Ramos et al. preferred dissection of the angle of His as the first step of the operation, whereas in the larger studies of Skrekas et al. and Andraos et al. it was the final step of the dissection of the greater curvature of the stomach. Mobilization of the greater selleck chemical Bicalutamide curvature is performed using either a LigaSure Vessel Ligation System (Covidien) or a Harmonic scalpel (Ethicon Endo-Surgery, Inc., Cincinnati, Ohio) initially by opening the greater omentum at the transition between the gastric antrum and gastric body. Once access to the posterior wall is achieved, the greater curvature vessels are dissected distally up to the pylorus and proximally up to the angle of His. Occasionally, posterior gastric adhesions are also dissected to allow optimal freedom for creating and sizing the invagination properly.

The next step is the introduction of a bougie which was of a diameter of 36Fr in the Skrekas et al. study with 135 patients, and of 32Fr in the studies of Andraos et al. and Ramos et al. with a total of 166 patients. Subsequently, the gastric plication is initiated by imbricating the greater curvature and applying a first row of extramucosal interrupted stitches which guided two subsequent rows created with extra-mucosal running suture lines. The first row stops 3cm before the pylorus. The reduction results in a stomach shaped like a large sleeve gastrectomy. Choice of suture material varies amongst surgeons, (absorbable versus nonabsorbable) but all appear to be using multifilament sutures for the first row of interrupted sutures, and monofilament for the subsequent lines of running suture.

Another important issue addressed by most authors, especially in the largest studies, is the distance between Dacomitinib sutures, with all of them stressing the importance of a maximum distance of no more than 2cm. Skrekas et al. modified their technique after 93 cases, and subsequently performed a double or even triple invagination creating a double mucosal fold on endoscopy. Reported results on this modification were similar in operating time and EWL with reduction of some complications resulting in shorter hospital stay [9]. An intraoperative methylene blue leak test was performed in most studies, with the exception of the Skrekas et al. study. No drains were placed in any of the cases. In the Khazzaka-Sarkis group, Nissen fundoplication was performed after mobilization of the greater curvature, followed by plication of the body and antrum of the stomach. 6.5.