The procedure

combines a typical

sleeve gastrectomy

(SG) with a transit

bipartition (TB).

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This creates a shortcut to the ileum while maintaining access to the duodenum. The procedure may be performed in a  laparoscopically, where the SG is performed through laparoscopy . Here, we describe the laparoscopic method. Pneumoperitoneum is obtained using a Veress needle. Six trocars are positioned, including three 12-mm trocars (1 in the midline 3 to 5 cm above the umbilicus and 2 others in the upper left and right quadrant) and three 5-mm trocars (1 in the epigastrium for the liver retractor and 2 at each lateral flank). The omental bursa is opened, and the greater omentum is sectioned with a sealer and divider device (Ultracision or Ligasure).

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The greater curvature is freed from 2 cm proximal to the pylorus up to the angle of His, including the left arm of the hiatal crura. If a hiatal hernia is present, then a hiatoplasty is performed. A typical sleeve gastrectomy15 is performed with a laparoscopic linear cutting stapler starting at the gastric greater curvature at a point located 4 to 5 cm from the pylorus up to 0.5 cm from the angle of His. A 33-45 French bougie is passed to the stomach to guarantee that the remnant gastric tube, which is positioned by the lesser curvature, has an internal lumen 3-cm wide. A seromuscular running suture is sometimes used to cover the stapling line to reduce bleeding. After the SG, the ileocecal transition is located. A single stitch is used to mark the point at the ileum 80-150 cm from the ileocecal valve. The point at 230-300 cm is then located, and a perforation is made with the cautery to allow the insertion of one arm of the linear stapler into the ileum lumen. Another hole is created in the stomach antrum at the end of the stapling line by applying the cautery against the bougie’s protuberance. The other arm of the stapler is inserted in the stomach from the patient’s left to the right, toward the pylorus, to create a 3- to 4-cm wide latero-lateral gastroileal anastomosis in an antecolic position. A 3-0 absorbable extra mucosal running suture closes the residual defect. In the following sequence, the small bowel cranial to the gastroileal anastomosis is laterally widely anastomosed to the ileum at 80-150 cm from ileocecal valve (previously marked) in a lateral-lateral mode. A laparoscopic linear stapler with a 60-mm white cartridge is used for the anastomosis). A nonabsorbable running suture closes the mesenteric borders to prevent internal hernias. At the end of the procedure, the segment between both anastomoses is interrupted with stapling and cutting. A closed suction drain, lying along the sleeve gastrectomy staple line, is exteriorized through the lower left port incision. The other laparoscopic incisions are closed.