE Junction and 150 ml methylene blue leak test is then performed. The tube can then be removed completely. Interrupted 2.0 vicryl gastropexy stitches are then done between the sleeved stomach and the

pre-pancreatic facia to keep the stomach aligned. A 5 mm Neleton free gravity drain is then inserted at the right upper quadrant with the tip near the GE Junction. The excised stomach is then removed from the 15 mm trocar port. Both 12 and 15 mm port sites would be closed using 1 vicryl Endo closure. The skin is then closed at all port sites with 3.0 monocryl in a subcuticular fashion with surgeon pore dressing done.

Bypass (GBP) to stabilize the size of the reservoir in the GBP operation [10, 11]. This resulted in better and sustained weight loss as compared to the non-banded GBP [12]. The same concept was applied to the LSG by placing a ring/band loosely around the proximal sleeve. This resulted in better and sustained weight loss compared to the non-banded sleeve [13–15]. Placing this ring/band enhances three mechanisms that result in weight loss maintenance:

3. the forced compliance of the patient having to eat slowly, chew the food thor-

Creation of the Sleeve Gastrectomy (SG) starts with mobilizing the omen­tum along the greater curvature of the stomach (Fig. 2), starting at a point 1–2 cm from the pylorus up to the gastroesophageal junction, exposing the left crus of the diaphragm. The sleeve is formed by transecting the stomach, starting from 3–4 cm from the pylorus using a green Ethicon Endo-stapler (Johnson and Johnson) (Fig. 3). The stapled resection of the stomach is continued with blue sta­plers alongside a 38 French bougie in the stomach leaving a sleeve estimated at 90–110 cc in size.